Inspection on 19/09/07 for Westwood House

This inspection was carried out on 19th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westwood House 23/11/06

Westwood House 15/11/05

Westwood House 04/05/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Westwood House Belmont Crescent Swindon Wiltshire SN1 4EY Lead Inspector Pauline Lintern Unannounced Inspection 19th September 2007 10:30 Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westwood House Address Belmont Crescent Swindon Wiltshire SN1 4EY 01793 542069 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.milburycare.com Milbury Care Services Ltd Cassandra Stribbling Care Home 10 Category(ies) of Learning disability (10), Learning disability over registration, with number 65 years of age (1) of places Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users accommodated may be aged between 35 years and 64 years. Only the named female service user referred to in the application dated 1 December 2004 may be aged 65 years and over. 23rd November 2006 Date of last inspection Brief Description of the Service: Westwood House is one of a number of services owned and managed by Milbury Care Services. Westwood House was opened in December 2004 and provides 24 hour care for a maximum of 10 service users with learning disabilities and associated mental health issues. The aim of the home is to provide a structured environment that enables service users to develop their skills and achieve maximum potential to live as independent a life as possible. The home is staffed by a minimum of four staff on duty on each shift throughout the day. There are three waking night staff and a senior member of staff on call. The current fees charged at Westwood House range from £1400 - £2400 per week. Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We made two unannounced visits to the home. The first site visit was one morning from 10.30 am to 1.00 pm. During this visit we carefully observed how people who live at Westwood House spend their time in the home and how staff gave them support. The second unannounced visit was from 10.00 am until 4.00 pm. We met with the manager and three staff members to obtain their views. We spoke to three people who live at Westwood House obtaining their views where possible on the support they receive. We looked at all the rooms and also checked a range of records in the home. We looked at previous reports and letters received since the last inspection. We received four survey forms from people using the service, four from staff members, two from healthcare professionals and two from social workers. Their comments are included within this report. We considered in detail the care given to three people and compared what we saw and what they were able to tell us with the records and comments by staff, general practitioners and social workers. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: Most people felt they were able to make a choice about whether to live at Westwood House. People have the opportunity to visit the home and stay for a meal prior to accepting a place. The service user guide is full of pictures and explains what people can expect from the service. People living at Westwood House have a spacious environment, which enables people to ‘have their own space’ if they wish. Generally the staff are friendly and caring. People can help out in the home if they wish and look after the home’s pets. A feature of this home is the high staffing levels. Staff are safely recruited, inducted and trained. People are encouraged to be part of the local community. Various trips out are provided to suit individual needs. Where appropriate people are encouraged to take responsibility for managing their finances. Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 6 Case files are person centred and confirm that people using the service are involved in planning their care. Westwood House provides a flexible menu, offering people the opportunity to devise their own menu (under supervision) if they so wish. What has improved since the last inspection? What they could do better: It would be good practice to ensure that there are no gaps left between entries in the recorded daily notes. Where possible all care plans should be signed by the person living at the home or their representative. Staff members should be reminded of the importance of recording the administration of medication. It is recommended that the manager seek guidance to identify the number of days a particular person using the service needs to have refused their medication before advice is sought from GP and records this within their care plan. Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 1, 2, 4. Quality in this outcome area is good. Prospective people to the service are given good information about the service and opportunities to try the service before making a decision. This enables them to make an informed choice. Each person has their needs fully assessed before they are offered a service to ensure they can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear and useful Statement of Purpose and Service User Guide to inform on what can be expected from the service. Both documents are supported with pictures and photographs and easy to read text. They include information on the aims and objectives of the home and staff qualifications. There is a section that provides the reader with the procedures for making a complaint or raising any concerns. There has been one new admission since the last inspection. This was an internal transfer from another Milbury home where it was agreed by a multidisciplinary team that the person’s needs could be better met at Westwood House. The person told us that they had settled in well and liked their new home and bedroom. They confirmed that they have everything they need. Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 10 On the second day of the site visit a person was moving into the home in the afternoon. The manager explained that they had previously visited the home a number of times. Their bedroom was clean and tidy and ready for their arrival. One member of staff said they would have the opportunity to attend the Gateway club with others from the home that evening if they wished or they could choose to remain at the home and settle in. The manager reported that there are plans for one person currently living at the home to move to another placement in the near future. The person told us that they have spent a great deal of time visiting the new home and having meals there. They reported that they would be going there for tea on the day of our visit. Case files confirm that each person has had their needs assessed prior to being offered a place at the home. Any restrictions to someone’s freedom or liberty are agreed within a multi-disciplinary team and the reasons are clearly documented and kept under review. Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 6, 7, 9. Quality in this outcome area is good. People’s care plans reflect their assessed needs. People are involved where possible in the development of their person centred files. Staff members support people using the service to make decisions about how they live their life. Potential risks are identified and strategies are put in place to minimise them whilst still enabling people to live as independent a life as is safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at a random choice of care plans for people living at the home and compared them with observations of the care and support people needed and how staff responded. The records included personal profiles about people’s histories, their likes and dislikes, and details of their skills. Evidence showed that plans are kept under review and are mostly signed by the person using the service or their representative. However one file sampled did not have a Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 12 signature by either. Staff members told us that people living at the home have the opportunity to attend their review meetings although they sometimes choose to leave after a short while. The manager reported that following a recommendation set at the last inspection all case files have been revisited and irrelevant information has now been removed and archived. Person Centred plans have been developed and contain entries by the person they belong to. Plans include photographs and pictures of things important to the person using the service. People at the home are encouraged to make decisions about the way they choose to live their lives. Daily notes record that one person had chosen to stay in their room and that a staff member had knocked their door suggesting they come downstairs when they needed a drink or food, which they did when they were ready. All of the people living at the home are provided with a key to their bedroom, although they do not all choose to use them. The home does not currently operate a key worker system. One staff member told us they prefer it this way as it enables everyone to work with each person living at the home. Risk assessments were sampled and this showed evidenced that they are kept under review. Following the last inspection each person living at the home has a risk assessment completed in relation to the potential hazards to some individuals using the main staircase. Where people who may be at risk if they leave the home unobserved clear guidelines are put in place to minimise the associated risks. When observing the support being given by staff, we noted that generally most staff interacted well with the people using the service. It was noted that some people had significant emotional and communication needs and these people tended to require more attention than others, which they received. Feedback from our surveys includes comments: 1. The home is good at consistency of approach, interpretation of wants, needs and verbal and non-verbal communication. 2. The residents need direction and support to access the community and the ability to make informed choice is limited. 3. They take great care of everyone, all the staff I have met are very nice, no complaints, it’s a very nice place. 4. My relative told us they like it at the home, they look happy too. I am relieved they are there and well cared for. They are doing a good job looking after the residents. The staff are friendly and cheerful, we get a good welcome. Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 13 5. Particular issues for my individual are religious faith; this has received relevant attention /care, and they appear to be able to understand how situations has affected them and make adjustments. Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 12,13,15,16,17 Quality in this outcome area is good. People living at the home have the opportunity to take part in appropriate activities within the local and wider community. Links with family and friends are encouraged and supported. Peoples’ rights are respected and recognised. Mealtimes are flexible to suit the needs of the people living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the number of activities available for the people living at the home has increased. There is an activities board on display in the hallway and each person also has an individual programme within their care plan. Opportunities are available for some people living at the service to attend college regularly. The manager reported that other activities which people using the service participate in include swimming, shopping, pub visits, Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 15 feeding the birds, trips out, Gateway club, Jubilee Gardens, music alive, market visits and going for walks. Activities within the home include board games, watching television and DVDs, bingo and colouring and drawing. We observed staff doing puzzles and looking at books with the people living at the home. During both days of the site visit staff were observed supporting people to the shops and going out for walks. One staff member reported that due to the high staffing levels at Westwood House staff are able to accompany the people living there on various activities within the community. They commented, “There are superb staffing levels here and I love getting people out and about”. One person living at the home told us about their recent holiday to Disneyland, Paris confirming they had enjoyed it. Another person had spent time in Scotland visiting their family with staff support. Photographs of these visits were on display along with other holidays and events that had taken place. Daily diaries show that people living in the home make decisions regarding if they choose to participate in day trips and activities or not. One person told us they had been to see a musical show in Reading the previous night, which they had enjoyed and ‘clapped along with’ according to the staff member who had accompanied them. Links with families and friends are encouraged. Relatives told us they are made to feel welcome when they visit the home. Records show that staff support the people in the home to make telephone calls to their families and friends when they choose. Weekly menus are displayed on the kitchen wall. The manager explained that some people living at the home devise their own menu to suit their needs. She added that one person living there had said they did not like the food on the main menu so was encouraged to choose his own food for each meal for a week. The manager confirmed that the contents of their menu was monitored as ‘chips’ with each meal could affect their well being so some days compromises were agreed. During the inspection one person using the service was observed refusing their lunch as they had not long had their breakfast. It was noted that a little later a member of staff asked them again if they wished to have something to eat. One person told us they had been out for lunch and had enjoyed a roast dinner with roast potatoes at a reasonable price. The home ensures that people living there with specific dietary needs are provided for. Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 18, 19, 20 Quality in this outcome area is good. Improvements have been made in the way that people living at the home are offered personal support. People have access to healthcare professionals when required. Arrangements for managing medication have generally improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One social worker told us “During my visits I make unannounced visits to gain as realistic a picture as possible, and I encourage them to be more proactive with their hospital appointments”. They added that they felt the home has a realistic interpretation of unwanted behaviours, looking for triggers and working towards their reduction. Evidence shows that the local consultant psychiatrist who regularly visits the home supports the staff team. Records are kept of any interventions, which may have been used. All staff members attend regular training in the use of Non-Violent Crisis Intervention (CPI) and refresher courses. Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 17 At the last inspection there were some concerns relating to the standard of personal hygiene and the lack of motivation for some people using the service. We were concerned that this may decrease people’s feeling of self-respect and self worth. The staff team appear to have taken on board our comments and have actively encouraged the people living there to take a pride in their appearance. Staff members confirmed that many people living at the home have ‘come out of themselves’ and were now having a better quality of life. They also told us that communication skills had also improved for some people and they were now using new words to make their needs known. The inspector also observed this. The management of medication has improved since the last inspection. A new fridge for storing medicines has been purchased and the temperatures are recorded. Records showed temperatures on the range of the recommended 4ºC. All ‘as required’ (PRN) medications are now signed for and recorded on Medication Administration Record (MAR) stating why given /refused. The administration of controlled drugs is recorded in a separate book, signed by 2 members of staff and doubly locked in secure cupboard. There is now hand wash and paper towels available. Medication stock checks take place monthly. The manager carries out refresher training every 3-6 months on the administration of medication. On the first day of the visit to the home it was noted that two entries on the MAR sheets had not been signed by the staff member, however the medication had been administered when checked. Staff need to be reminded of the importance of proper recording. Pictures of each person in the home who have medication are on the wall in the medication room, showing who has what medication on each day. A risk assessment is in place for disposal of sharps for blood tests. Records show that the person who has regular blood tests signs the record book himself with support of a member of staff. Staff have been trained in taking blood by the district nurse. Staff support people to collect their own medication from the pharmacist. It is suggested that the home need to identify number of day’s one person living at the home needs to have refused their medication before advice is sought from the doctor. The manager reported that they usually only refuse for one day at a time and she is currently waiting for a letter from the doctor confirming that the drugs stay in their body for a certain time and no action is needed. This will be placed on their medical notes. Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 22, 23 Quality in this outcome area is good. The home has now developed a log for recording any complaints received. People tell us they know how to make a complaint if necessary and who to approach. Staff members are trained to recognise any suspected abuse and the local protocols they need to follow. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has now developed a complaints log, which was sampled during the inspection. The manager confirmed that there has been one complaint received in the last twelve months and the complaints log confirmed this. As mentioned previously in this report each person living at the home has a copy of the complaints procedure in an accessible version. People using the service and their families and representatives are provided with an accessible version of “letting us know what you think” policy and procedures and each person living there has a “help card”, which inform how to raise a concern. People also have the opportunity to raise concerns during regular house meetings. One relative told us “I was concerned about my relative not speaking to me on the phone so I wrote to the Social Worker and to the manager. The manager Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 19 replied to me confirming that my family member was fine which eased my mind”. Staff members were able to explain the procedure for reporting any suspected abuse. Training records demonstrate that staff receive training in safeguarding people and a copy of Wiltshire and Swindon’s ‘No Secrets’ is made accessible to each person. In the last twelve months the manager reports there has been one safeguarding referral made and the local protocols were followed. One staff member told us “we deal well with people with challenging behaviour; I’m hoping they feel good in the house”. A healthcare professional commented, “The staff respond to challenging people sensitively while ensuring safety of the person and others who live at the home, balancing individual needs with risk assessment, they have their own specialists for example on managing challenging behaviours who can be brought in to advise”. They added that they felt the home has a realistic interpretation of unwanted behaviours, looking for triggers and working towards their reduction. Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 24,30 Quality in this outcome area is good. Risks relating to safety and security are assessed and mechanisms put in place to reduce them. The cleanliness and tidiness of the home had improved at the time of the visit to the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We toured the building and found that the leaking toilet identified at the previous inspection had been repaired. Individual bedrooms appeared cleaner and tidier than found at the last inspection. This could be said for all communal areas also. Discussion with the manager took place regarding the need for some redecoration to parts of the home. She confirmed that provision has been made for this to take place within the next year’s budget for maintenance. It was noted that some people living at the home had purchased new beds and chairs for themselves. Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 21 All bathrooms and toilets were found to be clean and hygienic at the time of the inspection. There were supplies of anti-bacterial hand wash available in hand washing areas. There was a supply of gloves available for staff to use to reduce the risk of cross infection. Training records show that staff are trained in Infection Control. The laundry was found to be clean and hygienic. The home uses red alginate bags to transport soiled laundry to the washing machine. Clinical waste is well managed and collected weekly. Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 32, 34, 35, 36 Quality in this outcome area is good. Staff demonstrate overall competency and appear to be sufficient in numbers, properly recruited, inducted and trained. Staff receive regular one to one formal supervision. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the last visit there were seven staff on duty in the morning and eight in the afternoon. The rota shows that these staffing levels are consistent. The home does use agency staff to cover staff sickness and annual leave. The manager reports that before a new agency worker works a shift they are provided with an induction shift where they receive payment and have the opportunity to familiarise themselves with the needs of the people living at the home. During a two-hour period of observation it noted that the majority of staff took time to interact with the people living at the home. Mostly the engagement between the people living at the home and staff was task based for example, giving a drink or food, or giving a game /book. During this period there was Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 23 only one interaction between two people living at the home, a few engagements with a visitor, but mostly it was with staff members. Feedback on the observation period was provided to the manager at the end of the inspection. The current staff team appears to be a good mix of age, experience and gender and represents the racial mix of the local community. People told us they felt staff listen to them, comments include, 1. The staff I have met are usually acting appropriately and have the skills and experience required, but some lack confidence in dealing with hospital appointments - perhaps a little too difficult. 2. Westwood House is a house, which creates a good atmosphere both for clients and staff. I feel comfortable to work in this house with my colleagues, we can rely on each other and we work as a team, which brings a positive outcome. 3. The carers are doing a good job and they listen. I know my relative is well cared for each day. Staff members told us that the training offered by Milbury is updated when required such as for manual handling and CPI. The staff that met with the inspector confirmed that they had completed their mandatory training. The training summary for November 2007 demonstrated that there are opportunities for staff to attend courses in person centred planning, safeguarding people, medication, principles of care, diabetes, nutrition and health, autism, equality and diversity, infection control, risk assessments and dementia. Some of the training is now completed with the use of an El Box. This can be accessed electronically by staff and is then submitted for approval. Staff told us that they like this method of training as they can access it whenever there is a quiet time and at their own pace. Staff are supported to complete their National Vocational Qualification (NVQ). There is evidence to show that staff have been safely recruited. Two references have been sought along with satisfactory checks with the Criminal Records Bureau (CRB) and the Protection of Vulnerable Adults (POVA) list before the commencement of employment. The three staff that met with us confirmed that they receive regular one to one supervision with their line manager. This was further endorsed in the staff survey forms. Evidence shows that staff receive annual performance appraisals to aid their personal development. The staff team at Westwood House appears stable and many staff have worked there for many years. This means that people living at the service have consistent care and are supported by people who know them well. Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 24 Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 37,39,41,42 Quality in this outcome area is good. People’s views of the service have been canvassed by the home. The health, safety and welfare of people living at the Westwood House is promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: “The management team are excellent and always there to help me and they have always been supportive especially when I was having personal problems”, and “Ms Stribbling is very kind to all of the people using the service”, are two comments received from our surveys relating to the management of the home. The manager has now successfully completed the registration process with the Commission. She has over 15 years experience and holds her Registered Managers Award (RMA) and level 4 NVQ. Her approach appears to be very Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 26 open and ‘hands on’. During both visits she was observed interacting with people living at the home, who appeared to be relaxed in her company. There is evidence to indicate that Miss Stribbling accompanies people on trips out and shopping. Since the last inspection the home have developed questionnaires, which have been sent out to the people using the service, their families or representatives, social workers and healthcare professionals as part of a Quality Assurance exercise. At the time of the inspection the responses had just started to be returned. Milbury also complete an Annual Quality Audit, which helps to form their annual development plan. Monthly management audits are completed and these are available for inspection. It is recommended that any gaps between entries in the daily notes be clearly crossed out to avoid additional entries being made. A number of health and safety records were checked, and were found to be up to be date. There is a gas safety certificate and evidence that Portable Appliance Tests (PAT) has been completed. The fire records were up to date and a fire risk assessment was in place. People’s finances are carefully recorded and the balances matched the cash in the tin of the one sampled. Some people using the service access their cash point to obtain their cash and use their own PIN numbers with staff support. This promotes their independence. Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 28 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) Requirement The registered manager must ensure that arrangements are made for the safe administration and recording of medication. Timescale for action 19/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA6 YA41 YA20 Good Practice Recommendations As good practice it is recommended that where possible each person living at the home or their representative sign their care plan to agree it’s contents. It is recommended that there are no gaps left between handwritten entries in the daily notes. It is recommended that clarification is sought from the GP for the refusal of medication for one person using the service and this is then recorded within the care plan. Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Westwood House DS0000061297.V345054.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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