Care Home: Westhope Mews

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What the care home does well Westhope Mews is an established, well-managed and well maintained service that continues to provide good quality care and support for the people who live there. The comfortable, relaxed and welcoming environment has evolved over several years and reflects the stability and commitment within the staff team and the open and inclusive management style. Thorough policies and procedures are in place for the admission and ongoing care and support of residents. Effective communication and consultation systems enable service users to be directly involved in developing and reviewing their individual support plans as well as many decision making processes within the home.Service users are enabled and supported to take part in a variety of recreational and leisure activities, both within the home and in the wider local community. An indication of the commitment of care staff at the home is the fact that an impressive 100% have achieved NVQ level 2 in Care, or are currently studying for the award. What has improved since the last inspection? Policies and procedures relating to the control and safe storage of medication have been reviewed, as required. Since the last inspection two new medicine cabinets have been provided, to ensure that service users` medication is stored safely and securely. Before administering medication, all staff now receive appropriate training, from a qualified pharmacist, regarding the control and safe handling of medicines. Since the previous inspection, the lounge, dining room, kitchen and hallway have been redecorated and a new three-piece suite, chosen by the service users, has been provided. What the care home could do better: It is important, for the protection of service users, that all Controlled Drugs held in the home must be stored in a secure Controlled Drugs cupboard. CARE HOME ADULTS 18-65 Westhope Mews 6 Denne Parade Horsham West Sussex RH12 1JD Lead Inspector Nigel Thompson Unannounced Inspection 13th March 2008 10:00 Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 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 Westhope Mews DS0000062779.V359535.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 Adults 18-65. 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. Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westhope Mews Address 6 Denne Parade Horsham West Sussex RH12 1JD 07768 461144 01403 791794 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) Westhope Ltd Mrs Sally Teresa Kelly Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Westhope Mews is registered to provide care for up to eight service users with learning and physical disabilities. Service users are accommodated on the ground floor. A separate unit on the first floor accommodates people under the supported living scheme and is not part of the registered home. The building is a detached house situated in the town centre of Horsham and was converted from business premises two years ago. Local amenities such as shops, leisure centres and public transport are nearby. Each service user has a bedroom with en-suite facilities. Six bedrooms can accommodate people who are wheelchair users. Communal space includes a lounge, dining room and activity room. There is an enclosed courtyard to the front of the property. The responsible individual on behalf of the organisation in Mr Dermot Hurford and the registered manager in charge of the day-to-day running of the home is Mrs Sally Kelly. Information about the service, including the Statement of Purpose, Service User’s Guide and CSCI reports is made available to prospective service users or their relatives, on request, as part of the admission process. At the time of this inspection fees ranged from £1135:02 to £1951:91 per week. Service users pay individually for chiropody, hairdressing, toiletries, papers and magazines and in one case an annual holiday. Westhope Mews DS0000062779.V359535.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 took place over four hours in March 2008. It found that all the key National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was good. The purpose of this inspection was to assess compliance with the requirements of the previous inspection and to generally monitor care practices at the home. Although registered to accommodate eight people, on the day of the inspection there were seven service users living at the home. The inspection process involved a tour of the premises, observation of working practices, examination of records and documentation and discussion with two service users, one professional visitor, three members of staff and the registered manager. Service users observed and spoken with during the inspection expressed satisfaction with the home, the staff and the service provided. The focus of the inspection was on the quality of life for people who live at the home. What the service does well: Westhope Mews is an established, well-managed and well maintained service that continues to provide good quality care and support for the people who live there. The comfortable, relaxed and welcoming environment has evolved over several years and reflects the stability and commitment within the staff team and the open and inclusive management style. Thorough policies and procedures are in place for the admission and ongoing care and support of residents. Effective communication and consultation systems enable service users to be directly involved in developing and reviewing their individual support plans as well as many decision making processes within the home. Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 6 Service users are enabled and supported to take part in a variety of recreational and leisure activities, both within the home and in the wider local community. An indication of the commitment of care staff at the home is the fact that an impressive 100 have achieved NVQ level 2 in Care, or are currently studying for the award. 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. Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The thorough admission policy and procedure ensures that service uses are admitted only on the basis of a full needs assessment, undertaken by people competent to do so. Prospective service users know that the home is able to meet their individual care and support needs. EVIDENCE: There have been no service users admitted to Westhope Mews since the previous inspection. However a full and comprehensive admission policy and procedure made available for inspection contained details of the thorough assessment process, evidently undertaken by the manager, to identify an individual’s care and support needs. The manager confirmed that, prior to moving in, a prospective service user would be invited to visit the home to look around and get a feel for the place. During these visits the individual would also have the opportunity to meet with members of staff and existing residents. A comprehensive ‘Daily living and needs assessment’ has been developed and implemented, ensuring that an individual’s required level of support is identified, ranging from guidance through practical support to full care. Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 9 On moving in, a flexible trial period is provided to establish whether the individual’s assessed needs are able to be met and decide on their suitability for the home and their compatibility with existing service users. The significance of this was emphasised by the manager: ‘Compatibility is so important. The service users here get on so well together, we wouldn’t want anyone coming in and upsetting the apple cart’. Comprehensive information relating to the service is made available to all prospective service users, their relatives and associated care managers. Relevant documentation including a Statement of Purpose ‘ and ‘Service User Guide’ was examined and found to be satisfactory. For the benefit of service users with limited verbal communication, it was evident that these documents have also been produced using symbols, signs and pictures. It was noted that a formal contract, recently reviewed and updated, is in place for each service user and has been signed by the individual themselves or a representative, to acknowledge understanding and confirm acceptance of the stated terms of residency. Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users’ care plans enable staff to meet assessed needs in a structured and consistent manner and individual plans, including risk assessments reflect changing support needs. Systems for consultation and participation remain effective and service users are treated with respect and encouraged and enabled to make decisions about their day-to-day living. EVIDENCE: High quality, ‘Person centred’ care and support plans have been developed and implemented for each service user. Individual plans that were examined contained personal risk assessments and comprehensive details of their physical, psychological and emotional support needs and were found to be accurate, up to date and well maintained. Detailed guidelines for staff have been developed and implemented, ensuring consistency of approach and continuity of care. This guidance relates to the Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 11 delivery and provision of individual care and support, in accordance with the identified wishes of service users. Staff, spoken with during the inspection, acknowledged the benefits to service users of a more structured care and support programme: ‘It doesn’t matter who is on duty, service users get the same level of help and support in the same way. Consistency and routine is so important for the people living here’. The manager confirmed that service users and, where appropriate, a relative or representative continue to be directly involved in six monthly care plan reviews. Such reviews are held to discuss and monitor an individual’s progress, review previous goals, as well as agreeing action points and setting goals for the future. Independence and individuality continues to be encouraged and promoted within the home and is reflected in the personalising of service users’ rooms, the choice of bedclothes and colour schemes and individual preferences for occupational and leisure activities. Staff, spoken with during the inspection, confirmed that service users are encouraged and supported to make decisions regarding many aspects of their daily living, including menu planning, what clothes they wear and how they spend their day. The manager emphasised the importance of staff developing close working relationships with individual service users. Despite the variable and limited verbal communication of some service users, effective and regular interaction and consultation takes place constantly throughout the home. This was evident from direct observation of service users being supported in a professional, sensitive and respectful manner. Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users are enabled and supported to maintain contact with family and friends as they wish and effective links with the community enrich their social and educational opportunities. Service users benefit from appropriate recreational and leisure activities and menus that are balanced and nutritious, reflecting their individual likes and preferences. EVIDENCE: The recreational and leisure interests of service users are identified and recorded in their individual care plan and they continue to be supported to access activities and facilities, reflecting their individual needs, preferences and abilities. Individual support plans examined confirmed that service users are enabled to access a variety of recreational and leisure activities. Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 13 Community participation evidently remains a focus in the home and staff confirmed that service users are encouraged and supported to attend day services, work experience and college as well as visiting local shops and other amenities. A full time activities coordinator is employed in the home. She often works on a 1:1 basis with service users ‘planning their weekly activities and promoting choice and independence’. A separate activities room provides the opportunity for service users to take part in arts, crafts, games and other recreational activities. Visiting to the home is largely unrestricted and relatives and friends are made welcome at any reasonable time. Service users are encouraged and supported to maintain family links. Menus examined were found to be varied and balanced and are evidently based on service users’ identified likes and preferences. An alternative to the main meal is always available. A colourful weekly menu, using pictures and photographs of food, is displayed in the dining room and clearly shows, for each day, what meal service users can look forward to. Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff have developed close and positive relationships with service users and demonstrate an awareness and sound understanding of their individual care and support needs. Service users are protected by improved, clear and comprehensive policies and procedures in place for the control and safe administration of medication. EVIDENCE: The manager emphasised the importance of staff developing close working relationships with individual service users and being aware of changes in mood or behaviour. In accordance with their personal care plan, service users are fully supported and enabled, as far as practicable, to exercise control over their lives and maintain maximum levels of independence and individuality. As previously documented, during the inspection service users were observed being supported in a sensitive, professional and respectful manner. Documentary evidence was in place to demonstrate that the health and emotional care needs of service users continue to be met within the home. Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 15 All service users are registered with local GPs and have access to other health care professionals, including district nurses, speech and language therapists and dentists, as required. All medical appointments with, or visits by, health care professionals are recorded. The manager confirmed that the service also works very closely with the local Community Learning Disability Team, (CLDT), which provides valuable guidance, support and specific staff training. Up to date and detailed policies and procedures relating to the control, storage, administration and recording of medication are in place. Medicines are stored and recorded appropriately. All staff responsible for administering medication have received training, as part of their comprehensive induction programme, and are individually assessed and authorised to do so. It was noted that since the previous inspection, as required, the storage of medication has been improved by the provision of two secure medicine cabinets. However following discussion with the manager, the safe storage of controlled drugs on the premises is to be reviewed. The manager confirmed that, following risk assessments, one service user currently self-administers their own medication. Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home’s complaints procedure ensures that service users, staff and visitors feel able to express any concerns, confident that they will be listened to and acted upon. Service users are protected, through updated policies and procedures relating to abuse and safeguarding vulnerable adults. EVIDENCE: A simple, concise and accessible complaints procedure has been developed and implemented for the benefit of service users, staff and other visitors to the home. A copy of the procedure is displayed in the entrance hall. All complaints received are appropriately recorded, including details of any actions taken and outcomes achieved. The manager was keen to describe the situation at Westhope Mews, where ‘close working relationships’ and ‘effective communication and consultation’ provides adequate opportunities for any concerns to be raised and discussed before they become complaints. Service users and members of staff confirmed that they would have no hesitation in speaking to the manager or making a complaint if necessary and each person was confident that they would be listened to. It was noted that there have been no concerns or complaints recorded by the home since the last inspection. Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 17 The home has produced detailed policies and procedures, relating to adult protection and abuse, including a whistle blowing policy. These documents have evidently been reviewed and updated, in accordance with the recently implemented multi agency guidelines for safeguarding vulnerable adults. The manager confirmed that all care staff have undertaken appropriate training regarding abuse awareness and procedures relating to ‘Safeguarding Vulnerable Adults.’ This was confirmed through discussions with members of staff and supported by training records examined. Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 28 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The service is accessible, safe and clean and remains clearly suitable for it’s stated purpose. Service users benefit from pleasant accommodation that is comfortable, reasonably well maintained and decorated to a satisfactory standard. EVIDENCE: During my ‘guided tour’ of the premises it was evident that the generally well maintained décor and adequate furniture and furnishings continue to provide a comfortable, safe and pleasant environment for service users. The manager confirmed that independence and individuality continue to be promoted within the home and, as previously documented, this is evident from the personalising of service users’ rooms, reflecting individual taste, preference and interests. Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 19 Since the previous inspection, the lounge, dining room, kitchen and hallway have been redecorated and a new three-piece suite, chosen by the service users, has been provided. Identified maintenance requirements are evidently documented and addressed, by the maintenance worker, as necessary. The manager confirmed that a Business Plan has been implemented for 2008, identifying areas within the home that require attention. Infection control policies and procedures are in place and clearly adhered to. Service users, with key worker support as necessary, are evidently responsible for keeping bedrooms clean and tidy and on the day of the inspection, levels of cleanliness and hygiene throughout the home were found to be satisfactory. Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users benefit from there always being sufficient trained and competent staff on duty to meet their assessed needs. Robust staff recruitment policies, procedures and documentation help to ensure the protection of service users. EVIDENCE: Through discussion with the manager, care staff and residents, it is evident that sufficient staff are employed to meet the current assessed support needs of service users and to ensure consistency and continuity of care. Agency staff are not employed in the home. The manager confirmed that staffing levels are closely monitored and are directly linked to the service users’ identified levels of dependency. A duty rota has been developed and implemented to detail the staff on duty at any given time and their designation. Appropriate core skills training is provided, including first aid, moving and handling, food hygiene and fire safety. Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 21 This was confirmed through discussions with staff and evidenced by training records examined: ‘There is always plenty of opportunity for training here’. It was noted that all of the staff employed in the home have either achieved NVQ level 2 in care, or are currently studying for the award. This demonstrates sound commitment and reflects the evident enthusiasm and motivation within the staff team. This was supported by the visiting NVQ Assessor, spoken with during the inspection: ‘I always enjoy coming to this home. There’s a buzz about the place that I really like. I am always made very welcome and the staff are so keen to learn – very motivated and obviously committed to the service users.’ Formal and structured staff supervision is provided on a regular basis and is appropriately recorded. The manager is clearly aware of the need for thorough and robust recruitment procedures, to ensure the protection of residents. Individual files that were examined, relating to recently appointed members of staff, were found to be well maintained, containing all relevant and necessary information, including two satisfactory references, proof of identity and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures. Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users benefit from a competent management structure. They are protected by satisfactory health and safety procedures and their best interests are safeguarded by effective quality monitoring systems. EVIDENCE: The experienced and competent registered manager has been in post since the service opened and was directly involved in setting up the home, recruiting staff and admitting service users. She has worked in the care sector for over ten years and demonstrates an awareness and sound understanding of the often complex support needs of adults with learning and physical disabilities. The manager is clearly committed to maintaining and improving standards and promoting a good quality of life for people living in the home ‘regardless of their disability’. Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 23 She holds the Advanced Management for Care certificate, City and Guilds 325/3 and is a qualified NVQ Assessor. She continues to keep up to date with current practice and maintains her own training and skills development. From discussions with staff and service users, during the inspection, it is evident that the manager is very approachable and has created an open and inclusive atmosphere within the home. Staff clearly feel valued and supported by her and are comfortable with her relaxed but effective management style. ‘She (the manager) is the reason why this place runs so well and why everyone – service users and staff - is happy here’. Quality Assurance systems in place includes regular audits and annual surveys for service users, family members, staff and visiting professionals. The manager confirmed that the health, safety and welfare of service users and staff remain of paramount importance within the home. Staff training is provided in many aspects of safe working practices, including moving and handling; food hygiene; fire safety and first aid. All staff training is satisfactorily recorded. COSHH assessments and guidelines are in place. Regular fire drills are undertaken and recorded. Fire alarm systems are regularly checked and records maintained. Temperature regulators are fitted to all hot water outlets, accessible to residents. All accidents, incidents and injuries are recorded and reported, as required. Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 3 X X 3 X Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 (2) Requirement It is required that all Controlled Drugs must be stored in a Controlled Drugs cupboard, complying with the Misuse of Drugs (Safe Custody) Regulations 1973. Timescale for action 31/05/08 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 Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Westhope Mews DS0000062779.V359535.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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