Care Home: Leisure Care Home Limited (Westcotes)

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What the care home does well The home is well-run and provides a comfortable and homely place for the people who live there. There is a high-quality standard of care, given in a respectful, dignified and supportive manner by well-trained and safely-recruited staff. Residents are given choice in all aspects of their lives. The manager is available and approachable for them at all times. People have a healthy and balanced diet provided, and they have choice over the food they are given. What has improved since the last inspection? An activity organiser has been employed to provide dedicated time for activities. This is to ensure that all residents living at the home have opportunity to do group and individual activities, especially those unable to go out of the home to attend some of the activities provided in the local community. The improvements to the bathrooms on both the ground and upper floors are now complete so that residents do not have only one bathroom for all of them to use, and they can bathe in pleasant surroundings. The new bath has been installed with a hoist seat to help residents with restricted mobility bathe more easily. Although at the last inspection a key worker system was tried out, it was found not to work well or be suitable for the residents` needs. The manager is assessing this again to formulate a plan that is more appropriate to their needs and wishes. The manager created a quality assurance questionnaire and when it was completed, audited it to show that they are aware of what is needed to improve the service according to the preferences and needs of the people there. Since the last inspection, the manager has been registered by us as being capable to run the home and the home has been re-registered with us although it is still owned by the same provider. CARE HOMES FOR OLDER PEOPLE Leisure Care Home Limited (Westcotes) 70 South Parade Skegness Lincolnshire PE25 3HP Lead Inspector Vanessa Gent Unannounced Inspection 29th July 2008 09:00 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 Leisure Care Home Limited (Westcotes) DS0000071304.V369017.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. Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Leisure Care Home Limited (Westcotes) Address 70 South Parade Skegness Lincolnshire PE25 3HP 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) 01754 610616 01754 610616 rebeccaphilpott@btconnect.com Leisure Care Homes Ltd Mrs Rebecca Leigh Philpott Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP The maximum number of people who can be accommodated is 17 This is a new service although it existed in its Date of last inspection present capacity prior to the latest registration. It was last inspected on 04/04/07. Brief Description of the Service: Westcotes is a privately-owned care home, providing personal care for up to seventeen people of both sexes over the age of 65 years. The home has been trading under the same management for nearly twenty years but has recently been re-registered to ensure it is in line with the commission’s regulations. The home is situated on the Promenade at the south end of the town, overlooking crown bowling greens and public gardens and within walking distance of the seafront and various community facilities, including shops, pubs, seafront hotels and entertainment centres. The home has been converted and extended from former holiday flats to provide accommodation on three floors with a stair lift giving access to both the upper floors. There are sixteen single rooms and one double. Nine of the bedrooms have an ensuite toilet and wash basin and two have full bathrooms. There is one double bedroom. Communally, there is a small sun lounge at the main entrance, two lounges and a separate dining room, two bathrooms, one on the ground and one on the first floor and four toilets. The home has a small open-air area to the side of the house but this is not accessible for people to use. At the front entrance to the home, leading from the pavement through a small-concreted area, residents can sit in the small sun lounge. Some of the bedrooms overlook the sea, and have a small balcony for individual residents to sit on. There is no car parking available to the front of the house except on the street, which is restricted during the holiday season. However, there is a large pay and display car park nearby. Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 5 The fees for residential care at the time of the inspection visit range from £351 to £500 per week. People pay for their own hairdressing and chiropody charges, personal newspapers and magazines. Information about these costs as well as the day-to-day operation of the home can be found in the home’s statement of purpose and service user guide. These documents and a copy of the last inspection report are available to people who live there and those interested in coming to live at the home. The home’s philosophy of care is to treat people as individuals and give them as much independence, with support as required, as they want and choose. On the day of the inspection visit, fifteen people were living at the home. Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. An unannounced visit was made to the home as part of a key inspection. It started at 09.15 and lasted six hours. The manager had completed a self-assessment questionnaire called the Annual Quality Assurance Assessment (AQAA) giving important information about the service, and this was used to contribute to the inspection process. Questionnaires had been returned from six residents, some of whom had been supported to complete them by a staff member or relative. We also received surveys from two relatives and one staff. Information from these sources, as well as that which we hold about the service, was used to plan the visit and produce this report. The main method of inspection used is called ‘case-tracking’. This involves choosing a proportion of residents, and tracking the care they receive through the checking of records, discussion with them, the care staff, any visitors and observation of care practices. Our visit to the home focused on whether key standards had been met and to check on how people feel about the service provided. The care received by four people was followed in detail to ensure their health, safety and welfare needs were fully met and that they were supported to maintain their dignity, autonomy and choice. We spoke with all the staff on duty, more than half of the fifteen residents, including those being case-tracked, and two visitors to the home. People spoke about their experience of living at the home. Any comments we received will be mentioned in the main body of this report. The personal records, general house records and staff records were looked at and the way care was given to the people was observed. We saw most areas of the home and sampled the main meal. The manager was present throughout this inspection. What the service does well: Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 7 The home is well-run and provides a comfortable and homely place for the people who live there. There is a high-quality standard of care, given in a respectful, dignified and supportive manner by well-trained and safely-recruited staff. Residents are given choice in all aspects of their lives. The manager is available and approachable for them at all times. People have a healthy and balanced diet provided, and they have choice over the food they are given. What has improved since the last inspection? What they could do better: Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 8 The owner of the home visits often, up to three times a week. She records very briefly what she checks in the environment in a ledger book. However, she does not visit on a monthly, unannounced basis with the intention of formally checking aspects of the whole service provided and speaking with people involved with the home, nor record this on an appropriate form. This is required by law in order to demonstrate that the providers regularly assess, and show that they know, what is being provided, what is happening in the home and what is needed for improvement. Staff told us that the manager is always available, “her door is always open” and she speaks with them informally every day. However, formal one-to-one meetings with staff have not been held as often as we recommend and they have not been documented or recorded in any way. This means that there may not be any records or evidence to show how often, if at all, that they took place. 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. Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 9 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 Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 10 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, 3 (Standard 6 N/A) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with enough information to help them choose if they want to live at the home. The assessment processes used help to ensure that the care team can meet each new person’s individual needs. EVIDENCE: The Statement of Purpose and Service User Guide we saw are up-to-date and available for residents and those interested in coming to live at the home. In the manager’s assessment form, she states, “we offer short-term holiday breaks”. This helps people to decide if they want to live at the home permanently, at a later stage of their lives. The care plans showed that pre-admission assessments are done for anyone choosing to come to live at the home or staying for respite care, to ensure the staff can meet the needs of all the people who live there. Residents, in the Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 11 surveys we sent them, confirmed that they had enough information about the home before they moved in. One person told us that their daughter came to look at the home and decided it would be appropriate for her mother’s needs and wishes. The manager does not provide an intermediate care service. Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 12 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. Residents are cared for appropriately and with dignity, and their needs are met by clear care plans, regular liaison with other professionals and safe medication practices. EVIDENCE: The care plans we looked at detailed the residents’ health, welfare and social needs and preferences. Care staff told us they know what is in the care plans. The senior staff write in them and review them monthly. We saw evidence of residents and their representatives agreeing to the care plans. One resident told us they know all about their care plans but is not bothered to see them regularly as they know staff care well for them and that if they were ill, they would call the doctor or take them to the hospital and inform their relative. Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 13 The care plans, people’s comments and a healthcare professional indicated to us that there is good contact with community healthcare professionals, so that people’s health is monitored and their needs are treated appropriately. A healthcare professional told us that the manager and staff liaise well with people from the local doctor’s surgery, calling the surgery “straight away”. This includes the times of patient reviews, for pressure area issues, when someone becomes poorly and at the end of life. They said that in all these areas, the staff are very good, very friendly, very helpful. Everyone living at the home requires assistance to take their medications. Medication practices were observed. Only staff who have had training from the supplying pharmacist give out the medicines; certificates in the staff files and the previous inspection report also confirmed this. The pharmacist audits the medication practices regularly and reports back to the manager. We saw the last monitoring review, which was satisfactory. The manager told us, in the AQAA, that they “respect each individual’s privacy and dignity by taking their views into account and the staff to continue to treat them as a real person and giving all a quality of life they deserve”. She told us she reminds staff to “treat residents in their care the same as you would your own family or even yourself”. She told us, and the feedback from residents in their surveys and verbally to us, confirmed that the staff are “getting it right”. People told us that staff always listen to them and act on what they want. There was a positive rapport between staff and the residents throughout the visit time at the home. Leisure Care Home Limited (Westcotes) DS0000071304.V369017.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 are able to make their own choices about how they want to live their lives, and what they want to do. They benefit from a variety of activities and a healthy diet that is based around their needs and preferences. EVIDENCE: The manager’s self-assessment said, “We have purchased a new wide-screen television with freeview channels. We have changed the lounges round as more residents have indicated that they like to sit quietly rather than watch TV.” “We intend to continue to find new activities and outings, more social interests.” In the surveys we received, people responded that mostly they have enough activities. Some of them attend clubs and activities outside of the home. For others, the activity organiser and staff accompany them on walks or trips by wheelchair around the vicinity of the home, along the Promenade, to the beach or to the shops. One relative responded to our survey saying, “I feel it would be good for residents to be taken out more, especially during summer months.” But residents told us they do go out whenever they want, often Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 15 accompanied by staff. During our visit to the home, the activity organiser went out several times with people, some in wheelchairs, during the afternoon and a resident was collected by mini-bus to attend a weekly club. Visitors told us they are always made very welcome at the home and are included in communal activities and events that the staff arrange. Residents told us they have choice in everything, wherever possible and this was confirmed at the visit by staff asking what residents wanted. Everyone agreed that the food is “superb”, “delicious”, “excellent”. We sampled the lunch meal, a homemade casserole, which included plenty of fresh vegetables and the pudding was homemade and tasty. Very little food was left on anyone’s plates at the meal and all the residents said it was lovely. Although there is only one choice of main course, residents told us they can and do have alternatives if they do not like or fancy the main course. Salads or jacket potatoes could also always be chosen as an alternative. Residents who needed some assistance with the lunchtime meal were treated with dignity, by staff who chatted with them and were patient. Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 16 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. Residents are protected by knowing they can always voice any concerns and will be taken notice of, and by staff who are trained to prevent abuse and who are conscientious and caring to the residents at all times. EVIDENCE: When, in the AQAA, we asked what the manager did well, she replied, “continue not getting complaints” and “keep up with training”. In the past year, the manager has “found better a training package to help protect the residents”. Neither we nor the manager or owner directly have received any complaints or issues regarding people’s safety since the last inspection. The home has a file with many compliment and thankyou letters and cards in it to show how much people appreciate the care given to residents who have lived there. At the visit to the home, staff files showed, and the staff and manager confirmed, that they have received training to safeguard the residents. Staff told us, “we all work as a close team and have confidence in each other”. One staff member said that the manager has discussed with them about the outcomes of the surveys so that improvements can be made to the service provided to keep residents safe at all times. Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 17 Residents said that they felt safe and well-cared for at the home and the “staff are lovely, very caring”. Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 18 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. The manager provides a comfortable, clean, well-maintained environment to ensure the residents are cared for safely and feel ‘at home’. EVIDENCE: We saw that the home was in a clean, tidy and fresh state, and it was confirmed by the residents and some visitors to the home that this is always the case. Some residents who have lived at the home for many years told us that although things change often, they are happy living there and wouldn’t want to live anywhere else. The outstanding requirement for finishing the improvement to the communal bathrooms has been acted upon. Improvements have completed to the bathrooms on both the ground and upper floors so that residents do not have only one bathroom for all of them to use, and they can bathe in pleasant Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 19 surroundings. The new bath has a hoist seat to help residents with restricted mobility bathe more easily. A person told us that they now have as many baths in the week as they want. Risk assessments were in place for health and safety measures in the home, as confirmed in the manager’s assessment form. However, at the visit to the home, maintenance records did not fully describe how health and safety was maintained or individual repairs and replacements completed. The need to document what was required and what was accomplished was discussed with the manager. She agreed to create a file for this purpose. Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 20 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 good. This judgement has been made using available evidence including a visit to this service. Residents are in safe hands with well-trained and caring staff to ensure their comfort and well-being is maintained. EVIDENCE: People told us that there are always enough staff on duty and that they come straight away when a residents needs them. One resident told us, “the staff are very, very good to me. They spoil me, and they are very patient with some of the others who need extra attention”. They said there are always enough staff on duty, “definitely! Even when people are demanding.” The staff duty rotas indicated there was an appropriate number of staff on duty, taking into account the levels of needs of the fifteen residents. In the surveys received from residents, all were positive about the level and quality of care given. At the visit to the home, we were told that staff are “very respectful, jovial”, “a good bunch”, “wonderful”. We saw residents being treated with respect and staff chatting with them in a gentle, friendly and cheerful manner. A health care professional told us that all the staff show a very caring nature to the residents and are always very helpful. They said that staff are aware of the residents’ needs at all times and liaise with them as and when necessary. Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 21 Staff say they all work as a “close team”, “get on very well together”, “good buddies together” and are supported by the manager in their duties. Recently-employed staff told us that their recruitment and induction training had prepared them well for the tasks they had to do and to keep the residents safe and happy. The staff files confirmed that the manager’s recruitment process was satisfactory. In her self-assessment, the manager stated that “staff recruitment is followed step-by-step to protect clients’ and others’ safety and equality”. Staff told us, and their files confirmed, that they are well trained. We also saw a staff training matrix the manager had developed to monitor the staff training programme. Staff said that the manager had sourced training sessions for them and encouraged them to attend. The manager told us that she and two senior staff have attended a course on understanding the Mental Capacity Act to help them to appreciate better the needs and individuality of the people who live at the home. Staff told us they also have got or are doing the nationally-recognised qualifications that help them do their job better and more confidently. Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 22 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, 32, 33, 35, 36, 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 run in the interests of the residents and staff. Residents feel safe, happy and enjoy living at the home. Staff are happy in their jobs and feel supported by the manager. EVIDENCE: The manager has been in post since 2004 and has achieved her Registered Manager’s Award to enable her to care more effectively for the people in her care. The manager told us that she works mostly in her managerial role, unless sickness or staff holidays leaves the caring or catering staff short of a worker. She recognised that if this happens too often, it may affect the quality and Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 23 quantity of management work she can do, and that this can cause her to “get behind with the paperwork sometimes”. Everyone we spoke with and who returned their surveys told us that the manager is approachable and has an ‘open-door’ policy. The manager said she goes round to all the residents every time she is on duty to have a word with them. Residents confirmed that the manager often speaks with them and they think “she is lovely”. Staff said the manager is “brilliant” and “very approachable”. The manager gave out annual quality assurance questionnaires to the residents. From these, she completed charts with graphs to show areas that were satisfactory and those areas that needed reviewing. She then was able to discuss the issues with the provider, residents and staff to make adjustments according to the residents’ wishes and needs. In her assessment form, the manager told us she is planning to hold “more group meetings with clients and families and possibly have a committee where issues can be raised.” Records we looked at showed that the owners visit frequently to check the environment is safe for the people to live in. However, there are no formalised records to show that the owners know what is being provided, what is happening in the home, what people think of the service provided and what is needed for improvement. Most residents choose to look after their own finances and personal allowances. Where people have asked for support, the manager holds personal allowances and she keeps clear records with receipts for each transaction. The annual appraisals of staff have mostly been completed and documented. The manager and staff told us that one-to-one meetings are held for staff but these have not been regular or as frequent as we recommend. However, staff told us that she is always available and speaks with them informally every day, although this is not documented or recorded in any way. The manager realises that the supervision sessions with staff need to be formalised so that staff feel more valued and records give evidence that they have taken place. We saw from the manager’s self assessment form, and other records at the home, that health and safety measures are checked and documented as well as the policies and procedures being updated annually. Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 24 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 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 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 X 3 Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 25 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 OP36 Good Practice Recommendations It is recommended that staff receive supervision sessions at least six times a year and that they are documented and signed by both parties. This is to ensure the staff feels supported and valued in their work and that they are working safely at all times. Leisure Care Home Limited (Westcotes) DS0000071304.V369017.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Leisure Care Home Limited (Westcotes) DS0000071304.V369017.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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