Inspection on 29/05/07 for Westwood House

This inspection was carried out on 29th May 2007.

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 but made no statutory requirements on the home.

Other inspections for this house

Westwood House 14/04/08

Westwood House 30/11/06

Westwood House 22/11/05

Westwood House 05/05/05

Westwood House 07/09/04

Westwood House 06/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Westwood House 35 Tamworth Road Ashby De La Zouch Leicestershire LE65 2PW Lead Inspector Keith Charlton Key Unannounced Inspection 29th May 2007 09:45 X10015.doc Version 1.40 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 DS0000031586.V334325.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 Older People. 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 DS0000031586.V334325.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westwood House Address 35 Tamworth Road Ashby De La Zouch Leicestershire LE65 2PW 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) 01530 415959 01530 415990 db@westwoodcare.co.uk System Associates Ltd Rebecca Taylor Care Home 16 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (16), of places Physical disability over 65 years of age (16) Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That the person mentioned in application number V31066 dated 17/03/2006 who is 64 years of age be admitted to the home. No person to be admitted to Westwood House in categories DE(E), PD(E) or OP when 16 persons in total of these categories/combined categories are already accommodated in this home. 30th November 2006 Date of last inspection Brief Description of the Service: Westwood House is a care home registered to provide personal care and accommodation for up to sixteen older people that may also have a physical disability and / or dementia. The home is owned by Systems Associates Limited who run a number of care homes in the Midlands region. The home is located close to the town centre of Ashby De La Zouch and its shops, pubs, the post office and other amenities. It is easily accessible by private or public transport. The home is a converted house with a purpose built extension. This is a three-storey building and residents have access to all floors with the use of the passenger lift or stairs. The building has level entry access which is suitable for wheelchair users. There are eight single bedrooms without en suite facilities and four double bedrooms, one with en suite and three without en suite facilities. There are gardens to the front and rear of the building, which are accessible to all residents living in the home. The weekly fees for living at the home are based on levels of need. The minimum to maximum fee is £330 to £430 per week – this information was provided by the Registered Manager on the day of the inspection. The home provides information to residents and prospective residents in the form of a Statement of Purpose that describes the services it offers, and a copy of the last Inspection Report. Both can be provided to enquirers to give them a view as to the quality of life for residents. Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided… The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. This was an unannounced Inspection. The Registered Manager was on duty. Planning for the Inspection included checking on the notifications of significant events sent to the Commission for Social Care Inspection, the last Inspection Report and reading Comment Cards returned by residents and relatives. There have been no complaints made to the Commission for Social Care Inspection since the last inspection. The Inspection took place between 09.45 and 15.45 and included a selected tour of the home, inspection of records and indirect observation of care practices. The Inspector spoke with six residents, two staff members, and two relatives. The Inspection was concluded the next day with the Registered Manager. What the service does well: Residents said that staff were always very friendly and helpful towards them, that they were encouraged to retain their independence as much as possible, and reported that staff welcome visitors. Staff were observed to be friendly and positive towards residents. The inspector observed a relaxed and friendly atmosphere in the home. Residents said they would feel confident to raise concerns if they ever had any and were satisfied that these would be listened to and acted on by staff and management. Residents liked the food and said the portion sizes were good. Residents spoke positively about the activities arranged by staff and said they liked staff spending time with them when they were able to do so. Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 6 Relatives are told when their relative in care is not very well and are consulted over the support that is given. Relatives can spend time in the home and provide care if they wish to, and staff will help residents keep in contact with family. There are regular residents meetings where any issues and ideas are shared. The home is generally clean, warm and comfortable for residents. Staff thought they were valued and supported in the performance of their jobs by the Registered Manager and that training is encouraged in order to equip them to meet residents needs. The Registered Manager has a positive attitude in seeking to improve the care standards in the service and was receptive to ideas as how to improve the service for residents. Sixteen Comment Cards were returned from residents and their representatives. They were overwhelmingly positive as to the high standard of care that staff provide. What has improved since the last inspection? What they could do better: The Registered Provider needs to ensure that the welfare of residents is assured by ensuring that possible thefts of monies are regarded as an issue of protection and that procedures be followed in order so that strategies can be identified to protect residents from these incidents, that all the social and cultural needs of residents are contained in the pre admission assessment and Care Plan so that staff can follow this information, and that residents access to hot water temperatures is restricted and residents are protected from burning by ensuring radiators do not pose a risk to residents, that fire systems are Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 7 tested at proscribed intervals, so as to ensure full fire safety, that the level of care staff on duty for afternoon periods must be reviewed and increased to meet all residents needs and staff must not commence employment until the return of two written references with evidence of a Protection of Vulnerable Adults check on file. As the home accommodates residents differing conditions – e.g. diabetes, sight impairment etc, staff need be trained in these conditions in order to provide a service that meets residents needs. 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 DS0000031586.V334325.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process is good and the pre-admission process ensures that most of residents needs are met. EVIDENCE: Residents/relatives said they had been provided with a service users guide to the services the home offers and they have received contracts from the Company. There were contracts on file to evidence this. It was recommended that the Statement of Purpose and copy of the last Inspection Report be displayed to be easily noticed and accessible to current residents and their representatives. Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 10 Relatives spoken to said the manager visited them and the resident either at hospital or at home, to assess their needs. All residents case tracked had copies of the placing authority’s community care assessment on their file. Residents said that they could visit the home if possible prior to their admission usually by way of a trial period, to give them a good idea of what services the home offers. There was evidence of assessments undertaken by the Registered Manager available on the residents files examined by the inspector, which covered their needs, medical conditions etc. It covers very important issues such as pain control though not all National Minimum Standard issues are covered so the Registered Manager was recommended to use the list of issues contained in the Standards to ensure that all relevant issues were included. The home does not offer intermediate care facilities. Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans describe identified care needs to ensure proper care is supplied by staff though they need to include all relevant cultural and medical information. Medication systems are good though one aspect needs to be strengthened to always protect the safety and welfare of residents. EVIDENCE: Some residents said they knew they had a Care Plan. The Registered Manager said that residents and their representatives could participate in setting them up. Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 12 Residents needs are detailed in their Care Plans and all residents case tracked had a plan of care in place. Care plans and risk assessments continue to be generally satisfactory and are now easier to track because information relating to the health and welfare needs of the residents is kept together. There are some gaps, for example regarding the cultural needs and religious needs of residents and when health checks took place – dental, optical, hearing tests etc so that these can be arranged at regular intervals. There is now a risk assessment for what the risks are if the resident goes out independently and what are the appropriate measures for promoting safety and wellbeing. This limitation on freedom of movement has been removed and so protects this resident’s rights. It was noted how one resident has bed rails and there is now an individual risk assessment in place to cover this. There was reference to the continence needs of a resident, but this did not contain a referral to the continence nurse to see if any action could be taken to help with this or to establish what the need was as to when the resident needed to go to the toilet. The Registered Manager said this issue would be put in place. The registered manager stated that care plans are reviewed monthly and this was seen as recorded in the Plans. It is recommended that there is a record of residents normal routines, capabilities/requirements, getting up and going to bed routines etc., and that all residents full personal histories are compiled so that they can be seen as individuals with a valued history. A staff member said that she had read all the residents Care Plans. The Registered Manager said that she asks staff to do so. It was noted that some residents personal information was available in bedrooms, which can compromise confidentiality. The Registered Manager said this issue would be reviewed and followed up. Both the residents and their relatives again said that staff were very kind and caring and that the standard of care was always of a high standard and that the Registered Manager and the staff were very approachable and always treated the residents with respect and dignity. The inspector noted that staff always addressed residents in a friendly manner. Relatives said that they were always made very welcome. The inspector viewed accident records. There was a discussion with the Registered Manager as to when medical services should be called if there had been a potentially serious injury, e.g. a head injury, and the Registered Manager said this policy was already in place and acted upon. Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 13 The medication system was inspected. The Registered Manager and staff confirmed that only senior staff issue medication and the inspector saw a certificate of medication training. Medication recording was nearly complete with a small number gaps observed on the record of medication issued to residents. The Registered Manager said this issue would be followed up. Controlled drugs records were viewed and appeared to be satisfactory. Medication is kept locked away. The Registered Manager was asked to follow up with the pharmacist as to whether the cabinet was sufficiently robust as the previous Inspection Report recommended that a metal cupboard be purchased, in line with Misuse of Drugs (Safe Custody) Regulations 1973 and the National Minimum Standards. Any remaining medication from the previous cycle is now carried forward onto the current MAR so that there is an audit trail for checking that medicines have been given as prescribed. Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to lead full lifestyle and can exercise choice. Menu planning is thorough and residents are appreciative of the food though choice of main meal needs to be reviewed for one resident with cultural needs. EVIDENCE: Residents said that there were a range of activities at a good level and frequency, and that there was a choice as to whether they wanted to attend them. An Activities Programme is displayed. The Registered Manager said this would be amended to state that activities are provided seven days per week, and not the five days a week the Activities Programme refers to. Residents said they like the musical, pampering and bingo sessions they get. There were some comments about having more outings. The Registered Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 15 Manager said this issue has already been thought of and would be put in place for the residents who wanted to go. The Registered Manager said that there is a file dedicated to recording what recreational activities have been provided to residents and this record shows that meaningful time is spent with residents’ everyday. There are residents meetings held monthly, and minutes of the last meeting show that residents are consulted over what activities they enjoy doing. The Registered Manager was recommended to consider the provision of ‘memory boxes’, containing valued items, to be set up for residents, particularly for residents with dementia, so as to provide valuable reminiscence material for staff to talk to residents about. Residents said that there were no rules that they knew of, e.g. no one reported that there were set going to bed and rising times, and all thought the atmosphere of the home was friendly and relaxed. Some residents spoken with were glad staff gave them medication so they didn’t need to worry about keeping it themselves. Residents also spoke of being able to maintain their independence in other ways – personal care etc. One resident is able to go out to the local shop and buy himself things. The Registered Manager said that residents religious needs are respected; and that they residents are asked if they wish to attend places of worship, and religious people can visit if this was wanted. Information as to the requirements of residents who were case tracked was not fully recorded as to whether this residents wanted to see a priest or go to Church. The Registered Manager said this issue would be put in place. Inspection of residents accommodation demonstrated that they were able to bring in to the home their personal possessions. Residents confirmed this. Both residents and the relative stated that visitors are always welcomed to the home and no one reported any restrictions. The visitors spoken to thought that staff were very friendly and welcoming. There were positive views regarding the food. The Registered Manager is recommended to introduce a system in place whereby the cook meets the resident/representative and records likes and dislikes and any equipment needed to help with feeding. The Registered Manager agreed to display the menu board in the dining room rather than the kitchen to give residents information as to what food they were to get. Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 16 Menus were varied. The Registered Manager said that she had reviewed the menus to ensure that choices were adequate so that, for example, bacon sandwiches were not offered as a choice for a full meal. On the day of the inspection the mealtime was observed to be relaxed with residents having the choice of cheese pie or faggots followed by a rhubarb crumble with custard, or fruit. The inspector tasted the food and found it to be of a good flavour. Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are confident in the system of managing complaints. Staff have a good level of understanding regarding the prevention of abuse though practice needs to be strengthened to ensure that residents are always protected from possible abuse. EVIDENCE: Residents said that they thought that if there was a problem then they thought that the Manager or other staff would sort it out. The Complaints Procedure is generally satisfactory but does not give the complainant the opportunity to go to a relevant outside Agency at the initial stage, e.g. the local Social Service Department, as per the National Minimum Standard, and that complaints must be made in writing. The Registered Manager said this would be altered to reflect this standard. Staff members spoken with were not all aware of the procedure regarding the Agencies to contact if the in house arrangement failed. The Registered Manager said this issue would be followed up by drawing up a short procedural Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 18 statement as to the contact details of all statutory agencies that staff need contact should this be needed. Minutes of a staff meeting recorded two instances of possible theft from residents. There was no evidence that any further action of reporting these incidents was taken. There are local procedures to be followed when possible incidents of abuse occurs, by reporting to the Social Service Department, who is the lead agency in adult protection, and police if necessary, to identify strategies / risk assessments to minimise the risk of such an incident occurring again, and to ultimately protect all residents living in the home. Such incidents also need to be reported to the Commission for Social Care Inspection under the Regulation 37 procedure so any necessary action can be monitored. The Registered Manager said this action would be followed in future. The homes records were inspected and there was one complaint recorded in the file, which was appropriately recorded with relevant action taken to deal with it. The Commission for Social Care Inspection have received no complaints about the service since the last inspection. Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Facilities are seen as homely, clean and well maintained by residents. Odour control is of a good standard though one bedroom did not meet that standard. EVIDENCE: The residents spoken to were all content with their bedrooms and happy they could bring in their own furniture. Comment Cards returned by residents and relatives were generally satisfied with the facilities though there were some statements that décor needs to be updated. The Registered Manager said this was planned for the future. The inspector spent time in the communal lounges and looked at a number of bedrooms. All areas of the home seen were decorated, furnished and Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 20 maintained to a satisfactory standard. Furnishings are comfortable. Residents said that they liked the home’s gardens where they could sit out in warm weather if they choose. The inspector found that the home was generally clean. There was a slight odour in one bedroom, which also had staining on the carpet. The Registered Manager said this issue would be followed up. A stair carpet was threadbare and needed replacing. The Registered Manager said this would be replaced. There was a maintenance book available, which indicated that facilities were assessed on a regular basis and action taken as needed to maintain facilities to a good standard. There are screens in the shared bedrooms be for use, to give residents privacy and dignity if they wish them to be used. There was a discussion with the Registered Manager as to facilities being signed to help orientate residents with dementia etc. Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels may not meet residents needs. Recruitment processes need to be strengthened to ensure the protection of residents from unsuitable staff. A good staff training system is in place though needs to be extended to cover training on all residents conditions. EVIDENCE: There were some adverse comments regarding staffing numbers and the ability of staff to always respond to residents needs in the afternoon/evening. The rota and the Registered Manager confirmed that there was a minimum of three care staff on duty during the morning and two on duty for the afternoon/evening period (unless the home has the full occupancy of sixteen residents when there are supposed to be three care staff on duty, though this was not always the case on the rota), with two awake staff on duty during the night. In addition there are catering and domestic staff. For a home accommodating up to sixteen residents with the majority having dementia/physical disabilities, it would be expected that there would be three care staff on duty during the daytime/evening as there are a number of Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 22 residents who need to be assisted by two staff. In these instances there is no staff available on the floor for the other residents. It was also recommended that domestic and catering cover is extended to seven days a week. The Registered Manager said this issue would be put in place. Residents were again very happy with the staff team and said they are very helpful at all times. Three staff files were inspected and contained statements that Protection of Vulnerable Adults checks were received prior to staff commencing employment. However there needs to also be the evidence that such checks have been received. Other information, references etc. were generally in place, though one reference was received after the staff member commenced employment. The Registered Manager said she would ensure that this practice was changed to ensure that legal requirements are met and residents fully protected from unsuitable staff. Training files contained evidence of training regarding mandatory training, such as food hygiene, moving and handling, first aid, dementia awareness, wound management, risk assessment and protection of vulnerable adults training, though not all staff had received training on training on residents health conditions – stroke, diabetes, hearing and sight impairment etc. This is recommended. The Registered Manager and staff stated that there is encouragement to undertake National Vocational Qualification level 2 training and that the home was easily meeting the National Minimum Standard of 50 of staff with National Vocational Qualification level 2 training, as there are over 90 of staff with this training. There is an induction programme used for new staff, which was on file. Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are not fully in place to protect the health and safety of residents. EVIDENCE: Residents, relatives and staff said that they thought the Registered Manager was organised as to the running of the home and that she carried this out in a positive and friendly manner. The Registered Manager is currently completing her National Vocational Qualification level 4 in care. Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 24 There was evidence on staff records that staff have one to one supervision and staff confirmed this occurred on a regular basis though records to evidence this were not all in place. The Registered Manager said this issue would be followed up. Staff Meetings have been held and there was evidence of one being recorded in 2007. It is recommended that meetings are held more regularly and staff asked if they would like to add items to the agenda. Residents meetings are held, and minutes of the last meeting were available at the time of inspection, which discussed all pertinent issues regarding the running of the home. The Registered Manager said a Quality Assurance system was in place for 2006 though there was only a blank form on file to evidence the system as the completed ones are held at the Company office. These also need to be held in the home, open for inspection. Questionnaires had been supplied to residents to gauge their views as to the services the home provides. It was recommended that other interested parties be supplied with questionnaires – GPs, District Nurses, relatives etc and Action Plans to improve services included in the Statement of Purpose. There is a Health and Safety folder with Risk Assessments for safe working practices. There are a number of issues missing from this regarding the need for, e.g. radiators with covers to protect residents from burning, window restrictors etc, which are important for promoting and protecting the health and safety of residents. The Registered Manager keeps records of residents monies. It was recommended that relatives be asked to sign when they deposit monies so that a proper audit trial is available. The manager and an administrator that visits the home audit all residents’ monies held by the home on a regular basis, as indicated in records. Fire Precautions: The inspector noted that most fire doors were on approved closures so that they could be held open, as they would shut and preserve fire safety when fire bells sounded. Fire training is regularly carried out though a fire drill had not been recorded for seven months between 2006/07, when they need to be recorded on a three monthly basis. System testing was not on required weekly schedules for fire bell testing, as there had been no test since 19/4/07, though it had been properly carried out for emergency lighting. The Registered Manager said these issues would be followed up and put in place. There was a fire risk assessment on file. Staff members were asked about the fire procedure and were aware of what to do. Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 25 The hot water temperature was checked in a bathroom and found to be 44.5c; close to the National Minimum Standard of 43c, which was generally satisfactory, but records showed that the hot water temperature from the laundry was measured at 64c and it was observed the laundry door was often open, so this tap was freely accessible to residents. The Registered Manager said this door would be kept locked to prevent residents from scalding. Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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 OP18 Regulation 13 Requirement The Registered Manager must notify Social Services in line with Safeguarding Adults procedures, following such incidents of possible theft, so that strategies can be identified for residents’ protection. Staffing levels need to be reviewed and increased to ensure that residents needs are always met. The revised rota needs to be sent to the Commission for Social Care Inspection. The Registered Provider must provide evidence of, as a minimum, a POVA first check and two written references for the named staff member, prior to the commencement of employment. The Health and Safety systems in the home must protect the welfare of service users from harm. This includes protection from burning, scalding and fire DS0000031586.V334325.R01.S.doc Timescale for action 30/05/07 2. OP27 18 30/07/07 3. OP29 19 30/06/07 4. OP38 13 30/06/07 Westwood House Version 5.2 Page 28 systems. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Westwood House DS0000031586.V334325.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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