Inspection on 23/01/07 for Westwood Park

This inspection was carried out on 23rd January 2007.

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

The inspector 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 Park 18/01/10

Westwood Park 27/10/09

Westwood Park 20/01/09

Westwood Park 08/11/05

Westwood Park 07/07/05

Westwood Park 07/12/04

Westwood Park 17/08/04

Westwood Park 03/03/04

Westwood Park 19/11/02

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Westwood Park 4 Langholm Close Beverley East Yorkshire HU17 7DH Lead Inspector Diane Wilkinson Unannounced Inspection 23rd January 2007 10:00 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 Park DS0000019737.V326432.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 Park DS0000019737.V326432.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westwood Park Address 4 Langholm Close Beverley East Yorkshire HU17 7DH 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) 01482 862170 01482 887860 Londesborough Health Care Limited Mrs Kathleen Mary Monica Foley Care Home 51 Category(ies) of Dementia - over 65 years of age (51), Old age, registration, with number not falling within any other category (51) of places Westwood Park DS0000019737.V326432.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th November 2005 Brief Description of the Service: Westwood Park is a privately owned care home that is registered to accommodate and care for 51 older people, including those with dementia. The company own another care home in a nearby town. Information about the home is provided to service users and others in the home’s statement of purpose and service user guide. Fees paid range from £328.80 to £550.00 per week and there is an additional charge for hairdressing, beauty therapy, private chiropody, toiletries and newspapers. Private accommodation is provided in 47 single rooms and two shared rooms, and there are various communal rooms available. The home is close to local amenities such as shops, banks, cafes, public houses and transport facilities. All areas of the home are accessible to service users via the provision of a passenger lift, a stair lift and ramps. The garden has been specially designed to meet the needs of the people living at the home and is attractive and easily accessible. There is a small car park available for visitors and staff. Westwood Park DS0000019737.V326432.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information obtained from the pre-inspection questionnaire completed by the registered manager, information received by the Commission for Social Care Inspection (CSCI) since the last inspection of the home and from the site visit on the 23rd January 2007. This unannounced site visit is part of a key inspection and was undertaken by one inspector over one day; the site visit commenced at 10.00 am and finished at 4.30 pm. The site visit consisted of a tour of the premises and examination of documentation, including five care plans. On the day of the site visit the inspector spoke on a one to one basis with three residents, three relatives, three members of staff, the registered manager and the registered provider. Surveys were sent out to eight members of staff, three GP’s and one care coordinator. Six were returned from staff; these evidence that staff understand the complaints and adult protection procedures that are in place at the home, and that staff understand their role as key worker. No surveys have been returned from health and social care professionals. Following the site visit to the home, the inspector spoke to district nursing staff. They said that staff at the home ask for advice appropriately, follow any advice given by health care professionals and provide a high standard of care to service users. Feedback about the responses already received was given to the registered persons (anonymously). Surveys were sent to 9 relatives a few days prior to the inspection and none had been returned at the time of completing this report. Feedback will be given to the registered manager before this report is published. Comments from discussions with service users and others, and respondents in surveys, will be included throughout the report (anonymously). The inspector would like to thank service users, staff, relatives, the registered manager and the registered provider for their assistance on the day of the site visit, and to everyone who spoke to the inspector or responded to a survey. What the service does well: Service users are assessed prior to their admission to the home and only offered accommodation if their assessed needs can be met. Care planning at the home is good, and there is evidence that service users or a representative are involved in this process. Westwood Park DS0000019737.V326432.R01.S.doc Version 5.2 Page 6 District nurses state that the standard of care provided by staff at the home is very high, and that staff always follow advice offered by nursing staff. The home is comfortably furnished, clean and in good decorative order. Recruitment and selection arrangements for the home are robust and ensure the safety of service users. Service users and visitors told the inspector that they are happy with the laundry service provided and that their clothes are well cared for. 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 Park DS0000019737.V326432.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 Park DS0000019737.V326432.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): 3 (Standard 6 was not assessed as there is no intermediate care provision at the home) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are only admitted to the home following a needs assessment that evidences that their current care needs can be met. EVIDENCE: The inspector examined the records for two new service users. These included pre-admission assessments, admission forms, biographical assessments and moving and handling assessments as well as other assessment information. There is evidence in care plans and from discussions with service users and relatives that service users are visited at their current address by staff at the home, that service users or their relatives visit Westwood Park and that some service users have respite care at the home prior to making a decision about Westwood Park DS0000019737.V326432.R01.S.doc Version 5.2 Page 9 permanency. One service user had been invited to stay at the home for short periods during the day prior to their respite stay at the home. The registered persons told the inspector that service users are only admitted to the home if their needs assessment indicates that their specific care needs can be met. Westwood Park DS0000019737.V326432.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of service users are met in a way that respects their privacy and dignity. EVIDENCE: The inspector examined five care plans; these included a copy of the community care assessment and care plan undertaken by the local authority Social Services Department, where appropriate, and a copy of the home’s own assessment. Appropriate risk assessments have been undertaken by staff at the home, including the risk of falls, dependency levels and moving and handling. Key workers record a monthly summary of the care provided to each service user, and this includes information about activities undertaken, health care needs, contact with health and social care professionals and visits by family and friends. Care plans have been reviewed; some care plans have been reviewed by Social Services, some by the home and some by both. Risk Westwood Park DS0000019737.V326432.R01.S.doc Version 5.2 Page 11 assessments are also reviewed. Service users who are able to do so sign some of their care planning documentation as evidence that they are involved in the care planning process. A record is kept of all contact with health care professionals, including the reason for the contact and any outcome. Relatives spoken to on the day of the site visit expressed satisfaction with the care offered by staff at the home; they said that they are kept informed of important events regarding their relative and that they feel confident that their relatives are receiving the best of care. District nurses told the inspector that care staff ask for advice if they are unsure about an area of care or practice, and that they follow any advice given. They said that the standard of care provided to service users is very high and that they have good working relationships with managers and staff. Continence care and pressure care are promoted at the home. Some service users have been provided with special pressure care equipment such as mattresses and cushions. A service user’s individual needs regarding this type of care is recorded in assessments and care plans, and reviewed appropriately. Nutritional screening takes place and this includes service users being weighed on a regular basis. One of the district nurses told the inspector that staff at the home are particularly skilled in caring for service users with a terminal illness, and always follow advice given by nursing staff. On the day of the site visit, the medication system was being changed, i.e. the services of a new pharmacist had been secured and medication was going to be supplied in blister packs rather than a ‘nomad’ pack. This was to ensure that the two homes owned by the organisation were using the same medication system. The inspector examined medication records and storage arrangements; both were satisfactory, apart from some minor omissions in recording, i.e. when a service user refuses medication. Staff were reminded that there should be a signature on medication administration records each time medication is due to be administered. The arrangements for the storage, administration and recording of controlled drugs are satisfactory. The inspector was informed that a new medications fridge had been ordered; staff were reminded that temperatures need to be taken on a regular basis and that these should be recorded. The inspector observed medication being given to service users – all were provided with a drink with which to take their medication. All service users were observed by staff to ensure that they actually took their medication. The pre-inspection questionnaire submitted to the Commission for Social Care Inspection (CSCI) prior to the inspection recorded that all staff that administer Westwood Park DS0000019737.V326432.R01.S.doc Version 5.2 Page 12 medication have undertaken accredited training; this was confirmed on the day of the site visit in individual training records seen by the inspector. The need to treat service users with respect and to maintain their privacy and dignity is included in staff induction training. The inspector observed that staff treat service users with respect and that their privacy is maintained as far as is possible; service users were assisted with eating their meals and with visiting the toilet in a sensitive manner. This was confirmed by service users and relatives on the day of the site visit, and in discussion with staff. Westwood Park DS0000019737.V326432.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are given the opportunity to engage in a variety of activities and to maintain contact with family and friends. They are assisted to exercise choice and control over their lives and receive a wholesome, appealing and balanced diet. EVIDENCE: The inspector observed that service users are able to spend the day as chosen by them. Some service users remain in their room and some sit in the lounges. Service users are able to choose where to take their meals; most use one of the home’s two dining rooms but some take their meals in their bedroom. Care plans include life histories and key worker notes record any activities undertaken by service users. Service users are encouraged to follow interests and leisure pursuits, and are supported to go out with relatives and staff. Service users are also supported to form appropriate friendships within the home. Westwood Park DS0000019737.V326432.R01.S.doc Version 5.2 Page 14 One of the district nurses told the inspector that one of her patients likes to stay in bed quite late; this is always accommodated by the home. A movement to music class is held every week and someone visits the home to play the piano once a week. Service users can choose whether or not they wish to attend these sessions. Other service users prefer to spend time on their own watching wildlife in the garden, knitting, watching TV or reading. Service users told the inspector that they are able to get up and go to bed when they choose. Visitors are made welcome at the home. Some stay with relatives for a large part of the day and some take their relative out. They told the inspector that they are always made welcome and are able to be involved in the day-to-day lives of service users if they wish to do so. A volunteer is currently working at the home; the inspector was informed that a CRB check and two written references have been obtained for this person. The volunteer takes service users to the local pub and sits with other service users talking about their hobbies. The inspector observed the serving of lunch in one of the lounges and in one of the dining rooms. Service users that needed assistance had their lunch in the lounge and were assisted appropriately by staff. More independent service users had their lunch in the dining room and minimal assistance was provided. Service users chatted over lunch and the inspector observed that lunchtime was promoted as a pleasant occasion for service users. There is a menu on display and this evidences that there is a choice of meal at each mealtime; this was confirmed by service users, staff and relatives on the day of the site visit. One member of staff said, ‘The menu is a healthy balance of good old fashioned food. The presentation is good and Christmas dinner was an exceptional 4 course meal enjoyed by all’. Westwood Park DS0000019737.V326432.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected from abuse, and they and their relatives can be confident that their concerns will be listened to, taken seriously and acted upon. EVIDENCE: There are appropriate policies and procedures in place to inform service users and others how to make a complaint and how it will be dealt with by the home; these are made available for service users, relatives and staff. Service users and relatives told the inspector that they would speak to a member of staff if they had a concern or a problem. Relatives told the inspector that they were confident that their concerns would be listened to and acted upon. The responses received in staff surveys evidence that staff understand the home’s complaints procedure and that they would use it themselves if needed. Staff stated that they have approached the management with issues, and that these have been dealt with well and promptly; one member of staff said, ‘I felt at ease’. The inspector examined the complaints log. The two complaints that the CSCI was aware of were recorded in the complaints log. The inspector noted that only brief entries were made about the investigation undertaken and the actual Westwood Park DS0000019737.V326432.R01.S.doc Version 5.2 Page 16 outcome. However, in discussion with the registered provider and the registered manager, it is apparent that a lot of effort went into undertaking the investigation. They were advised that there should be a full record of the complaint made, the investigation undertaken and any outcome to evidence that the complaint was dealt with in a satisfactory manner and this was agreed. Complaints made by service users are recorded in the complaints log – the most recent was fully investigated and recorded. Comments made in staff surveys evidence that there is an understanding of adult protection policies and procedures. Training records evidence that all staff have undertaken training on adult protection. The pre-inspection questionnaire records that managers have undertaken adult protection awareness training during the last 12 months; this was confirmed on the day of the site visit. There have been no reported allegations or incidents of abuse at the home since the last inspection. Westwood Park DS0000019737.V326432.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, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe, well-maintained and clean environment. EVIDENCE: It was snowing on the day of the unannounced site visit; the inspector noted that the path to the front door of the home had been ‘salted’ to make it safe for service users, staff and any visitors to the home. The home provides comfortable, homely and attractive accommodation for service users. Furnishings and décor are comfortable, domestic in nature and of good quality. The conservatory and all lounge areas overlook either Beverley Westwood or the attractive garden, giving service users plenty of access to sunlight and the opportunity to observe wildlife. Westwood Park DS0000019737.V326432.R01.S.doc Version 5.2 Page 18 There is a maintenance programme in place as well as a maintenance list recording all of the day-to-day jobs that are undertaken by the handyman. The inspector noted that some of the work recorded in the maintenance programme had been undertaken, and the handyman was present on the day of the site visit laying new flooring in the upstairs dining room. The inspector observed that all service users have been asked if they would like the lock on their bedroom door to be changed. This has been recorded as part of a risk assessment. The home was clean and hygienic on the day of the site visit and there were no strong odours. The inspector saw the laundry facilities at the home; ample washing machines and dryers are provided to ensure that laundry is dealt with effectively. There is a separate sluice facility - this was being refurbished at the time of the site visit. A domestic assistant is employed to undertake laundry duties and this arrangement is working well. Service users and visitors told the inspector that they are happy with the laundry service provided and that their clothes are well cared for. Westwood Park DS0000019737.V326432.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of trained and competent staff employed to ensure that service users’ needs are met, and service users are protected by the home’s recruitment policies and practices. EVIDENCE: Sample staff rotas were sent to the CSCI with the pre-inspection questionnaire. The rota records the actual role of each member of staff, and that there are five care staff on duty each morning and four staff on duty each afternoon/evening, plus two managers (Monday to Friday). On the day of the site visit the inspector observed that the staff recorded on the staff rota were actually on duty. There are three staff on night duty. A cook, a kitchen assistant, two domestic staff and a laundry assistant are employed in addition to care staff; this enables care staff to concentrate on care duties rather than domestic duties. Service users, relatives and staff told the inspector that there are sufficient staff on duty to meet the needs of service users, although one member of staff said that they did not have enough time to spend with residents. Westwood Park DS0000019737.V326432.R01.S.doc Version 5.2 Page 20 Six care staff have achieved NVQ Level 2 or above in Care. A further 10 staff are trained nurses, although the registered persons need to establish whether the qualifications held by these nurses, some of who were not trained in this country, are recognised by the Nursing and Midwifery Council and/or the General Social Care Council. Until this is clarified, it will not be possible to determine if the requirement for 50 of care staff to be qualified to NVQ Level 2 in Care or equivalent has been met. The inspector examined the recruitment records for a newly appointed member of staff and the records for other staff members. These evidence that thorough recruitment practices are followed at the home. All staff are issued with a contract of employment. Copies of work permits were seen for the staff that have been recruited from other countries. Staff undertake a thorough induction programme and some core training is undertaken as part of induction and again as ‘refresher’ training. There is a training and development plan in place. The pre-inspection questionnaire records that staff have undertaken various training programmes over the last 12 months, including moving and handling, safe handling of medicines, basic first aid, health and safety and intermediate food hygiene. This was confirmed by staff and by records held in staff files. Staff received training on the newly introduced medication system on the day of the site visit to the home. Eleven staff are booked on First Aid Appointed Person training in March 2007 and a fire training session is booked for February 2007 – all staff are expected to attend. Individual training records, including certificates of achievement, were seen in staff files. Westwood Park DS0000019737.V326432.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, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed, including the handling of service user monies, and the health, welfare and safety of service users and staff are protected. Service users and others are able to affect the way that the home is operated. EVIDENCE: The registered manager is a qualified nurse and has maintained her registration with the Nursing and Midwifery Council. The registered provider and the registered manager have almost completed the NVQ Level 4 Registered Manager’s award; they expect to finish by the end of July. The registered manager keeps her practice up to date; she recently attended Westwood Park DS0000019737.V326432.R01.S.doc Version 5.2 Page 22 Intermediate Food Hygiene training and is due to update her medications training shortly. There are clear lines of accountability within the home and the registered manager is responsible for only one home. There is an effective quality monitoring system in place. Surveys had been sent to service users and relatives in September 2006 – these are in the process of being analysed and the results will then be published on the home’s notice board. Staff meetings and resident/relative meetings are held twice yearly. Staff are invited to add items for discussion to the agenda and told the inspector that they are able to raise any concerns, problems or suggestions and that these are listened to and acted upon appropriately. The most recent resident/relative meeting was poorly attended but relatives that did attend recorded that they welcomed the opportunity to raise their views and be involved in such meetings. The home has achieved QDS Parts 1 and 2 (the local authority’s quality assurance scheme). There is a Quality Assurance calendar in operation and an annual development plan entitled ‘Westwood Park Business Objectives 2006/7’ has been produced. Health and safety audits take place within the home as part of the quality monitoring system. The home holds personal allowances for some service users. The inspector examined the records held and associated monies, and all were found to be accurate. Receipts are obtained for monies spent, and records include a ‘running total’ and the balance of monies held. There are relevant health and safety policies and procedures in place, and there is a record of safe working practices, including risk assessments. There is evidence that staff undertake health and safety training on an on-going basis. All equipment is well maintained, including the passenger lift, stair lifts, bath hoists and mobility hoists. The fire alarm system has been serviced by a qualified contractor and in-house fire safety checks are satisfactory. Oil boilers were serviced in January 2006 and electric installations were checked in November 2006. Portable appliances are tested on a regular basis. Water temperatures are regulated and these are tested (and recorded) on a regular basis to control the risk of scalding and the risk of Legionella. Accidents are recorded in the accident book and the inspector noted that these were cross-referenced to care plans. Most of these had been forwarded to the CSCI as a notification under Regulation 37 of the Care Homes Regulations 2001. However, there were some omissions – it is recommended the CSCI should be notified of any accident or incident that requires input from a health care professional. Westwood Park DS0000019737.V326432.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 X X 3 X X N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Westwood Park DS0000019737.V326432.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard OP9 Good Practice Recommendations More care should be taken to ensure that medication administration records are signed on every occasion that a service user refuses the medication that is offered to them. The registered persons should establish if the nursing qualifications held by care staff are recognised by the Nursing and Midwifery Council. The registered manager should continue with training to ensure that NVQ Level 4 in Management is achieved by the end of July 2007. Most accidents and incidents are reported to the CSCI appropriately but the registered persons should ensure that this occurs on all occasions that accidents have required any input from health care professionals. 2. 3. 4. OP28 OP31 OP38 Westwood Park DS0000019737.V326432.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Park DS0000019737.V326432.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!