Inspection on 23/11/06 for Westwood House

This inspection was carried out on 23rd November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westwood House 19/09/07

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 Key Unannounced Inspection 23 November 2006 10:00 rd Westwood House DS0000061297.V309919.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.V309919.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.V309919.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) londonroad@tiscali.co.uk Milbury Care Services Limited Mr Philip Pederson 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.V309919.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. 15th November 2005 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 two waking night staff and a senior member of staff on call. Westwood House DS0000061297.V309919.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key unannounced inspection took place over a five-hour period and was carried out by two inspectors. The acting manager was present who informed the inspectors that the previous manager had now transferred to another role within Milbury Care Services. The acting manager has applied for the permanent position and reported that she should know if she was successful by the end of the week. The inspectors looked at service users’ records, including care plans, assessments and risk assessments. Staff recruitment, complaints, supervision and training records were also seen. Medication policies and procedures were looked at along with some health and safety records. Seven staff were on duty at the time of the inspection, which enabled the inspectors to talk to three staff. At the start of the inspection all of the service users were at home so the inspectors had the opportunity to meet them all. The inspectors were was unable to communicate effectively with all of the service users to understand their experience of the service. Surveys were sent to the three service users who would be able to respond to them. The fees charges at Westwood House range from £1,300 to £2,000 per week. What the service does well: What has improved since the last inspection? Westwood House DS0000061297.V309919.R01.S.doc Version 5.2 Page 6 The home is addressing the need for service users to have the opportunity to access a range of activities and there is an activity board in the hallway for service users to refer to. Service users who may display challenging behaviours have records kept to enable staff and healthcare professionals to evaluate and monitor interventions and medications that are being used. Service users now have the opportunity to attend house meetings, where they can share their views and ideas. The home are developing effective ways of monitoring staff training by using a training matrix, which enables quick reference. What they could do better: 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. Westwood House DS0000061297.V309919.R01.S.doc Version 5.2 Page 7 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.V309919.R01.S.doc Version 5.2 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Each service user has their needs assessed before they are offered a service. Quality in this outcome area is good. This judgement was made from evidence gathered both during and before the visit to the service. EVIDENCE: Service users’ files were examined during the inspection and there is evidence that each prospective service user had an assessment prior to being offered a place at the home to ensure that they could meet their needs. Both the acting manager and the deputy visited the last person to be admitted in their own home to complete their pre-assessment. The service agreements are informative and ensure that all aspects of the service users’ care needs can be met. These include mobility, behaviours, cultural, social, health and assessment of risk. One service users pre- admission assessment identified that there should be some restrictions on their choices and freedom, which have been regularly reviewed. Westwood House DS0000061297.V309919.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Each individual has a care plan in place, however they do tend to contain a lot of information that is not relevant. Service users are encouraged to make decisions regarding their lives however the home needs to remember that they also have a duty of care in relation to personal care. Risk assessments are in place to enable service users to live as independent a lifestyle as possible whilst minimising any potential risks. Quality in this outcome area is adequate. This judgement was made from evidence gathered both during and before the visit to the service. EVIDENCE: Each service user has an individual care plan and a support plan. The support plans do not provide the reader with sufficient information, however the care guidelines tend to be more informative. It is recommended that each care plan is revisited and where a service user has more complex needs these are explained in more detail within their plan. For example to state ‘needs assistance to get into the bath’, does not provide adequate information to ensure that routines are consistent or carried out in the service users preferred way. The manager confirmed that she would work through all of the care plans Westwood House DS0000061297.V309919.R01.S.doc Version 5.2 Page 10 to ensure that they provide sufficient information. The files that were examined showed that they would benefit from being ‘cleared out’ to reduce the contents so that it would be easier to reach the detailed care guidelines. Outdated information should be archived for future reference. There is evidence that care plans are reviewed every three months. The home has a quick reference file, which is in place for any agency staff that may be on duty to ensure that they have access to all information. Staff members have started to develop person centred plans with service users. Again these could be developed further to ensure that they are appropriate to the service user as they provide limited information. There is evidence that one service user has been fully involved in the development of their plan which includes hand written entries and personal photographs. Discussion took place between the manager and the inspector regarding the communication needs of one service user and how this could be developed to enhance their quality of life. The manager confirmed that this is something that she and the staff team can build on. Other service users may also benefit from using some communication tools. Observation of the staff team and service users demonstrated that service users are provided with information and assistance to make decisions about their lives. Following the visit to the college to enrol on courses for the next term the manager asked a service user which course they had chosen to attend. Although it was evident that service users are encouraged to make decisions and choices regarding their lives there was some concerns relating to service users and their personal hygiene. We would expect a care plan to be developed to assist service users to ensure their hygiene needs are met. Risk assessments are in place and there is evidence that they are regularly reviewed. All staff members sign to say that they have read and understood the risk assessments. Westwood House DS0000061297.V309919.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Service users are able to access appropriate activities. There is evidence that service users are part of the local community. Contact with family and friends are encouraged with staff support if necessary. Service users are treated with respect. Mealtimes are flexible to suit the needs of the service users. Menus looked nutritional and varied. Quality in this outcome area is good. This judgement was made from evidence gathered both during and before the visit to the service. EVIDENCE: The home is actively trying to access further activities for the service users. The manager reports that some service users enjoy music so they are exploring what opportunities are available. One service user commented that they attend the ‘Jubilee Garden’, where they enjoy potting seedlings and general gardening. They have pictures of themselves in their person centred plan carrying out their gardening. In the afternoon of the inspection three service users went to college to enrol on different courses. One person said that they had signed up for a bereavement and dealing with emotions course. They said that they were looking forward to starting. Westwood House DS0000061297.V309919.R01.S.doc Version 5.2 Page 12 One service user reported that they were going to the gym that evening. The manager commented that some service users go to the pub in the evening while others prefer to watch television, play games or attend the ‘Gateway’ club. Activities on offer have improved since the last inspection. There is a new activities board located in the hallway, which shows the planned activities for the day for each service user, although this did not seem to really match what they were doing. During the inspection one service user was seen to be playing a board game and another person was completing a wooden puzzle. It was evident that staff support service users to make contact with their families and friends. During the inspection two service users had spoken to their relatives on the telephone. One staff member said that some of the service users go home to visit their families. Each service user holds their own key to their bedroom. It is recommended that there is some way of identifying which room belongs to whom, maybe by having a photograph or their name on the front of the door. When we toured the building the manager asked service users if it was acceptable for us to enter their rooms. The home demonstrates that they promote independence, individual choice and freedom of movement. Where there are restrictions in place these are documented in the care plans. Service users were observed interacting with each other and the staff members. There was lots of joking and ‘leg pulling’ between two particular service users, which suggests that friendships are encouraged within the home. The service user guide states that no one new will move into the home without everyone’s approval, as it is his or her home. The guide also says that pets are allowed again with approval from everyone. Some of the service users are smokers and there is clear guidelines and risk assessments in place to ensure the safety of all. Meal times appear to be very relaxed and informal during the day. Service users can have their food when they wish and have the opportunity to have an alternative to the menu. One service user writes up his or her own menu for the week although the manager explained that it usually followed the main menu. The manager reported that the evening meal is more of a social occasion with everyone usually sitting together around the dining room. The menu looked to be nutritional and varied. Westwood House DS0000061297.V309919.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 There is room for improvement relating to the way service users are offered personal support. Service users rights should be balanced against the homes’ duty of care to ensure that they are treated with dignity and maintain a feeling of worth. Service users have access to healthcare professionals to ensure their needs can be met. Policies and procedures relating to medication need to be addressed to protect service users where possible. Quality in this outcome area is adequate. This judgement was made from evidence gathered both during and before the visit to the service. EVIDENCE: Although it was evident that service users are encouraged to make decisions and choices regarding their lives there was some concerns relating to service users and their personal hygiene. Some service users may need extra encouragement to get out of bed, take a bath or wash their hair. It is recommended that staff look at ways of making these activities more enjoyable and pleasant for the service user, which will also promote a better quality of life and a feeling of self-respect. Service users could be given more support and direction to take a pride in their appearance. Staffing levels are good so there should be sufficient staff on duty to undertake this. Westwood House DS0000061297.V309919.R01.S.doc Version 5.2 Page 14 The manager reported that one service user likes to buy clothes but did not like to interact within the home preferring to stay on the sofa. We discussed the possibility of staff bringing in clothes books or catalogues to try or encourage them to participate in picking clothes or even putting the pictures into a scrapbook. There is evidence that service users medical health care needs are being monitored and their mental health needs being met. On the day of the inspection the Community Psychiatric Nurse had visited one service user and the manager confirmed that the Consultant Psychiatrist visits service users every three months. All service users are registered with a local doctor. The medication administration procedure was observed, which appeared mainly satisfactory. Staff attended to one service user at a time. All medications were stored correctly. The temperature of the fridge, which holds medicines, must be recorded daily. At the moment all ‘as required’ (PRN) medicines are recorded on a separate sheet however they do need to also be recorded on the MARR sheet and staff need to write the reason why the PRN is being given on the back of the medication record. Soap and paper hand towels are needed in the medication room for hand washing. The medication Temazepam needs to be documented in separate record with two members of staff to sign out the medication and then kept in a controlled drug cupboard. It would be good practice to ensure that a monthly system is in place to check that all medication is in date and that each medication sheet has a photograph of the service user on the front for identification. Staff would benefit from having regular updated ‘in house’ training on the administration of medication. This would ensure that they maintain their competency. Westwood House DS0000061297.V309919.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 House meetings provide service users with the opportunity to share their views and concerns. The service user guide provides information on how to make a complaint if necessary. The method of recording complaints needs to be improved. The risk of harm to service users is minimised as far as possible, to ensure their safety and well-being. Quality in this outcome area is adequate. This judgement was made from evidence gathered both during and before the visit to the service. EVIDENCE: Records show that service users are able to raise concerns if they wish however the home needs to develop a complaints log that details timescales and outcomes. The manager reports that there have been no complaints since the last inspection. There have been two referrals to the Vulnerable Adult team made in the last twelve months, which the home demonstrated that they acted appropriately too. One of the referrals did highlight certain areas for improvement, which the are implementing. Staff who spoke to the inspector confirmed that they have attended abuse awareness training and have seen a copy of the Wiltshire and Swindon ‘No Secrets’ guide. Staff records show that staff signs to say that they have read and understood the homes policy and procedure for safeguarding adults. Staff report that they would know what to do if they suspected abuse of any form. Examination of the house meetings indicates that service users are able to share their views and concerns. The last meeting was held on 12th November 2006 and records show that four service users attended. Westwood House DS0000061297.V309919.R01.S.doc Version 5.2 Page 16 Service user guides are in a format that is easy to understand but not individual to suit each service users abilities. The manager commented that she is intending to develop the guide to make it more suited to each person’s needs. All staff receive training in physical intervention and attends regular refresher courses to ensure that their skills are relevant. There have been twenty-one incidents when restraint was used in the last twelve months. All intervention appears to be in accordance with the homes’ physical intervention policy and procedures. Records are now being kept of when physical intervention has been used and there is an evaluation of medication used kept on the medication file. Westwood House DS0000061297.V309919.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The premises are safe and secure however parts of the house need to be assessed for risk. The home would benefit from redecoration and having new furniture to give it a cheerful, bright and homely feel. Generally the home would benefit from having a structured cleaning system in place to ensure that no areas get missed. Quality in this outcome area is adequate. This judgement was made from evidence gathered both during and before the visit to the service. EVIDENCE: The service users are living in a safe environment generally, however each service user should be individually assessed for the use of the main staircase. The manager commented that at the present time each service user could use the staircase safely but agreed to assess each person and review this regularly. The home has large airy rooms, which provides service users with the opportunity to be away from others if they choose. The dining room in particular is in need of ‘brightening’ up, as it feels slightly dark, with no homely furnishings. The manager reported that there is provision in the next years budget for this to be redecorated and that they are planning to replace some of the sofas. Westwood House DS0000061297.V309919.R01.S.doc Version 5.2 Page 18 When the inspectors toured the building they found that one service users bedroom had a strong offensive odour, which was found to be due to a broken leaking toilet in their bathroom. This must be repaired or replaced without delay. The manager commented that some service users choose to leave their rooms in a slightly untidy state. Although it is their choice the home also have a duty of care to ensure that their environment is pleasant, clean and hygienic to enable the service users to have a feeling of self worth. It was noted that most service users bedroom doors did not have their name on them or a photograph of themselves. It is recommended that the manager address this to ensure that the service user realises that it is his or her own space. One of the toilets had a tablet of soap to wash hands with. This could be a source of cross infection and it is recommended that the home replace this with an anti-bacterial hand wash gel. Discussion took place with the manager regarding appropriate aids that could be developed to enable service users with specific needs to become more independent when manoeuvring around the house. This also applies to accessing information. It is felt that some service users would benefit if staff explored sensory and tactile objects to promote sensory stimulation and awareness, which would provide an improved quality of life for the service users. Two service users told the inspector that they were happy with their bedrooms. The laundry was found to be clean and organised. The home uses red alginate bags for the transportation of soiled laundry to the washing machine. Clinical waste is well managed and is collected weekly. Westwood House DS0000061297.V309919.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Staff members are provided with training to ensure that they are competent to carry out their duties. Records demonstrate that the homes recruitment and selection process protects service users where possible. Staff have the opportunity for training and personal development. Staff members receive regular supervision. Quality in this outcome area is good. This judgement was made from evidence gathered both during and before the visit to the service. EVIDENCE: Staffing rota’s are in place with good staffing levels. Staff members were observed interacting well with the service users and being approachable. One staff member reported that they had received ‘lots of training’ since starting work at the home. They explained that they often worked with one particular service user who has specific needs and the staff member reported that they feel adequately trained to be able to meet the person’s needs. Staff who were observed during the inspection indicated that they have a good understanding of the non-verbal service users’ use of gestures and sounds and what is being communicated to them. Westwood House DS0000061297.V309919.R01.S.doc Version 5.2 Page 20 At the time of the inspection the manager confirmed that four staff have achieved their National Vocational Award (NVQ) level 3 and six staff have their level 2. Three recruitment files were sampled during the inspection process. Criminal Record Bureau checks were seen for these three staff and these were all in order. Prospective staff complete an application form and provide at least two references. During their induction period staff are provided with a workbook to complete, which covers all aspects of care and mandatory training. Staff members are asked to sign a training agreement. The homes training matrix shows the training, which staff have attended. This includes Non Violent Crisis Intervention (NVCI), principles of care, person centred planning, protection of vulnerable adults, challenging behaviour, infection control, epilepsy, equality and diversity and autism. Before new agency staff work a shift they are provided with an induction shift where they receive payment and have the opportunity to meet the service users and understand their needs. They never work a shift without completing this induction shift. This is good practice. Staff supervision records were examined and demonstrated that staff receive regular supervision and annual appraisals. Westwood House DS0000061297.V309919.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The home needs to develop their own quality assurance tool to ensure that they can obtain the views of service users, their relatives and care managers. Service users health and safety is protected where possible. Quality in this outcome area is adequate. This judgement was made from evidence gathered both during and before the visit to the service. EVIDENCE: The acting manager reported that the previous manager has moved to another position within the organisation. To comply with the care home regulations this should have been reported to us by the provider. The acting manager confirmed that she has applied for the permanent position and was hoping to hear the results of the interview by the end of the week. To comply with Regulation 26 the monthly audits, which the provider completes should be available at the home for examination. The manager explained that they have been completed but they had not yet received the copy to be kept at the home. The last audit available was dated 9th June 2006. It was evident from the inspection that the service users have an excellent relationship with the acting manager and felt comfortable in her company. Westwood House DS0000061297.V309919.R01.S.doc Version 5.2 Page 22 A requirement at the last inspection was for quality assurance to be addressed, this has not yet been met and it was discussed with the manager to ensure that service users, their families, health care professionals and funding authorities have the opportunity to share their views on the service provision and to enable the service to develop further. The manager explained that they have recently held a cultural evening for staff and service users. Staff made food from their home countries and some made flags. Some service users from other Milbury homes also had the opportunity to attend. Training files show that all staff attends mandatory training such as manual handling, fire safety, health and safety and basic food hygiene. Refresher courses are provided when required. Regular checks take place on the fridge and freezer temperatures and also water temperatures are recorded weekly. There is a cleaning rota for the kitchen, which is carried out by the waking night staff. There is daily hand over sheets that are completed to ensure that all of the daily duties are carried out. The fire log was examined and it showed that all checks and drills relating to fire systems are managed and recorded appropriately. There is a fire risk assessment in place dated 28/12/05 therefore this is due to be reviewed in the near future. All rooms are assessed for fire hazards regularly. All accidents and incidents are recorded appropriately however it is recommended that these are then audited monthly to look for any trends that may occur. Westwood House DS0000061297.V309919.R01.S.doc Version 5.2 Page 23 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 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 2 2 2 x 2 X 2 X X 3 x Westwood House DS0000061297.V309919.R01.S.doc Version 5.2 Page 24 YES 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 YA9 Regulation 13(4)(a) Requirement Timescale for action 23/01/07 2. YA39 3. YA37 4. YA39 5. YA20 The registered person must ensure that use of the staircase is risk assessed for each person and kept under review. 26(4)© The registered provider must prepare a written monthly report on the conduct of the care home and make a copy available for inspection. 39(a)(b) The registered person must inform the Commission in writing if a person ceases to manage the care home and if a person other than the registered manager manages the care home. 24(1)(a)(b) The registered manager ensures that mechanisms are in place to measure Quality Assurance. This requirement has not been met with a timescale of 15/01/06. Timescale now set for 25/02/07 13(2) The registered manager must ensure that all ‘as required’ medication is signed for and recorded on the medication administration record (MAR) sheet, stating why it has been DS0000061297.V309919.R01.S.doc 23/12/06 23/11/06 25/02/07 23/12/06 Westwood House Version 5.2 Page 25 given on the back of the record. 6. YA30 23(2)(d) The registered manager must ensure that the care home is kept clean and hygienic and that the leaking toilet is repaired. The registered person shall ensure that the medication Temazepam be documented on a separate record, signed out by two members of staff and kept in a controlled drug cupboard. The registered person shall ensure that hand wash and paper towels are available in the medication room for hand washing. The registered manager shall ensure that they keep a daily record of the fridge temperatures for the storage of medicines and consider replacing the existing fridge. 23/12/06 7. YA20 13(2) 23/11/06 8 YA20 13(3) 23/01/07 9 YA20 13(2) 23/12/06 Westwood House DS0000061297.V309919.R01.S.doc Version 5.2 Page 26 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. Refer to Standard YA7 YA18 Good Practice Recommendations It is recommended that the registered person develop communication/sensory tools and purchases specialist equipment to enhance the quality of life for service users. It is recommended that the registered person should continue to offer choices to service users’ however they need to also consider how to provide support and direction to encourage service users to build on their self esteem. It is recommended that the registered manager consider identifying service users’ bedroom doors to personalise them. It is recommended that the registered manager removes ‘historical’ information from service users’ care plans and ensures that they contain relevant information. It is recommended that the registered manager reviews each care plan to ensure that the information details clearly how tasks are to be carried out It is recommended that the registered manager complete a monthly audit of the accident records. It is recommended that the registered manager ensure that a monthly system is in place to check that all medication is in date. It is recommended that a complaints log be kept in the home, which details timescales and outcomes. It is recommended that the registered manager completes refresher training with staff members on the administration of medication on a six monthly basis and records this. 3 4. 5. 6. 7. 8. 9. YA24 YA6 YA6 YA42 YA20 YA22 YA20 Westwood House DS0000061297.V309919.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 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.V309919.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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