Care Home: Westbourne Care Home Limited

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What the care home does well What has improved since the last inspection? The owner re registered the home as a limited company on 20th January 2009. This means that we consider the home as a new service. This was the first inspection since the home was re registered. What the care home could do better: Although some risk assessments were undertaken, for falls and moving and handling, people were not assessed regarding their nutritional status and were not always weighed on a regular basis. Closer monitoring should be introduced to ensure that any weight loss is identified quickly. The cupboard used for the storage of controlled drugs did not meet legal requirements and must be replaced. Further consultation should take place with people living at the home to ensure that a range of social events is available that meets their needs and expectations. People told us they were bored and that there was very little happening at the home to provide mental stimulation. The environment for people was homely and comfortable but could be used to better effect, for example using the second lounge more so different groups of people could engage in different activities. Opinions about staffing levels within the home varied and some concerns were expressed about a recent reduction in the numbers of staff on duty in the evenings. This needs to be kept under review to ensure that enough staff are always on duty to provide appropriate support and supervision to people.Westbourne Care Home LimitedDS0000073128.V376566.R01.S.doc Version 5.2 Although the quality assurance report refers to feedback obtained from people living at the home the manager needs to make it clearer how this information is acted on to affect how the service is delivered. Key inspection report CARE HOMES FOR OLDER PEOPLE Westbourne Care Home Limited 41-43 Lea Road Heaton Manor Stockport Cheshire SK4 4JT Lead Inspector Mrs Fiona Bryan Key Unannounced Inspection 15th July 2009 09:00 DS0000073128.V376566.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Westbourne Care Home Limited DS0000073128.V376566.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Westbourne Care Home Limited DS0000073128.V376566.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westbourne Care Home Limited Address 41-43 Lea Road Heaton Manor Stockport Cheshire SK4 4JT 0161 432 3100 0161 431 9001 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) Westbourne Care Home Limited Sylverene Sharon Hackney Care Home 16 Category(ies) of Dementia (16), Mental disorder, excluding registration, with number learning disability or dementia (16), Old age, of places not falling within any other category (16) Westbourne Care Home Limited DS0000073128.V376566.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 people of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP. Dementia - Code DE. Mental disorder, excluding learning disability or dementia - Code MD. The maximum number of people who can be accommodated is: 16. Not applicable Date of last inspection Brief Description of the Service: Westbourne is a care home providing personal care and accommodation for sixteen older people. The registration allows for people who have a mental health or dementia type illness to be admitted. Mr Shortt owns the home and is in day-to-day contact. Mrs Sylverene Hackney is the registered manager. The accommodation is spread over three floors, with each floor having bathroom and toilet facilities. The laundry, office and staff room are situated in the basement. There is a four-person passenger lift, which allows access to all floors, including the basement. To the front of the house is a well-maintained mature garden with seating for the residents. There is also a lawn and patio area to the rear of the house with car parking facilities for visitors. The home is located in the Heaton Moor area of Stockport and is close to local shops and other amenities such as:- cafés, restaurants, public houses, banks, post office and a cinema. There are churches of most denominations, a library and a selection of health centres, dentists and opticians. Stockport town centre, motorway network and public transport is easily accessible. There is a service user guide and statement of purpose available for all prospective residents. A copy of the inspection report can also be viewed. The fees range from £365.00 to £442.00. Westbourne Care Home Limited DS0000073128.V376566.R01.S.doc Version 5.2 Page 5 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. This key unannounced inspection, which included a site visit, took place on Wednesday 15th July 2009. Staff at the home did not know this visit was going to take place. All key inspection standards were assessed and information was taken from various sources which included observing care practices and talking with people who live at the home, visitors, the manager and other members of the staff team. Three people were looked at in detail, looking at their experience of the home from their admission to the present day. A partial tour of the building was conducted and a selection of staff and care records was examined, including care plans, staff duty rotas and medicines records. Before the inspection, we asked for surveys to be sent out to people living at the home and 6 people responded. Comments from these surveys are included in this report. Before the inspection, we asked the manager of the home to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well, and what they needed to do better. This helps us to determine if the management of the home see the service they provide the same way that we see the service. The manager completed the form quite well, although in the area of peoples’ choice and opportunities for social activity her assessment of how the home was achieving this for people was more positive than what we found during our visit. What the service does well: People are assessed before they come into the home to make sure that staff will be able to meet their needs. People said staff were generally kind and treated them well. Everyone that returned surveys said they always or usually got the care and attention they needed and that staff listened and acted on what they said. Comments from people on the day of the inspection included, “Staff are very good – I’ve no Westbourne Care Home Limited DS0000073128.V376566.R01.S.doc Version 5.2 Page 6 quarrel with them”. One person, when asked whether they liked living at the home said they would give it “10 out of 10”. Visitors said they were made welcome and several people told us they were kept informed about any changes to the care needs of their relatives. People said they regularly saw the manager around and about the home and were confident that if they had any concerns these would be addressed. Records showed that the manager and provider took complaints seriously and used them to learn from and improve the service. The home was clean, tidy and comfortable and was fresh smelling. 90 of the staff working at the home had successfully completed National Vocational Qualifications (NVQ). This qualification is obtained following training in providing personal care. This meant staff had a good basic knowledge of the care they needed to provide. A quality assurance report is produced each year to help plan future improvements and staff training. What has improved since the last inspection? What they could do better: Although some risk assessments were undertaken, for falls and moving and handling, people were not assessed regarding their nutritional status and were not always weighed on a regular basis. Closer monitoring should be introduced to ensure that any weight loss is identified quickly. The cupboard used for the storage of controlled drugs did not meet legal requirements and must be replaced. Further consultation should take place with people living at the home to ensure that a range of social events is available that meets their needs and expectations. People told us they were bored and that there was very little happening at the home to provide mental stimulation. The environment for people was homely and comfortable but could be used to better effect, for example using the second lounge more so different groups of people could engage in different activities. Opinions about staffing levels within the home varied and some concerns were expressed about a recent reduction in the numbers of staff on duty in the evenings. This needs to be kept under review to ensure that enough staff are always on duty to provide appropriate support and supervision to people. Westbourne Care Home Limited DS0000073128.V376566.R01.S.doc Version 5.2 Page 7 Although the quality assurance report refers to feedback obtained from people living at the home the manager needs to make it clearer how this information is acted on to affect how the service is delivered. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Westbourne Care Home Limited DS0000073128.V376566.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westbourne Care Home Limited DS0000073128.V376566.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 is not applicable. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were assessed before coming to live at the home to make sure that staff would be able to meet their needs. EVIDENCE: Information about the home, in the form of a statement of purpose and service user guide was displayed on a notice board in the dining room. Six people living at the home returned surveys. All confirmed that they had received enough information about the home to help them make a decision about whether to live there. The care given to three people was looked at in detail. Each person had been assessed before coming to live at the home. Copies of assessments and care plans from the local authority were available and the information had been used to plan how staff would meet each person’s care needs. Westbourne Care Home Limited DS0000073128.V376566.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive the care and support that they need in a way that meets their expectations. EVIDENCE: We looked in detail at the care provided to three people. Each person had records that were kept in three different files. One file contained pre admission information and contracts etc, another file contained some risk assessments and records of visits from other health care professionals and a third file, which was a collective file used for every person living at the home, contained each person’s daily record, care plans and other risk assessments. The manager explained that this file was the one that staff used mostly on a day to day basis. Westbourne Care Home Limited DS0000073128.V376566.R01.S.doc Version 5.2 Page 11 Care plans had been written for each person which mainly addressed their care needs as identified during their assessment. Care plans had been reviewed monthly and many did contain some good detail about peoples’ abilities and preferences. However, the system of record keeping did lead to some duplication and there were 2 different formats of care plans available which we found confusing. Risk assessments had been undertaken for falls and moving and handling. Nutritional assessments had not been carried out and people were not routinely weighed on a regular basis unless it was identified that they were losing weight. The manager said that some people could not weight bear well enough to stand on the scales and the purchase of “sit on” scales was discussed. If this is not possible the manager should speak with the district nurses about other measurements that could be used to monitor peoples’ weight gain or loss. Records showed that people had seen GPs, dentists, opticians and podiatrists. Staff were proactive in referring people to the district nurses if they were concerned about the occurrence of pressure ulcers and several people were using special equipment under the care of the district nurses. We checked how staff were managing medicines for a small number of people. Systems were in place that reduced the risk of errors and records were well maintained. We looked at how controlled drugs (medicines that can be misused) were managed. A special register was used for record keeping and the system was being used correctly. The cupboard used to store the controlled drugs did not comply with current legislation and must be replaced. Most of the people we spoke to said that staff were kind and treated them with respect, although one person did say that one carer had not been very helpful, and she thought this was because the carer was rushing to do other jobs. Another person said, “They look after me well. The staff are very good – I have no quarrel with them”. We spoke with two visitors to the home and they said they were happy with how their relative was being cared for. All the 6 people living at the home that returned surveys said they always or usually received the care and support they needed and they received medical attention when they needed it. Comments included “help is always on hand”, “As the daughter of this resident I can say on most occasions if there are any difficulties I am contacted” and “the care of mum and me has been of a good standard overall”. Staff were very knowledgeable about the care needs of each person living at the home and were able to describe their abilities and daily routines in detail. Westbourne Care Home Limited DS0000073128.V376566.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a lack of provision of social activities that means people do not have opportunities to participate in stimulating and meaningful activities of their choice. EVIDENCE: A designated activities organiser is not employed at the home, as it is part of the role of the carers to identify and meet people’s social care needs. A programme of daily activities was displayed on the notice board in the dining room, which advertised events such as quizzes, bingo and armchair exercises. However, everyone we spoke to said that in reality there was very little to do and a number of people said they got very bored. People told us that they generally spent all day sat in the lounge and only moved to go to the dining room for meals. Westbourne Care Home Limited DS0000073128.V376566.R01.S.doc Version 5.2 Page 13 Social care plans were written for people but these were quite limited. Daily records did not offer any information about how people spent their day. The manager said staff were supposed to record in the diary what activities had been arranged and who had participated, so they could evaluate what people were interested in but the diary only showed that there had been a sing-along on 15/5/09 and a musical morning on 18/5/09. No other activities or social events had been recorded for nearly 2 months. We spent some time sitting in the lounge with people and noticed that staff popped in and out occasionally but didn’t spend any significant time in the lounge sitting down and chatting with anyone. Several times staff came to the doorway and looked in without speaking to anyone before leaving again. Each person living at the home was designated a key worker but staff said that the role of the key worker was mainly to ensure that peoples’ care files were up to date. Further development of the key worker role could help staff to work with people more closely to discover their interests and identify ways in which these could be maintained and developed. The majority of people we spoke to said the food provided at the home was good, although many were unsure as to whether there was a choice of dishes available each mealtime. The manager said that people could read the menu and ask for an alternative if they did not like the main meal on offer. However, the menus were written in quite small print and were pinned to the notice board so many people may not have been able to read them. Consideration should be given to making the menus more accessible earlier in the day so people have the option to request alternatives in plenty of time before the meal is served. The manager did say that because the home is quite small the cook knows individual likes and dislikes and does cater for these. Lunch was served at 12.30 pm in a bright, airy, pleasant dining room with large bay windows overlooking a lovely garden. The meal was roast pork, stuffing, roast potatoes, peas and gravy. Everyone said it was nice and there was very little waste. The atmosphere was relaxed and unhurried with staff allowing sufficient time for people to eat at their own pace and helping where necessary. Westbourne Care Home Limited DS0000073128.V376566.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints are handled well and taken seriously ensuring people feel listened to. EVIDENCE: The complaints policy is included in the home’s statement of purpose. Of the six people living at the home that returned surveys, 5 said they were aware of the complaints procedure and one person said it “hadn’t been discussed at this time” but they had only recently moved into the home. We asked people if they knew who to speak to if they were not happy about something and everyone said they would speak to the manager. People told us they saw the manager regularly and were confident she would sort out any problems. A record of complaints had been maintained, which showed how the complaints had been investigated and responded to. The records showed a good response from the manager and/or the owner, acknowledging and apologising where necessary and informing the complainant what steps had Westbourne Care Home Limited DS0000073128.V376566.R01.S.doc Version 5.2 Page 15 been taken to improve the service. We had been made aware of one of the complaints and were satisfied with how it was dealt with. Most staff had attended training in safeguarding adults and the manager and deputy manager had recently undertaken training in the the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (MCA DOLS). At the time of our visit no one living at the home was subject to an application being made under these requirements. A safeguarding policy was available for staff but this needed reviewing as the information was out of date and did not refer to the Stockport inter-agency policy, which should be followed in the event of abuse or suspected abuse taking place. Westbourne Care Home Limited DS0000073128.V376566.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A clean, pleasant and comfortable environment is provided. EVIDENCE: A partial tour of the home was conducted. The home was safe, clean and hygienic and smelled pleasant and fresh. All the people that returned surveys said the home was always or usually clean and fresh. Comments included, “Cleanliness is something so high a standard at Westbourne”. Evidence was available to show that the required standards in infection control had been achieved. Westbourne Care Home Limited DS0000073128.V376566.R01.S.doc Version 5.2 Page 17 Communal space consisted of 2 lounges and a dining room. All were nicely decorated and one of the lounges in particular was very homely and comfortable, with family photographs and ornaments. Consideration should be given to using this lounge much more. Whilst we were sat in the main lounge some people wanted the television on, whilst others wanted to listen to music; this sort of situation would be easily solved by using the second “quiet” lounge more. The grounds were well maintained and had space for people to sit in the warmer weather. Peoples’ rooms were nicely personalised with photographs and mementos. Some people had brought in items of furniture as many bedrooms were of a good size. The providers had in place a maintenance programme for 2008-2009. Westbourne Care Home Limited DS0000073128.V376566.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive care and support from staff who have the skills to support them correctly. EVIDENCE: There were mixed views as to whether there were always enough staff at the home to meet peoples’ needs. One person said, “Some staff are a bit curt I think it’s because they are rushed”, but another said there were enough staff and someone else said staff came quickly when she needed them. Staff said they thought there were enough staff during the week in the mornings but did have some concerns that staffing had been reduced to only 2 carers from 4pm. Staff had concerns that they could not supervise people sitting in the lounge properly as they had to leave them unattended when they were helping people to go to bed. Also at weekends no cook is employed so staff again felt that this put additional work on them, taking time away from the people living at the home. Westbourne Care Home Limited DS0000073128.V376566.R01.S.doc Version 5.2 Page 19 We looked at two staff personnel files. Both had been recruited following a robust vetting procedure. Training records were kept on individual staff files. We looked at the records for 2 members of staff that had worked at the home for some time. Over the past year they had attended training in moving and handling, food hygiene, and safeguarding adults. Future training needs for staff had been identified in the quality assurance report for 2008-2009. In the AQAA it was reported that 90 of care staff had successfully completed NVQ training. Westbourne Care Home Limited DS0000073128.V376566.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a well managed, safe home. EVIDENCE: The manager has worked at the home for a number of years and has successfully completed the Registered Managers Award. The manager had attended training over the last year to ensure that her knowledge and skills remained up to date. People living at the home all knew who the manager was and said they saw her round and about the home frequently. Westbourne Care Home Limited DS0000073128.V376566.R01.S.doc Version 5.2 Page 21 Meetings for people living at the home were held from time to time. Minutes from the meetings showed that people had been asked for feedback and suggestions about the care they received and what activities and meals they would enjoy etc. A quality assurance report had been produced for 2008-2009, which outlined the environmental improvements that were planned, staff training needs and some views of people living at the home. However, it was unclear from the report how those views were going to be acted on and it is recommended that the plan more clearly defines what actions are going to be taken as a result of feedback. The manager said she administered peoples’ medicines each morning during the week and therefore informally checked that staff were continuing to follow the correct procedures. There was no formal system for checking other aspects of staff practice such as care planning and record keeping and it is recommended that the manager develops a system of audit as this will help her identify any shortfalls early and take corrective action. It was reported that small amounts of money were kept for people to use for sundry expenses. The manager said individual balance sheets were maintained for each person and receipts were kept for all transactions. We noticed that peoples’ care files were kept in the kitchen. The files contained some confidential information and should therefore be kept securely to comply with the Data Protection Act 1998. Regular checks of the building and equipment were carried out to ensure the health and safety of staff and people living at the home. The passenger lift had been serviced in June 2009 and did need some remedial work. The manager said this was being arranged. The record of fire drills showed that the same members of staff often attended whilst others had not taken part in any fire drills. It is recommended that fire drills are carried out at different times of the day in order to ensure that all staff have the opportunity to participate. Westbourne Care Home Limited DS0000073128.V376566.R01.S.doc Version 5.2 Page 22 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 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 2 X X X X X 3 STAFFING Standard No Score 27 2 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 3 Westbourne Care Home Limited DS0000073128.V376566.R01.S.doc Version 5.2 Page 23 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. 1 Standard OP9 Regulation 13 Requirement A legally compliant controlled drugs cupboard must be available to store controlled drugs. This will help to prevent mishandling and misuse. Timescale for action 31/10/09 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 OP8 Good Practice Recommendations People should be weighed regularly and a risk assessment regarding their nutritional status carried out. If staff are unable to weigh people alternative measures to assess weight gain/loss should be used. Further consultation should take place to develop the range of activities and social events provided so they meet peoples’ expectations and abilities. Expansion of the key worker system should be considered to enable staff to work more closely with people to meet their individual DS0000073128.V376566.R01.S.doc Version 5.2 Page 24 2 OP12 Westbourne Care Home Limited goals. 3 OP14 Consideration should be given as to how people can be supported in making choices, for example with regard to meals. The safeguarding policy should be reviewed to ensure it is up to date and in line with the guidance from the Stockport interagency policy. Consideration should be given as to how the communal areas within the home are used. Better use of the second lounge would allow more flexibility for people in how they spent their day. The manager should continue to review staffing levels to ensure that they are maintained at a level that meets peoples’ needs according to their dependency. The manager should develop the quality assurance report to show how she is using feedback from people living at the home to improve the service. A system of audit should be started so the manager can check staff practice and identify shortfalls. 8 9 OP37 OP38 Care files should be kept securely so that data is protected and confidentiality maintained. Fire drills should be carried out at varying times of the 24 hour day to ensure that all staff are able to participate. 4 OP18 5 OP20 6 OP27 7 OP33 Westbourne Care Home Limited DS0000073128.V376566.R01.S.doc Version 5.2 Page 25 Care Quality Commission Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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