Care Home: Westlands Residential Home

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What the care home does well Potential service users receive a thorough needs assessment to ensure the home can meet the care needs of the service users. Detailed care plans have been produced for all people who use the service, and these inform the care staff what they must do to meet the needs of the individual. There is a motivated and established staff team that consists of care staff who respond to service users in a respectful and appropriate manner. The home provides a pleasant and comfortable environment in which people can live. Individuals are encouraged to personalise their own rooms with their own furniture and personal belongings. Communication between people who use the service and staff was observed to be positive and open. The provision of meals and mealtimes are of a high standard. There is a robust recruitment procedure in place that ensures service users are protected from harm. There is a good range of policies and procedures, providing staff with relevant information about all aspects of care and the home/organisation. Health and Safety procedures are thorough and records are well maintained. The evidence seen and comments received indicate that this service meets the diverse needs e.g. religious, racial, cultural, disability of individuals within the limits of its What has improved since the last inspection? This is a new service so this area has not been assessed. What the care home could do better: The home must make sure they put in place guidelines for the administration of all `when required/when needed` medicines. These guidelines must include when the medicine is to be given and when it is not and must include information of when variable doses can be given. The home must make sure that moving and handling and fire training is brought up to date for all care staff. When care staff are required to hand write on a medicine chart they should make sure that the member of staff writing the chart signs and dates it, and a second carer checks the entry for accuracy and then initials the chart. In addition the entry should include a reference to where this information was sourced, such as the prescriber`s name. The carpets in some corridors, which have become thread-are should be replaced in the near future before they become hazardous. CARE HOMES FOR OLDER PEOPLE Westlands Residential Home 3 High Street Olney Buckinghamshire MK46 4EB Lead Inspector Barbara Mulligan Unannounced Inspection 18th March 2009 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 Westlands Residential Home DS0000072826.V374701.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. Westlands Residential Home DS0000072826.V374701.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westlands Residential Home Address 3 High Street Olney Buckinghamshire MK46 4EB Telephone number Fax number Email address 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) 01234 711545 01234 713650 westlands@standrewscarehomes.co.uk www.standrewscarehomes.co.uk St Andrews Care Homes Ltd Mrs Susan Beynon Care Home 22 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Westlands Residential Home DS0000072826.V374701.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category (OP) 2. Dementia (DE). The maximum number of service users who can be accommodated is 22 N/a Date of last inspection Brief Description of the Service: Westland’s is a privately owned care home providing accommodation for twenty-two older people, and this can include individuals needing dementia care. The accommodation is over two floors and access to the first floor is via a shaft lift, stair lift or stairs. The home has seventeen single bedrooms and two shared rooms with most of the bedrooms having en-suite facilities. The communal areas are well placed on the ground floor. The home is located in the centre of Olney, a small market town, close to all local amenities and looks out on the towns high street. The home is close to the motorway network and road links to the city of Milton Keynes, it is also served by public transport. The fees for the home range from £475 per week. Westlands Residential Home DS0000072826.V374701.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 unannounced key inspection was conducted over the course of one day and covered all the key National Minimum Standards for older people. Prior to the visit, a detailed self-assessment questionnaire was sent to the manager for completion. Information received by the Commission since the last inspection was also taken into account. The inspection consisted of discussion with the registered manager and other staff, opportunities to meet with some people who use the service, examination of some of the home’s required records, observation of practice and a tour of the premises. A key theme of the visit was how effectively the service meets needs arising from equality and diversity. The inspection officer was Barbara Mulligan and the registered manager is Mrs Susan Beynon who was in attendance throughout the visit. Feedback on the inspection findings and areas needing improvement was given to the manager at the end of the inspection. The manager, staff and service users are thanked for their co-operation and hospitality during this unannounced visit. What the service does well: Potential service users receive a thorough needs assessment to ensure the home can meet the care needs of the service users. Detailed care plans have been produced for all people who use the service, and these inform the care staff what they must do to meet the needs of the individual. There is a motivated and established staff team that consists of care staff who respond to service users in a respectful and appropriate manner. The home provides a pleasant and comfortable environment in which people can live. Individuals are encouraged to personalise their own rooms with their own furniture and personal belongings. Communication between people who use the service and staff was observed to be positive and open. Westlands Residential Home DS0000072826.V374701.R01.S.doc Version 5.2 Page 6 The provision of meals and mealtimes are of a high standard. There is a robust recruitment procedure in place that ensures service users are protected from harm. There is a good range of policies and procedures, providing staff with relevant information about all aspects of care and the home/organisation. Health and Safety procedures are thorough and records are well maintained. The evidence seen and comments received indicate that this service meets the diverse needs e.g. religious, racial, cultural, disability of individuals within the limits of its 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. Westlands Residential Home DS0000072826.V374701.R01.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 Westlands Residential Home DS0000072826.V374701.R01.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): 3 and 6 Quality in this outcome area is good. Service users needs are thoroughly assessed prior to admission ensuring that staff are prepared for admission and have a clear understanding of the service users requirements. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four completed needs assessments were examined, including those most newly admitted to the home. The home uses the Alzheimer’s society method of strength-based person centred care planning which; looks at the whole person, and includes spiritual and holistic care planning. It provides information about a person’s medical history, the support needed with personal care, information about the stage of dementia, mobility, hearing and sight and aids worn, speech and well-being. Some areas in two of the initial assessments were not completed. These areas were a person’s life history and personal history. Westlands Residential Home DS0000072826.V374701.R01.S.doc Version 5.2 Page 9 There was good information within the initial assessment from the hospital about one person’s diagnosis and specific needs as a result of the diagnosis. As part of the initial assessment the home completes a well being and ill being assessment. This is reviewed on a monthly basis. This information is readily available to staff who are expected to refer to the documentation to meet service users care needs. It is noted that the service users have been asked their preferred name which is indicated throughout any further documentation seen, this is noted as good practice. The assessment demonstrates that prospective service users, family members or representatives are included in the assessment process if this is appropriate. The home offers a settling in period of one month and both parties are able to reassess the placement. A formal review is undertaken at between six and eight weeks when care plans are agreed. The home does not admit service users for intermediate care. Westlands Residential Home DS0000072826.V374701.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is excellent. People who use the service are very well cared for and this is supported by good record keeping, risk assessments and support from other health care professionals in the community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four care plans were examined during this inspection, including those most newly admitted to the home. These are detailed and informative and reflect the changing needs of the individual. Personal and healthcare needs are identified with a very detailed action plan setting out guidelines detailing how staff will meet those needs. There is evidence that care plans are reviewed monthly and it is noted that this is a thorough process. Daily notes are detailed and informative and record the personal care received and activities that the individual has undertaken through out the day. Chiropody Services visit the home on a four weekly basis. Westlands Residential Home DS0000072826.V374701.R01.S.doc Version 5.2 Page 11 Additional support is accessed through the local GP surgery, where service users can access physiotherapists, occupational therapists and speech therapists. The home receives district nurse support twice weekly and they are available for advice regarding pressure area care and can assist in the provision of pressure relieving equipment. Staff provide support to individuals needing to attend outpatient and other appointments. The registered manager stated that eye screening is undertaken annually this is carried out by a domiciliary service who will also carry out hearing tests. The care plans set out in detail the service users preferred routines, likes and dislikes and partnerships with families, friends and relevant professionals outside of the home. The nutritional needs of service users are identified at the assessment stage and their weight is monitored on a regular basis. Referrals to the dietician are made via the individuals GP. There is a domiciliary dental service that visits the home on a needs only basis and service users can visit the local dentist. Healthcare information is recorded in detail in all files looked at. The procedures for the administration of medicines were examined during this inspection. Medication Administration Records (MAR), storage and policies and procedures were examined. At the time of the visit there were no people using this service who were able to administer their own medicines and there are detailed risk assessments in place for this. Medication records show no omissions. However, on several MAR charts there were handwritten entries and it is strongly recommended as good practice that when it is necessary to handwrite on a medication administration record chart in the home, the member of staff writing the chart signs and dates the chart and a second carer checks the entry for accuracy and then initials the chart. In addition the entry should include a reference to where this information was sourced, such as the prescriber’s name. There are systems in place to ensure that controlled drugs are handled in line with the Misuse of Drugs Regulations 1973. The Controlled drugs register was examined and this was up to date with no omissions noted. Training records demonstrate that staff have undertaken either distance learning training or training from the supplying pharmacist. There are no written guidelines for many “as required” (PRN) medicines and this is often left up to individual care staffs discretion to administer. A requirement is issued for the home to implement a system to be put in place that ensures service users plans include guidelines for the administration of all when required/when needed medicines. These guidelines must include when the medicine is to be given and when it is not and include a strategy for when variable doses can be given. Westlands Residential Home DS0000072826.V374701.R01.S.doc Version 5.2 Page 12 The inspector observed staff assisting people who use the service in a kindly and respectful manner. Staff are obviously aware of the importance of privacy and dignity and were seen to always knock on doors before entering and always addressing the individual by their preferred term of address. Preferred terms of address are identified at the initial assessment and the inspector saw evidence of this in care plans. The homes induction programme includes training regarding privacy and dignity. The Statement of Purpose and Service Users Guide include information about maintaining the privacy of service user’s. Service users can have a key to their rooms if they wish to use this facility and it is felt to be safe. Westlands Residential Home DS0000072826.V374701.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): 12, 13, 14 and 15 Quality in this outcome area is good. There is a range of activities available to residents who are encouraged and supported to follow their own interests, remain in contact with their families and friends and are supported to use local community facilities ensuring people do not become socially isolated. The presentation and standard of food is good and meets the nutritional needs of people who use the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans show individual routines of daily living and include bathing, rising and retiring times. As part of the admission process, the home complete usually complete a life history of the individual, to give staff information about previous leisure pursuits, hobbies and other interests. However in three of the four files observed this information was only completed in one file and there was limited information in three care plans about the individuals social care needs and how these are to be met. This needs to be addressed. The inspector was shown a further four files where this information has been well recorded. Westlands Residential Home DS0000072826.V374701.R01.S.doc Version 5.2 Page 14 The registered manager said that an activities programme is in place and activities are carried out on a daily basis depending on what the service users wish to do. There is a dedicated member of staff who undertakes the provision of activities. She was until recently supported by a senior carer. At the time of the visit the senior carer had left employment and the dedicated staff member was on sick leave. On the day of the visit several people were going out into the village to undertake personal shopping. A member of staff has undergone training & has successfully qualified as a Leader of Armchair exercises. She now organises exercise classes for service users and this has been timetabled in to the activity programme for the home. Service users are able to receive visitors in the privacy of their own rooms, and are able to choose whom they see and do not see. There are no restrictions on visiting, and this is documented in the Service Users Guide. Involvement by local community groups includes the local church and regular visits by the hairdressers and barbers and various visiting entertainers. Examples of involvement in the home by local community groups and individuals are visits by mobile hairdressers, various visiting entertainers and a monthly church service. Service users are able to receive visitors in the privacy of their own rooms and are able to choose whom they see and do not see. There are no restrictions on visiting, and this is documented in the Service Users Guide. Family and friends are invited to participate in some of the social event organised. The home provides information about outside agencies such as advocates and the home subscribes to Care Aware Advocacy service. People who use the service have a good level of autonomy. During the visit people were seen to go out when they requested, or stay in their room and receive visitors throughout the day. There is a residents meeting on a monthly basis. Minutes are kept of these meetings and were looked at by the inspector. These demonstrate that issues raised by people using the service are acted upon and recorded in the minutes. There is a notice board, which advertises the residents meetings and activities, and events organised by the home. Service users are offered three meals a day. The menu is rotated on a four weekly cycle. The inspector had the opportunity to observe a lunchtime meal in the main lounge where one person was having their lunch. This person has specific needs with feeding and the staff member supporting this individual was observed to have a good understanding of the persons needs and was seen to follow the guidance set out in the service users care plan. The meal was relaxed, unrushed and well organised. The food was attractively presented and the inspector was told that service users can take their meals in their rooms if they wish which some people chose to do on the day of the visit. Westlands Residential Home DS0000072826.V374701.R01.S.doc Version 5.2 Page 15 The home offers drinks and snacks throughout the day in accordance with needs of the service users. There is good nutritional and regular monitoring in all care plans seen. Westlands Residential Home DS0000072826.V374701.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. There are policies and procedures in place to protect people who use the service from harm and the home has an effective complaints procedure to ensure that people who use the service or their representatives are listened to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector examined the homes complaints procedure which illustrates timescales and how complaints are dealt with, and discussed how complaints are managed by the home. The registered manager said she welcomes any complaints or concerns and actively encourages residents and relatives to raise any issues they have at the earliest opportunity. The inspector examined the complaints log which details one complaint about the standard of the laundry. This has been responded to within the stated timescales, has been well recorded and resulted in a satisfactory outcome. A summary of the complaints procedure is included in the Statement of Purpose and Service Users Guide. No complaints or concerns have been received by the Care Quality Commission since the last inspection. Procedures are in place for safeguarding vulnerable adults and staff have access to a whistle blowing policy. The home has a copy of the local authority SOVA policy. Westlands Residential Home DS0000072826.V374701.R01.S.doc Version 5.2 Page 17 Training records demonstrate that staff have completed Safeguarding training and this is regularly updated and the registered manager has attended the Stage 2 SOVA course, Awareness of Investigations. The Annual Quality Assurance Assessment tells us that there have been twelve safe guarding referrals in the previous twelve months and these have been dealt with appropriately and in line with the local authority safeguarding procedures. The home has continued to keep the Commission informed of any safeguarding incidents. Westlands Residential Home DS0000072826.V374701.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 25 and 26. Quality in this outcome area is good. The standard of the environment within the home is good, providing people who use the service with an attractive and homely place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector toured the building and the gardens. Overall all areas were found to be cleaned to a high standard, and the furnishings and fittings are of a good quality. There were no offensive odours, and the rest of the building and grounds are well maintained. Since the previous inspection the garden has been redesigned & landscaped to take in the needs of the people using the service. All the communal living areas have been redecorated, refurnished and all soft Westlands Residential Home DS0000072826.V374701.R01.S.doc Version 5.2 Page 19 furnishings replaced. A kitchenette area has been created for service users and relatives to use. The homes main kitchen has been upgraded and new kitchen equipment has been purchased and installed. There are two main areas available for dining. There is one small dining area and another small conservatory area where service users take their meals if they require assistance to feed. These have been redecorated and are bright and spacious. Carpets for carpets in some corridors are threadbare and will need to be replaced in the near future before they become hazardous. This is recommended. There are accessible toilets available for service users throughout the home and several are close to the lounges and dining area. Laundry facilities are sited so that soiled articles, clothing and infected linen are not carried through areas where food is stored, prepared, cooked or eaten and do not intrude on service users. The laundry floor finishes are impermeable and these and the wall finishes are readily cleanable. The home has an infection control policy and the inspector observed this. Instructions are in place for the washing of soiled linen. Westlands Residential Home DS0000072826.V374701.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 AND 30 Quality in this outcome area is good. The staffing numbers and skill mix is satisfactory and staff training is sufficient and up to date to ensure that people who use the service benefit from staff who are who are competent to do their job. Recruitment procedures are undertaken to ensure staff have the right skills and competencies to support the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes staff rota demonstrates that there are adequate numbers and skill mix of staff on on duty at all times. The registered manager confirmed that there were additional staff on duty at busy times of the day. The deputy manager and the manager are supernumerary on the roster, allowing for flexibility during peak and holiday periods. The home employs bank staff to cover additional shifts and agency staff are used so that the home’s staff ratio is maintained. The inspector was told that the home uses one agency for staff and are keen to ensure that there is continuity regarding the staff they provide. The care team are also supported by full time housekeeping laundry and catering teams. The recruitment files for a selection of staff were examined including those new to the service. All files looked at contain the necessary documentation as detailed in schedule 2. There is evidence that all staff CRB Westlands Residential Home DS0000072826.V374701.R01.S.doc Version 5.2 Page 21 checks had been obtained and references had been undertaken before the staff member started work. All staff complete the five day common induction standards course via Milton Keynes Council. This is in conjunction with its own induction package. During the induction period the new employee is paired up with an experienced staff member. Training records showed that generally staff are up to date with mandatory courses. The home has its own dedicated room for training. All senior staff have attended a 2 day workshop on person centred dementia care and other care staff have attended a one day version of this training. The home has enrolled on the Skills for Care Passport Scheme, so that each staff member has received a personalised development plan. Westlands Residential Home DS0000072826.V374701.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. The home is well managed by a stable experienced management team and service users are protected by safe working practices ensuring the health and safety of people using the service. However some updating of mandatory training is required to ensure staff remain competent to undertake their jobs safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has been in post for almost a year and has completed her NVQ 4 in care, the Registered Mangers Award and is currently working towards a degree in Health and Social Care with the Open University. She undertakes regular training courses and continual professional development to Westlands Residential Home DS0000072826.V374701.R01.S.doc Version 5.2 Page 23 develop her skills further. The manager is supported by an area manger who also and holds NVQ L4 in care and the Registered Manager’s Award. The organisation & home has a clear and accountable management structure and the Manager is supported by the Area Manager, Managing Director and Development Director. The inspector noted good teamwork in progress and all the staff spoken to had a good working knowledge of the individual residents and their care needs. The home has implemented a Quality Assurance system that that includes regular clients meetings and sending out an annual service user surveys. Issues raised through the previous service satisfaction questionnaires were seen to have been addressed and at the time of this visit these had been sent out again and the manager was waiting for them to be returned. The registered providers undertake monthly Regulation 26 visit and the home presently uses the Blue Cross Mark of Excellence Quality Assurance system. This covers all the standards relating to older people. Service users are encouraged to look after their own financial affairs where at all possible. If this is not practicable then families will undertake this role. There are secure facilities available for the safe-keeping of money and valuables and record and receipts are kept of possessions left for safe keeping. Records were seen for fire safety. These cover the homes fire procedures, practice fire drills, fire prevention, fire alarm testing and emergency lighting testing. Testing of the homes fire alarm system is undertaken on a weekly basis and evidence was seen of this. There is a fire based risk assessment that is reviewed annually and id dated 11/04/2008. The last visit by the local fire authority was undertaken on 09/02/09 and no requirements were issued. Evidence of mandatory health and safety training demonstrates that staff are mainly up to date with mandatory training. However some moving and handling training needs to be updated for a small number of staff and fire training records show some staff have not completed this since 2006. A requirement is issued for improvement in this area. Service reports are in place for PAT testing dated October 2008, the certificate for electrical installation expires in December 2009, legionella April 2008 and Gas dated September 2008. The inspector looked at Infection Control guidelines that are available for all staff. Westlands Residential Home DS0000072826.V374701.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 x x x N/a HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 x x 3 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 4 x 3 x 3 X x 3 Westlands Residential Home DS0000072826.V374701.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 OP9 Regulation 13(2) Requirement The registered person is required to ensure the home implements a system to be put in place that ensures service users plans include guidelines for the administration of all when required/when needed medicines. These guidelines must include when the medicine is to be given and when it is not and include a strategy for when variable doses can be given. The registered person is required to ensure that moving and handling and fire training is brought up to date for all care staff. Timescale for action 30/06/09 2 OP38 18(1) 30/07/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Westlands Residential Home DS0000072826.V374701.R01.S.doc Version 5.2 Page 26 1 OP9 It is strongly recommended that when it is necessary to handwrite on a medication administration record chart in the home, the member of staff writing the chart signs and dates the chart and a second carer checks the entry for accuracy and then initials the chart. In addition the entry should include a reference to where this information was sourced, such as the prescriber’s name. It is recommended that the carpets in some corridors, which have become thread bare, be replaced in the near future before they become hazardous. 2 OP19 Westlands Residential Home DS0000072826.V374701.R01.S.doc Version 5.2 Page 27 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 Westlands Residential Home DS0000072826.V374701.R01.S.doc Version 5.2 Page 28 - 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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