Care Home: Westerley

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What the care home does well The registered manager has recently reviewed and updated the literature provided for anyone wishing to come to live in Westerley. There is a Statement of Purpose and resident guide, both of which provide in depth information about the facilities on offer at this service. The information is such that an informed choice about whether or not to move in can easily be made. Any prospective resident is fully assessed prior to a place being offered. The manager is always mindful of the needs of those already living in the home when the assessments are carried out and there is a trial period before the placement is made permanent. This is seen as a safeguard to all concerned. All those using this service have a full plan of care that is generated from the initial assessment of needs. The care plans are updated regularly to meet the changing needs of those living in the home. Medication records are kept in an appropriate way ensuring the safety of those who use this service. Healthcare needs are met through the local doctors` surgeries, district nurses and the community psychiatric nurses. Recreational activities are provided for those wishing to join in and a varied nutritious diet is provided. Special diets, including vegetarian and diabetic are available at all times. Environmental standards within the home are excellent ensuring the home is safe, warm and comfortable. There is an experienced and well-trained management and staff team providing a high level of care and support. The recruitment policy means that those using this service are safeguarded at all times. Staff training is constant with training courses completed "in-house" and/or provided by an external professional trainer. This home does not provide intermediate care. What has improved since the last inspection? Boots chemist now provides medication and the manager confirmed that this has considerably improved the way in which the medicines are handled. The service is available 7 days a week with any changes in medication dealt with immediately. There have been improvements to the environment since the last inspection with the 2 lounges having been re-decorated and the kitchen refurbished. Bedrooms have been decorated and new carpets and furniture purchased. A new management structure has been introduced and a key worker system is now in place.National Vocational Qualification (NVQ) training has improved with the introduction of a new training provider. One of the senior carers is now an NVQ assessor, which has meant more staff have gained the qualification at levels 2 and 3. What the care home could do better: There were no requirements or recommendations made during this inspection and we are confident that this service will continue to provide the high standard of care and support already given to those living in Westerley. CARE HOMES FOR OLDER PEOPLE Westerley The Esplanade Grange-over-Sands Cumbria LA11 7HH Lead Inspector Mrs Margaret Drury Unannounced Inspection 12th June 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Westerley DS0000022667.V365864.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. Westerley DS0000022667.V365864.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westerley Address The Esplanade Grange-over-Sands Cumbria LA11 7HH 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) 015395 32408 grange@lpma.co.uk The Leaders of Worship and Preachers Homes Mrs Elizabeth Lynne Davey Care Home 27 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (27) of places Westerley DS0000022667.V365864.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 27 service users to include: up to 27 service users in the category of OP (Older people, not falling within any other category) up to 4 service users in the category of DE(E) Dementia over 65 years of age) 6th June 2006 Date of last inspection Brief Description of the Service: Westerley is owned by The Leaders of Worship and Preachers Homes, a registered charity, trading under this name. It is registered to provide accommodation and care for up to 29 older people, 4 of whom may have varying forms of dementia. Mrs Elizabeth Lynn Davey is the registered manager. The home is situated near the centre of Grange-over Sands overlooking Morcambe Bay. The building, which was formerly a hotel, is an older property that has been adapted and extended for its present use as a care home. Accommodation for residents is on three floors that are served by a passenger lift and two small stair lifts. The rooms are mostly for single occupation but there is the facility of shared accommodation for married couples should this be requested. There are en-suite toilets and washbasins in all the rooms with seven also having showers. There are two lounges and a dining room. The home is equipped to assist people with a disability to move around the home. There is a well-kept garden and a parking area at the rear of the building. This home does not provide intermediate care. Westerley DS0000022667.V365864.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 3 star. This means the people who use this service experience excellent quality outcomes. This site visit that forms part of the key inspection took place over one day in June and we (The Commission for Social Care Inspection) were in the home for six and a half hours. Information about the service was gathered in different ways: • Annual Quality Assurance Assessment document completed by the manager • Survey questionnaires returned by residents, staff and family members. • Interviews with residents, visitors and staff on the day of the visit. • Looking at any information received from other professional agencies We looked at care planning documentation to ensure the level of care provided met the needs of those living in the home and a tour of the building to inspect the environmental standards was undertaken. Medication records were examined and staff training records and personnel files were also inspected. Discussions took place with the registered manager about the running of the home, staffing levels and the dependency of those living in Westerley. There were 8 surveys returned by relatives, 5 surveys returned by residents and 10 returned by members of staff. There was opportunity to spend time with residents during one of their weekly activities and speak with relatives and friends who were in the home at the time of the visit. We spent time observing the care delivered to those living in the home and the interaction between staff and residents. Westerley DS0000022667.V365864.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Boots chemist now provides medication and the manager confirmed that this has considerably improved the way in which the medicines are handled. The service is available 7 days a week with any changes in medication dealt with immediately. There have been improvements to the environment since the last inspection with the 2 lounges having been re-decorated and the kitchen refurbished. Bedrooms have been decorated and new carpets and furniture purchased. A new management structure has been introduced and a key worker system is now in place. Westerley DS0000022667.V365864.R01.S.doc Version 5.2 Page 7 National Vocational Qualification (NVQ) training has improved with the introduction of a new training provider. One of the senior carers is now an NVQ assessor, which has meant more staff have gained the qualification at levels 2 and 3. 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. Westerley DS0000022667.V365864.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 Westerley DS0000022667.V365864.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3, 4 & 5 were assessed. Standard 6 does not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Westerley provides detailed information about the facilities provided and undertakes comprehensive assessments prior to admission to ensure the service can properly meet peoples’ needs. EVIDENCE: The registered manager has recently reviewed and updated the literature provided for anyone wishing to come to live in Westerley. There is a Statement of Purpose and resident guide, both of which provide in depth information about the facilities on offer at this service. The information is such that an informed choice about whether or not to move in can easily be made. Any prospective resident is fully assessed prior to a place being offered. The manager is always mindful of the needs of those already living in the home when the assessments are carried out and there is a trial period before the Westerley DS0000022667.V365864.R01.S.doc Version 5.2 Page 10 placement is made permanent. This is seen as a safeguard to all concerned. A comment from a resident on one of the returned surveys was ‘ after enquiring I came and stayed several days’. All prospective residents and/or their families or advocates are invited and encouraged to visit the home prior to admission. This gives opportunity to meet the management, staff and those already living in the home. Residents we spoke to during the visit all confirmed that they visited to look around before making the decision whether or not to move in. They also confirmed how much they appreciated the help and support of the staff during the ‘settling in’ period. We also spoke to a visitor who said she was grateful for the help and advice she received when she was looking for accommodation with her mother. Westerley DS0000022667.V365864.R01.S.doc Version 5.2 Page 11 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): Standards 7, 8, 9 & 10 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The high standard of health and personal care people receive is based on their individual needs, with the principles of respect, dignity and privacy maintained at all times. EVIDENCE: We looked at the care plans for four residents and found them to be detailed and up to date with evidence that they are regularly reviewed to meet the changing needs of those using this service. The deputy manager has delegated responsibility for the care plans and takes great care to ensure they are always up to date. Twice yearly reviews with the resident and family member, if appropriate, take place and visitors confirmed that they are always kept up to date with any changes in the level of care provided. Comments from a family member on a survey form included ‘the home always rings me if there is something I should know’ and ‘I always get a call about medical matters or illness’. Westerley DS0000022667.V365864.R01.S.doc Version 5.2 Page 12 There is also a copy of the care plan kept with the daily notes which ensures all the staff are constantly aware of any changes in the dependency levels of those they are supporting. The organisation is currently looking at ways to make the care planning system even more person centred and we discussed this with the manager during the visit. Information was available about individual healthcare needs with evidence that hospital appointments, doctors’ visits and consultations with other healthcare professionals took place, helping to demonstrate that peoples’ health needs are monitored and treated correctly when necessary. There is a policy in place for staff to adhere to the procedures for the receipt, recording, storage, handling, administration and disposal of medicines. Records were examined to ensure all medication prescribed was administered in a timely and appropriate manner. Medicines were stored safely in a locked cabinet and provision is available to store any controlled drugs correctly, although there are currently none prescribed. Since the last inspection Boots’ Chemist has taken over the provision of medication to the home and the manager confirmed that this is proving very successful. The service is available 7 days a week with medication supplied weekly in a monitored dosage system. Any medication supplied outside the weekly system is supplied immediately with a Medication Administration Record (MAR) sheet, which negates the need for hand written records. Opportunity is given for those residents who wish to take responsibility for their own medication. Members of staff were observed demonstrating a caring, sensitive,dignified and respectful approach with residents responding in a positive way. It was evident that warm, yet respectful relationships existed between all the staff and those living in the home. Some comments made during the visit included,’ the staff are lovely’ and ‘the girls are wonderful and so caring’. Relatives comments on surveys included, ‘I have observed staff being very caring to residents often in challenging circumstances’ and, ‘Westerley is always very welcoming and shows care to mum’. Westerley DS0000022667.V365864.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 were assessed Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Relevant and appropriate recreational and leisure activities are provided demonstrating that people are motivated and stimulated. This gives those using this service a sense of wellbeing. EVIDENCE: Although there is no activities co-ordinator employed at Westerley one of the senior carers has delegated responsibility for organising activities within the home. There are outings organised during the summer and the manager has registered with Cumbria Community Transport and is able to hire a mini bus for under £1 per journey. These outings have proved very popular with the residents as many lived in the surrounding area before coming to live in the home. Croquet on the lawn has been introduced as a summer activity with staff and residents joining in. Residents told us how much they had enjoyed it and what great fun they had. A professional teacher comes into the home to provide armchair exercises and aerobics. There are craft classes, scrabble and dominoes and there is a weekly bible class organised by the residents themselves. Church services are held, Westerley DS0000022667.V365864.R01.S.doc Version 5.2 Page 14 which is much appreciated by those who are unable to go out to church and daily devotions are conducted for those who wish to participate. There is a programme of indoor event/activities provided for the winter months, a popular one being indoor bowls. The local community plays an important part in the life of this service with visitors and volunteers visiting on a regular basis. There is a social committee run by volunteers with two residents serving on it to discuss activities, entertainments and fund raising activities. Visitors are welcome at any time, this being confirmed by a visitor who spoke to us during the visit and comments made on the returned survey forms. Comments included,’Westerley is very welcoming’ and ‘I am always made very welcome when I visit my mum’. The kitchen area has recently been refurbished and all the residents said how much they enjoyed their meals. The menus showed that nutritious and appetising meals are prepared with a vegetarian choice at each meal. People can choose to eat in their rooms if they wish although the majority do come to the well-appointed dining room. This, together with the choice of meals, served to demonstrate that individual choices are accommodated as much as possible. The kitchen is spacious and was extremely clean. We observed the lunch being prepared and served. This was done in an easy and relaxed fashion with assistance on hand where needed. Comments from those living in the home regarding the meals included, ‘our meals are lovely and our cook is on her honeymoon’ and ‘I always enjoy the food’. The manager now holds ‘informal’ meetings with the residents every month over morning coffee. These have proved very popular with residents feeling free to make comments and suggestions about the running of the home. One suggestion that was made for a small kitchen area where residents and/or visitors can make tea and coffee has already been put in place with the work almost completed. Westerley DS0000022667.V365864.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using this service are confident any complaints or concerns will be listened to and acted upon. Policies, procedures and staff training in adult protection ensure residents are safeguarded. EVIDENCE: The home has a comprehensive complaints procedure in place with copies displayed around the home. Staff who spoke to us were all aware of the complaints procedure and what to do if a complaint was made. There have been no complaints made to the home and none received by CSCI. The residents we spoke to were all aware of the procedure to follow and all said they would speak to Lynn (manager) or Michelle (deputy). There is an in-depth policy and procedure in place regarding the safeguarding and protection of vulnerable adults. The deputy manager has completed the ‘train the trainers’ course run by Cumbria County Council and will pass this information on to the staff in the form of in-house training to add to that already completed by the staff. The policy also covers whistle blowing and when this was discussed with the staff they all knew what to do should they witness anything untoward happening. Training in the Mental Capacity Act has been completed and this will be updated on a regular basis as part of the annual training plan. Westerley DS0000022667.V365864.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 23, 24, 25 & 26 were assessed Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Westerly is clean, hygienic and extremely well maintained, helping to ensure people live and work in a safe, comfortable and pleasant environment. EVIDENCE: A tour of the home was completed and, throughout, the building was found to be of an excellent standard. Since the last inspection there has been a considerable amount of work completed to improve still further the environmental standards. Six bedrooms have been refurbished, toilets and bathrooms have had new flooring laid and the two lounges have been redecorated. Most of the bedrooms are for single occupation although there is a married couple sharing one of the registered double rooms and using the other room as Westerley DS0000022667.V365864.R01.S.doc Version 5.2 Page 17 a lounge. All bedrooms have en-suite toilet facilities and seven have en-suite showers. There are also ample communal toilets and bathrooms. The bedrooms were comfortable and well decorated and personal to each resident. Some had brought in items of furniture from home that, together with pictures and ornaments, made them comfortable and homely. There are lovely gardens to the front of the home and a sitting area next to the front door. As there are panoramic views over Morcambe bay this is a lovely area to sit in on a warm sunny day. Westerley employs domestic staff to ensure the home is always kept clean and hygienic and a maintenance man who carries out minor repairs in order to ensure the home is safely maintained. He is also responsible for the weekly check of the fire alarm system and water temperatures. Westerley DS0000022667.V365864.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team have been correctly recruited and have the necessary training, skills and experience to provide a high standard of care to vulnerable people. EVIDENCE: Westerly has recently introduced a new management structure with the appointment of a deputy manager and also two assistant managers and three senior carers. This means that there are always members of the senior team on duty. Staffing levels were checked and found to be more than adequate to care for those living in the home. There are a few vacant hours but these have already been filled with the staff starting work as soon as all the legal checks have been completed. These shifts are currently being covered by existing care staff. The manager is careful who she employs and always ensures any new member of staff will fit in and be suitable to provide the care needed to meet all the assessed needs of those living in the home, Staff training is up to date and despite past problems with the company providing National Vocational Qualification (NVQ) training there are now 7 members of staff qualified to level 2, 5 to level 3, 1 completing level 3 and 4 waiting to start level 2. One of the management team is now a qualified Westerley DS0000022667.V365864.R01.S.doc Version 5.2 Page 19 assessor and also has delegated responsibility for the 3 month staff induction programme. The home also uses the services of a professional training company. There is a thorough recruitment and selection procedure in place with all legal checks completed before staff start work. The staff files showed, application forms, references, health check forms and details of all past employment. This demonstrated that only suitable staff are appointed to care for those living in the home. The manager is mindful of the needs of the residents when appointing staff and tries wherever possible to recruit those people she feels will be able to work with the existing staff team and also be able to meet the diverse needs of the residents. During the visit staff demonstrated a caring, sensitive, dignified and respectful approach, with residents responding positively so it was evident that good relationships existed between residents and care staff. Residents knew all the staff by name and staff communicated well with those living in the home using their preferred term of address. Comments from staff in returned surveys included, ‘We have handover twice a day so we are all up to date’, I was given a thorough induction with various training courses and modules to complete’, ‘I don’t think there are any changes to be made at Westerley to make it happier than it is’. Westerley DS0000022667.V365864.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 33, 35, 37 & 38 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. This home is well managed and organised ensuring as far as possible that residents are safe and receive an excellent service. EVIDENCE: The registered manager has many years experience of working with older people and has completed the registered manager award. Since the introduction of the new management structure she and the deputy are spending less time ‘hands on’ which allows them more time to manage the home and to complete the administration involved in the running of a care home. Staff confirmed that she has an easy and relaxed style of management and is approachable and fair at all times. Visitors to the home confirmed that Westerley DS0000022667.V365864.R01.S.doc Version 5.2 Page 21 the manager was available to talk to at any time and was always ready to help in any way. We discussed quality audits with the manager who confirmed that questionnaires are sent to residents, staff and visitors annually. She also used the completion of the Annual Quality Assurance Assessment document as a quality audit check. She told us that not only did the completion of this form highlight what could be done to improve the level of care and support provided but also just how much progress had been made in the last 12 months. She will continue to visit and update this document as part of her internal quality audit system. Small amounts of personal allowance are held for some residents and the records were checked and found to be in order. Two members of staff signed all transactions and there was a monthly audit completed by a member of the head office staff during their monthly visit. All receipts were held on file. Westerley is part of a small group of homes and the manager has a clear vision for the home based on the organisation’s corporate vision and values. The manager works to a capital spending plan provided, with her input, by head office to ensure the home remains viable and fit for purpose. Equality and diversity and human rights are important and the organisation has changed the constitution in order to allow the admission of people from any faith and belief. A new executive director/responsible person has recently been appointed and monthly visits to the home are made in order to provide support to the manager, staff and residents. Monthly notifications under regulation 26 are sent to CSCI to keep us informed of events at the home. The home has a full set of policies and procedures provided by an external professional company that is available for staff to access at any time. Regular staff supervision ensures training needs are identified and discussed. Weekly staff meetings have been introduced that also incorporate handover discussions to ensure all staff are made aware of any changes in the needs of those living in the home. There was documented evidence to show that all mandatory training such as health and safety, manual handling and infection control are updated regularly. There is an up to date health and safety policy with individual and corporate risk assessments promoting the health and safety of those living and working in the home. All inspection certificates were checked and found to be in order and up to date. These included gas safety, electricity, hoists and bath aids, portable appliance and all fire equipment. Westerley DS0000022667.V365864.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 4 X 3 3 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 X X 4 4 4 4 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 4 X 3 4 Westerley DS0000022667.V365864.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. 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. Refer to Standard Good Practice Recommendations Westerley DS0000022667.V365864.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Westerley DS0000022667.V365864.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!