Inspection on 22/11/06 for Westwood Lodge

This inspection was carried out on 22nd November 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Westwood Lodge 08/06/09

Westwood Lodge 10/06/08

Westwood Lodge 24/09/07

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Westwood Lodge Brookview Helmsman Way Off Poolstock Lane Wigan Lancashire WN3 5DJ Lead Inspector Lynn Sharples Unannounced Inspection 22nd November 2006 09:30 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 Lodge DS0000067836.V314799.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 Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westwood Lodge Address Brookview Helmsman Way Off Poolstock Lane Wigan Lancashire WN3 5DJ 01942 829999 01942 826357 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) Meridian Healthcare Ltd Mrs M J Mather Care Home 76 Category(ies) of Old age, not falling within any other category registration, with number (76), Physical disability (7) of places Westwood Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 76 services users to include: up to 76 service users in the category of OP (Older People); up to 7 service users in the category of PD (Physical Disability under 65 years of age). The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 2. Date of last inspection Brief Description of the Service: Westwood Lodge Care Home is a purpose built home with 2 units, which offers care for 76 service users. The home is situated in a residential area of Wigan and is approximately 5 minutes drive from Wigan town centre and local amenities. It is pleasantly situated in its own grounds and has attractive garden, ample car parking space available at the front of the home. Accommodation is provided on two levels and in the annex, “The House”. All rooms are single and 74 rooms have en suite facilities. Level access to the home is provided and a passenger lift ensures access is provided to both floors. There are communal lounge/dining and quiet areas on both floors and within “The House”. The fees for the home are £387.64 – £560 per week. Westwood Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At the time of the visit there were seventy five people living at the home. The home did not know about the inspection and included a site visit to the service and it took nine hours. Residents, 3 relatives, the manager and the care staff were spoken with; 4 surveys from residents and 10 completed comment cards from relatives were received. The files relating to the service users, staff and the home were read and the premises toured. The home has received two complaints since the last visit and the home has investigated these complaints and has provided evidence that these have been dealt with. Two complaints have been made to the CSCI since the last visit, these related to the quality of care the residents were receiving. What the service does well: Residents’ individual health, personal and social care needs are clearly recorded. This provides care staff with the information they need to meet the residents care needs. The care plans are kept in the resident’s rooms and ensures that the resident and their relatives have access to the current plan of care. Personal care given by the staff was observed to ensure the residents dignity and privacy. Staff were seen knocking on residents doors. Residents have choice and flexibility how they spend their day in the home, and can pursue leisure activities according to their choice and preferences. This allows independence and individuality for each resident. Residents receive a balanced diet offering variety, which reflects the residents’ preferences. Visitors are allowed in the home at any reasonable time of day and residents may entertain their visitors in the communal lounge, or in their own bedroom. On the day of the inspection guests were seen at the home and they confirmed that they called at the home on a regular basis. The home has a satisfactory complaints system with evidence that residents feel their views are being listened to and acted upon. The premises are maintained to a good standard, both inside and out. The grounds were tidy and accessible. There is a programme of renewal of the fabric and decoration of the home. On the day of the visit the home was clean and free from malodour. The recruitment practices are adequate and appropriate checks are carried out. This ensures that the resident is not put at risk. The staff training provided Westwood Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 6 ensures that the staff are basically equipped to meet the needs of the service users. Some of the relatives said that they had a good rapport with the staff and that they were very good. There was evidence that the new owners visited the home monthly and that they produced a report on the conduct of the home. Feedback from the residents and their relatives will take place in January 2007. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Westwood Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 7 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 Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 8 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): 1,2,3,5,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes Statement of Purpose and Service User Guide are detailed providing service users and prospective service users with details of the services the home provides enabling an informed decision about the admission to the home. The home does not provide intermediate care services (Key Standard 6). This standard does not therefore apply. EVIDENCE: The Statement of Purpose is detailed and contains all the information a prospective resident and their representative would need to make an informed choice about whether to stay at the home. The Service User Guide is also available. Westwood Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 9 Four contracts were seen and they included all the information a resident would need before moving into the home such as the fees payable and terms and conditions of occupancy. The manager explained that new residents are visited in their own home or hospital. At the hospital the manager would speak with the nurse in charge to see if the home can meet the persons needs. The new resident is then offered the choice to visit the home usually the family visit. The home has a detailed needs assessment that is completed by the manager or a qualified nurse. This includes personal care and physical well-being, social interests and personal safety and risk. Some of the residents spoken with confirmed that there relative looked round the home before they moved in. The manager said that the home rarely has emergency admissions but the home has a policy regarding emergency admissions. The home does provide respite but this is subject to availability of rooms. Westwood Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 10 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): 7,8,9,10,11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ individual health, personal and social care needs are clearly recorded. This provides care staff with the information they need to meet the residents care needs. The medication at the home is not well managed and poses a risk to residents and does not promote good health. EVIDENCE: The 15 care plans that were looked at contained detailed and comprehensive care needs assessment that explains how best to support the resident with everyday living such as health, personal and social care needs. The plan is reviewed monthly with updates and changes recorded regarding the residents needs. The resident or relative signs some of the care plans. The care plans contained risk assessments relating to prevention of falls, bed rails and Westwood Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 11 wheelchairs. The care plans are kept in the resident’s rooms and ensures that the resident and their relatives have access to the current plan of care. The care plans included details of nutritional assessments, weight, dietary supplements, continence assessments, personal cleansing and dressing, moving and handling, resting and sleeping and pressure sore assessments. All residents in the home can access their NHS entitlements, which includes dentistry, opticians and chiropody services. The residents spoken with confirmed that if they were unwell or they request it the home would call a doctor. There was evidence that residents had access to speech and language therapist, diabetes nurses and dieticians. The plans include details of how to meet resident’s needs; for example if a resident has a visual impairment the plan suggests that “ you tell the resident who you are as you approach.” Residents spoken with were happy with the care they received and some relatives confirmed this. Some comment cards indicated that this was not always the case, one said that there relative can only see out of one eye and that they “ have to ask staff not speak to them on a their left side as they cannot see or hear them”. The daily records consist of a tick list to ensure specific health needs have been addressed. It would be beneficial if the daily records could include a written record of the residents day that includes health needs and if advice is given by a relative this could be included to ensure that residents are met. One relative commented on the care is very good and that the home “ tells me exactly what is going on”. The medication in one unit was examined, there were some errors found, the records indicated that one tablet should be left in the “blister pack” and there were no tablets left, this was found in two residents medication files. There was no quantity of paracetamol in stock on the medication administration record. Packets of cigarettes and lighter were also stored in the medication cabinet, these should be removed and only medication stored in the cabinet. These issues were discussed with the nurse on duty and the manager. Controlled drugs are recorded in a Controlled drugs register and were seen to be administered correctly. Personal care given by the staff was observed to ensure the residents dignity and privacy. Staff were seen knocking on residents doors. One member of staff was heard to speak disrespectfully about a resident and this was reported to the manager. There is one double room that is shared by a married couple. Residents spoken with said that they have their mail delivered to their room unopened. One resident had a telephone in their room. There is a section in the care plan that deals with dying and death. The home has policies on dying and death. Some qualified staff have additional training in palliative care and some care staff have received “end of life” training. The home has a resuscitation policy that states if a person has an advance treatment directive or living will not to be resuscitated that this is agreed after consultation with the residents doctor. Westwood Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 12 Westwood Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 13 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 choice and flexibility how they spend their day in the home, and can pursue leisure activities according to their choice and preferences. This allows independence and individuality for each resident. Residents receive a balanced diet offering variety, which reflects the residents’ preferences. EVIDENCE: The home has an activities co-ordinator who works five days a week for four hours in the afternoon. They explained that they are relatively new to the post, they worked as a carer previously at the home. They have devised five day activity list, this includes: - gentle exercise, art and crafts, music, mobile shopping day, bingo, beauty therapy treatment and general games. There is a trip to a large shopping complex organised for next month as well as a Christmas Fair and Christmas Party. The co-ordinator explained that in “The House” there is a recreational lounge that is also used by residents from the main home. The residents spoken with said that if they wish to join in Westwood Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 14 activities they can do so. Many residents preferred to spent time in their own rooms and some residents were confined to their beds. There are no records of staff visiting residents in their own rooms, particular those who are in bed. Some residents spoken with said that the staff did not come into their rooms between personal care giving and mealtimes. They said that they would like the staff to spend some time with them talking. The care plans included information on religious observance. On the day of the visit four residents were playing bingo on the first floor. The home should ensure that residents are given the opportunities for stimulation. When residents participate in social activities, it should be recorded in their daily record sheet, how they participated in the activity. This is to ensure that there is recorded evidence of how the resident coped or responded in the activity, and to their mood, emotions, physical dexterity. The recordings of the resident activities helps to complete a “full picture” of the residents progress, or even identify developing care needs. Visitors are allowed in the home at any reasonable time of day and residents may entertain their visitors in the communal lounge, or in their own bedroom. On the day of the visit guests were seen at the home and they confirmed that they called at the home on a regular basis. The home has resident and relative meetings that are chaired by the manager. There was a discussion about involving an advocacy service in these meetings to ensure that residents and relatives are free to comment about the home. The manager agreed to look into this. Resident’s bedrooms contained personal possessions. The home has some contact details of local advocacy services; this should be made available for all to read. The menus looked at offer a varied, wholesome and nutritious diet. The cook explained that they provide special therapeutic diets; they had a list of all the residents and if they required a diabetic diet or soften diet. They provided a several alternatives and if a resident wished to have something that was not on the menu this was provided. Residents spoken with said that they could have alternatives and that they enjoyed the food. The comments from relatives ranged from “excellent” to “ food is not very varied and is repetitive”. Residents were seen to have a choice of meals at breakfast, lunch and afternoon tea. Hot and cold drinks were being served throughout the day and jugs of juice or water were seen in residents rooms. The meals were served in a relaxed unhurried manner. Westwood Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system with evidence that residents feel their views are being listened to and acted upon. The home’s policy and training programmes for adult protection and whistle blowing ensure that the homes residents are protected from abuse. EVIDENCE: The home has a complaints procedure that is included in the Statement of Purpose and is displayed in the home. The home has received two complaints since the last visit and the home has investigated these complaints and has provided evidence that these have been dealt with. Two complaints have been made to the CSCI since the last visit, these related to the quality of care the residents were receiving. The residents spoken with said that if they had any concerns or complaints they would talk to either their relative or the manager. The relatives spoken with said that they had “ no complaints” but said that if they did they would raise this with the manager. One resident said, “ if you complain, the care staff always get the blame and it is not their fault”. The home should ensure that complaints are dealt with sensitively and appropriately. Westwood Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 16 The home has a policy regarding protection of abuse. There is also a document about “whistle- blowing” that advises staff what they should do if they have such a situation. Most of the staff have received training in Protection Of Vulnerable Adults training. The staff spoken with were able to demonstrate an awareness of the different forms of abuse and how to act as an alerter in terms of adult protection. Westwood Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 17 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): 19,22,24,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment is good, creating a comfortable and safe environment for the residents. The lack of grab rails leaves the residents at risk of harm and does not promote the residents independence. EVIDENCE: The premises are maintained to a good standard, both inside and out. The grounds were tidy and accessible. There is a programme of renewal of the fabric and decoration of the home. The entrance to the home has been modernised. Residents said that the home was clean. Westwood Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 18 “The House” and the ground floor did not have grab rails in the corridors and this could cause a risk of falls to residents. The hoists and assisted toilets were clean and regularly serviced. All bedrooms are furnished to a good standard and colour coordinated. The bedrooms are personalised and well maintained. There was evidence of personal items in the rooms such as photographs and mementoes; the rooms had either a television or music system or both. There were call systems in each room it was observed that some residents in their room could not reach them. The home should ensure that the residents have easy access to this facility, to ensure that they are safe. One resident explained that they could not reach the toilet roll in their bathroom as they used a wheelchair and had aids that prevented them from reaching the toilet roll. They also requested that the wardrobe rail was lowered to ensure that they could reach their clothes independently. The home should address these issues to ensure the residents dignity and independence. The laundry facilities are located on the lower floor and consist of washing machines and driers. The washing machines have the specified programming ability to meet disinfection standards. The laundress explained that they ironed the residents’ clothes. The staff were observed to wear protective aprons and gloves for specific tasks. The home has a new sluice room. On the day of the visit the home was clean and free from malodour. Westwood Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 19 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. The recruitment practices are adequate and appropriate checks are carried out. This ensures that residents are not put at risk. The staff training provided ensures that the staff are basically equipped to meet the needs of the service users. EVIDENCE: The rotas indicate that there are sufficient care staff on duty to meet the residents needs. The home tries to make sure that the staff work on the same units, to ensure consistency in the three units. On the day of the visit there were enough staff on duty to meet residents care needs. There are usually five staff on duty in the morning, 3 in the afternoon and two waking night staff, in each unit. Some of the staff has worked at the home for many years this provides continuity. The home uses bank staff to cover sickness and holidays. On the day of the visit there was a domestic staff in each unit maintaining the home in a clean and hygienic state. There are 49 care staff of which 24 care staff have achieved the NVQ level 2 in care, some care staff have the NVQ level 3 in care. The care staff were observed in the main being respectful and communicating effectively with the residents. They were friendly and there was a relaxed atmosphere in the home. The care staff spoken with were able to demonstrate a good Westwood Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 20 understanding of the needs of the residents. The comments from residents ranged from “staff are good and kind” to “ would like them to spend time talking with me”. Some of the relatives said that they had a good rapport with the staff and that they were very good. An examination of a sample of staff records indicated that all staff had two references, enhanced CRB checks, statements of terms and conditions on their personnel file. There was evidence that the Personal Identification Numbers (PINS) of all the registered nurses in the home was documented on Nursing Midwifery Council (NMC) stationery. There was a discussion with the manager regarding good practice of checking the PIN numbers every six months, the manager agreed with this. The staff records confirmed that the staff have received training in the last 12 months. The staff spoken with said that they had received training in a variety of areas such as: - tissue viability, palliative care, end of life training, manual handling and fire training. The staff would also benefit from training in other areas such as effective communication, dementia and diabetes to ensure that they can meet the changing needs of the residents. There was limited evidence on staff files that they had received an induction. The home must ensure that new staff are provided with induction and foundation training that meets the “Skills for Care” specification. Westwood Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 21 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): 31,33,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The record of self-review by the registered provider is good and provides the home with adequate quality assurance. The lack of supervision leaves the staff without clear direction. EVIDENCE: The manager has worked at the home for over 9 nine years; they are a qualified nurse and has the NVQ level 4 in management. The staff spoken with said that the manager was approachable and supportive. Some of the residents said that the manager was friendly and approachable. The manager demonstrated a good understanding of the needs of the residents. Westwood Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 22 The home has been operating with the new owners since July 2006. There was evidence that the new owners visited the home monthly and that they produced a report on the conduct of the home. Feedback from the residents and their relatives will take place in January 2007. The home does have residents and relatives meetings. The supervision records indicated that supervision took place on a regular basis. It was noted that nothing was recorded regarding these sessions. It is important that the supervisor can discuss all aspects of practice and the philosophy of care in the home and career development needs and that this is recorded. The unit supervisors had not received training in supervision. The home has current certificates in respect of electrical and gas safety. A current certificate of employer liability was displayed. The records stated that both the day and night staff have received fire drills this year. There was a discussion with the manager to ensure that day staff receive at least two fire drills a year and that night staff receive three fire drills a year. Maintenance and associated records were up to date. Westwood Lodge DS0000067836.V314799.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 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 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 X 3 Westwood Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 OP9 Regulation 13 Requirement The registered person must ensure that they make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the home. The medication cabinet should only contain medication relating to the residents at the home. The registered person must ensure that there is stock count of paracetamols at the home. The registered person must ensure that grab rails are located in the corridors. The registered person must ensure that new staff are given structured induction training. (e.g. Skills for Care format). The registered person must ensure that the care staff are given regular formal supervision and a detailed written record is kept. Timescale for action 27/12/06 2 3 4 OP9 OP22 OP30 13 23 18 27/12/06 22/01/07 22/01/07 5 OP36 18 22/01/07 Westwood Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 25 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 4 Refer to Standard OP8 OP12 OP14 OP24 Good Practice Recommendations It is recommended that the home has written daily records that ensure residents health needs are addressed. It is recommended that when residents participate in activities and these are recorded in their daily record sheets. It is recommended that the home contact a local advocacy group. It is recommended that the one resident who could not reach the toilet roll in their bathroom as they used a wheelchair and had aids that prevented them from reaching the toilet roll is able to reach the toilet roll. They also requested that the wardrobe rail was lowered to ensure that they could reach their clothes independently, this should also be addressed. It is recommended that the home check the Personal Identification Numbers of all qualified staff every 6 months. It is recommended that the care staff receive training in communication, dementia, and diabetes. It is recommended that all supervisors receive formal training in supervision. 5 6 7 OP29 OP30 OP36 Westwood Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Lodge DS0000067836.V314799.R01.S.doc Version 5.2 Page 27 - 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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