Care Home: Westbury Gardens (Residential Suites)

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What the care home does well Generally the home was found clean, warm, well lit and free from unpleasant odours. The atmosphere of the home was noted to be relaxed; individuals living in the home looked well cared for in their homely environment. Staff were interacting with service users in an informal, respectful, personalised and dignified manner. Prospective service users have detailed needs assessment using different tools before admission to the Home to ensure that the home is able to meet the individual`s need. The deputy manager stated that the Home ensures that a Service Users Guide is sent or given to the prospective service user or their relatives when they make enquires to enable them to make an informed choice about moving to the Home. Individuals spoken with at this visit confirmed this information. Evidence from the visitors book shows that families, friends, relatives and other visitors are encouraged to visit the home to ensure that regular contact is maintained. Relatives spoken with stated that they were satisfied with the care provided for their loved ones, staff are kind and that they are able to visit the home at any time without restrictions. There are ongoing training courses to enable staff to meet individual service users needs and to ensure that staff are aware of how to protect individuals from harm and abuse.Individuals living in the home are enabled to complain through a robust complaints procedure and the home would ensure that all complaints are thoroughly investigated and all required action (if any) implemented. What has improved since the last inspection? A review of the last inspection requirement in relation to medication administration evidenced that this has been met in order to provide adequate protection to the individuals from medication errors. CARE HOMES FOR OLDER PEOPLE Westbury Gardens (Residential Suites) Falcondale Road Westbury On Trym Bristol BS9 3JH Lead Inspector Grace Agu Unannounced Inspection 24th January 2008 09:40 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 Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.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. Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westbury Gardens (Residential Suites) Address Falcondale Road Westbury On Trym Bristol BS9 3JH 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) 0117 9079971 0117 9507913 moirapayne@btconnect.com Westbury Care Limited Mrs Penelope Anne Brown Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 22 persons aged 65 years and over requiring personal care 21st March 2007 Date of last inspection Brief Description of the Service: The Westbury Gardens Residential Suites are located within the grounds of Westbury Nursing Home and is operated by the Westbury Care Limited Group. It is registered to provide accommodation for 22 people, over 65 years, who require personal care. The building is a one-storey bungalow design and each bedroom has an en suite facility. It is located a short walk from the village of Westbury-on-Trym, where there are local shops, pubs and other amenities. It is also close to public transport. The fees charged for staying in a single room at the Home are £500 a week.The fee to stay in a double room is £750 a week. Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit which was undertaken as a part of akey inspection over eight hours to review the requirements made at the last inspection and also to review the care practice to ensure that it is in line with the legislation and that best practice is followed at the home. At the last inspection one requirement was made in relation to Medication Administration. It was pleasing to note that the home has made efforts to ensure that the requirement had been met. We met with Mrs Penny Brown the home manager and two deputy managers. Whilst touring the building, we spoke with a number of service users, staff, four relatives and a number of records were viewed. What the service does well: Generally the home was found clean, warm, well lit and free from unpleasant odours. The atmosphere of the home was noted to be relaxed; individuals living in the home looked well cared for in their homely environment. Staff were interacting with service users in an informal, respectful, personalised and dignified manner. Prospective service users have detailed needs assessment using different tools before admission to the Home to ensure that the home is able to meet the individual’s need. The deputy manager stated that the Home ensures that a Service Users Guide is sent or given to the prospective service user or their relatives when they make enquires to enable them to make an informed choice about moving to the Home. Individuals spoken with at this visit confirmed this information. Evidence from the visitors book shows that families, friends, relatives and other visitors are encouraged to visit the home to ensure that regular contact is maintained. Relatives spoken with stated that they were satisfied with the care provided for their loved ones, staff are kind and that they are able to visit the home at any time without restrictions. There are ongoing training courses to enable staff to meet individual service users needs and to ensure that staff are aware of how to protect individuals from harm and abuse. Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.S.doc Version 5.2 Page 6 Individuals living in the home are enabled to complain through a robust complaints procedure and the home would ensure that all complaints are thoroughly investigated and all required action (if any) implemented. 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. Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.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 Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home provides information to prospective residents and their representatives and ensures that the admission process provides safeguards to meet the assessed needs of the resident. EVIDENCE: The home’s Service Users Guide has full information as required by the regulations. This document is provided to prospective residents and their representatives when they visit or make enquiries to enable them to make an informed choice of moving to the Home. Reviewing the care file of recently admitted service users showed that the individual’s relatives visited to view the home before admission. The individual stated that whilst they were unable to visit and choose their rooms, they were satisfied with the services provided at the Home. Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.S.doc Version 5.2 Page 9 Another individual stated that the home manager visited them in hospital to obtain information about their needs to enable the home to determine whether the home is able to meet their needs. Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. Quality in this outcome area is good. The home offers care and support to individuals including at the end of their life, it protects service users with care plans on how to meet their needs. It also protects the individuals through satisfactory medication administration. EVIDENCE: Six care files were reviewed. All of the care files contained pre-admission information and contained individualised care plans, which described how the identified needs were being met. These care plans were regularly reviewed Individuals spoken with stated that they choose when they wake and when they retire. Two people spoken with stated that staff respected their privacy and dignity when providing them with personal care. The records seen were able to give staff clear information on how individuals at the home are supported in areas of personal care as well as individual’s social, emotional and physical support requirements. These are followed up by monthly reviews and intervention as needs change. Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.S.doc Version 5.2 Page 11 All the completed care files showed evidence of professional visits, to include General Practitioner, Chiropodist, Optician, Dentist and Community Psychiatric Nurse (CPN). One care file of a service user who is required to be nursed in bed contained records of referral and visits from the district nurses and the General Practitioner to provide guidance and support to staff in meeting the needs of this person. On the day of inspection the individual’s relatives were visiting and we had the opportunity to speak with them in other to find out if they were satisfied with the care of their loved one. The relatives stated that the care provided for their relative is ‘excellent mum is being looked after very well’. Also noted in the care files were doctors visits to review the medication and any other issues affecting comfort of the individual. The care file had risk assessments, in relation to manual handling, nutritional risk assessment and weight monitoring. These were regularly reviewed. Whilst touring the building we met two service users who were recently admitted to the home. The pre-admission assessment identified clearly the needs of the individuals to include slight confusion, hearing impairment poor appetite and history of falls anxiety and tearfulness. However no care plans were seen in the care files to enable staff to support the individuals in meeting the identified needs. The manager stated that care plans would be put in place for the identified needs and sent to the Commission before the report was completed. These documents were received at the Commission and were satisfactory. Procedures for medication administration, handling, records and storage were assessed. The home had policy and guidelines on medication. A local pharmacy provides medication using a monthly monitored dosage system. A check of the blister packs indicated that medication had been administered as recorded. All medication is ordered and received by staff. and stored securely. A Medicines trolley is used to transport medication around the home. The home has a medicine fridge and temperatures are recorded daily. The pharmacy supplys printed medicines administration record sheets each month. Records of administration of medicines were clear. Waste medication is recorded and disposed of via the supplying pharmacy. Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.S.doc Version 5.2 Page 12 The home has a Death and Dying policy and procedure to enable staff to care for people who use the service in the event of a terminal illness and at death. Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home enables the service users to maintain contacts with families, friends and representatives. It also provides them with meaningful activities; however, it fails to provide the individuals with a choice of meals. EVIDENCE: Service Users and relatives spoken with on the day of the visit confirmed that the Home enables and supports individuals living in the home to maintain contact with their families and friends. One individual spoken with stated that their son visits anytime and regularly. Two relatives met at the home confirmed that they are able to visit at any time and that there are no restrictions. People are also encouraged and supported to maintain links with the local community as they wish. For example, the manager told us that there is a non-denominational service twice a month for individuals who want to maintain their faith in that area and to promote equality and diversity. Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.S.doc Version 5.2 Page 14 People living in the home spoken with on the day told us that they have a choice of when to get up and when to retire and would have their breakfast in bed or in their rooms if they wanted to. One individual stated that he usually gets up to go down to the dining room for breakfast with few other people and that this was their choice. Evidence from the records we looked at showed that the home provides service users with activities and entertainment based on their choice. One individual told us that they prefer to stay in their room and read and watch the television. The person stated that he goes out for a walk with staff support when the weather is good. Activities and forthcoming entertainment is displayed in the manager’s office and on the notice board in the hallway. The manager stated that the home uses the services of a company that specialises in providing activities for older people to ensure that individuals living in the home remain stimulated whilst living in a care home environment. Examples of activities displayed included Music and Movement, Card Making, Day Trips with the company “7 seater minibus” to various places of interest, Art, Craft and Bingo. The home stated in the Annual Quality Assurance Assessment that they regularly review menus and now have a three week rotation which offers greater choice. Whilst the meal seen on the day was nutritious and well presented, the menu was different from the one originally presented to the service users to choose from. People spoken with stated that the meal was good but would have preferred to have what was ordered but were not informed. Furthermore one individual told us that he would have preferred to have a salad dish but was not consulted. One individual told us in the survey about the meals in the home “the residents should be able to have more say in the menu. Sometimes meals are too fancy, older people just want good well cooked meals” The manager assured us that the menu would be reviewed. She also stated that changing the menu without informing the people that live in the home is unusual and that the chef would ensure that individuals living in the home are informed if the menu is changed in future. Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.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): 16,17,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled to complain and are confident that the home is able to protect them from abuse. EVIDENCE: The home’s complaint procedure contains required information of how the people living in the home are to contact the Commission for Social Care Inspection if they were not satisfied with the outcome of their complaints to the organisation. This procedure was noted displayed at the entrance of the home. Two relatives spoken with on the day stated, “We have nothing but praise for staff on how they are looking after our sister, we have no complaint whatsoever”. No complaint was recorded in the complaints book. Two new staff members’ files reviewed evidenced that two satisfactory references and Criminal Record Bureau Disclosures had been obtained before commencement of employment to ensure that individuals living in the home are adequately protected. The home has a Whistle blowing policy to enable staff to report any bad practices without fear of any reprisal and staff files showed evidence of training on Protection of Vulnerable Adults. Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.S.doc Version 5.2 Page 16 The relatives told us in the surveys that we sent to them that they are satisfied with the services and care provided at the home. Records of service users’ monies viewed tallied with the amount in the individual accounts in the safe. People spoken with stated that they felt safe at the home. We have no evidence to suggest that service users are prevented from exercising their legal rights. Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.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): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a safe well -maintained environment where residents feel happy to live in. EVIDENCE: Westbury Gardens is a one-storey bungalow design, located a short walk from the village of Westbury-on-Trym, where there are local shops, pubs and restaurants and local amenities. The bus service that passes the home provides quick and easy access to the Bristol City centre. Each of the bedrooms has French doors that open out onto the garden area or side pathways. Each service user has individual rooms with ensuite facilities and these seemed to exceed the spatial National Minimum Standards (not measured). Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.S.doc Version 5.2 Page 18 Service users rooms seen whilst touring the home looked clean and pleasantly tidy with personal objects displayed and in use. The rooms appeared well maintained in a domestic style of decoration. The maintenance book was up to date clearly stating jobs/tasks to be carried out, date completed and any relevant comment in relation outstanding jobs. Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment procedure of the home is robust and offers protection to residents at the home. There is adequate numbers of staff that are competent to meet the needs of the service users. EVIDENCE: The home currently has a full staff compliment and does not use agency staff. This is good practice and ensures that continuity of care is provided for the service users. The deputy manager explained that four staff were allocated and that this is usual practice. The duty rota confirmed this. Two care staff cover the afternoon shift until 8pm. The home employs two waking night staff. In addition the home employs housekeeping staff. The manager stated that the catering staff work from the Westbury Nursing Home, which is located very close to Westbury Gardens. The home has a robust recruitment procedure to ensure that suitable staff are recruited to meet the needs of people living in the home. Record of one recently employed staff member contained required information to include Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.S.doc Version 5.2 Page 20 personal details’ previous employment details, two satisfactory references, Criminal Records Bureau disclosure and relevant qualifications. The Home manager stated that three care staff have achieved NVQ level 3 in care two staff members have achieved NVQ level 2, nine staff members are working towards NVQ level 2. All staff have completed traaining in fire awareness update, food hygiene, infection control, Principles of care, First Aid, Equal Opportunity, MRSA, Hearing Loss, Diabetes Care of the Dying and Protection of Vulnerable Adults from Abuse. Palliative care and Dementia care training are to be arranged. One staff member spoken with confirmed that she had attended training courses to enable her to perform her duties effectively. Individuals living at the home stated that staff are very kind and are sensitive to their needs. Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.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): 31,32,33,35,36,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs and best interests of individuals living in the home are central to the management approach in the home. Staff are supervised adequately through supervision and staff meetings. The health and safety of residents, staff, and visitors is protected. EVIDENCE: As stated at the previous inspection, the home continues to consistently demonstrate good, effective leadership and management that relates to the aims and purpose of the home. The home’s registered manager Ms Penny Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.S.doc Version 5.2 Page 22 Brown has many years of managerial experience working in Westbury Gardens and is well qualified both in management and training. It was evident from discussions with Ms Brown and her deputy managers that the home has a stable management team that supports a commitment to providing quality care for the benefit of the service users. The atmosphere at the Home on the day of inspection was positive and welcoming. Staff were noted interacting with residents in an informal and friendly manner. Evidence seen on the day showed that the service users are well cared for and staff showed clear understanding of the importance of providing high quality care for the people living in the home. Individuals spoken with made positive comment about, Penny Brown. One individual told us, “Penny is approachable is very good. I would complain to Penny first if anything is concerning me and I will take it further if I have no joy.” People who use the service told us in the questionnaire we sent to them that they are satisfied with the support offered at the home. Staff supervision was reviewed. Evidence from the records viewed and discussion from the deputy manager showed that staff have received regular supervision. The deputy manager stated that staff benefited from the exercise and that it afforded them the opportunity to express their opinion about the services provided at the home and to discuss areas of concern in relation to service users’ care. Evidence from the records of the newest staff member confirm that the person completed a comprehensive induction programme before working independently with service users. The fire log-book was noted to be up to date and evidence from records and confirmation from staff showed that staff have attended fire drills. Whilst the home has generic risk assessments of various areas of the home it needs to be updated to include individual service user’s bedrooms to ensure that the people who use the service are adequately protected. It was agreed that this would be reviewed at the next visit. We noted that accidents to service users have been well recorded however some risk assessments have not been reviewed to ensure that the accident is minimised or prevented. We discussed our concern with the Home manager and the deputy manager and it was agreed that this is carried out and a copy Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.S.doc Version 5.2 Page 23 sent to the Commission for review. This document was received and was found satisfactory. Quality assurance for the Home was reviewed. The deputy manager stated that the home checks the quality of its service using different methods. These include questionnaires for relatives and service users; Managers regular weekly one to one discussions with service users to ensure that concerns raised were resolved as soon as possible. Other tools include, staff supervision and discussions at residents’ and staff meetings care plan reviews and feedback from social workers. The home has policies and procedures to include Protection of Vulnerable Adults from Abuse, Medication, Whistle Blowing, Manual Handling, Infection Control and Missing Persons. These have recently been updated. Service users’ monies checked evidenced that the record is up to date, the amount seen and stored in the safe corresponded with the balance recorded in the book. Other residents’ documented information was noted securely locked away. Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.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 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X 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 3 3 3 Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.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. 1. 2 Standard OP7 OP15 Regulation 13.2 16 Requirement Care plans must be in place for all the assessed needs of identified service users Ensure that individuals living in the home are provided with their choice of meals and are consulted when the menu changes. To ensure that service users are adequately protected risk assessments must be kept under review. Ensure that generic risk assessment includes individual service users bedrooms. Timescale for action 24/03/08 24/03/08 3 OP38 13 24/03/08 4 OP38 13 24/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Westbury Gardens (Residential Suites) DS0000026642.V352334.R02.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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