Care Home: Westleigh

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What the care home does well The home has a clear, detailed statement of purpose and service users guide in place; these documents provide sound information about the services and facilities that able to be provided at the home. Good standards of care and service delivery remain at the home. Those spoken with during the inspection said they were happy and enjoyed life at the home. The staff team at Westleigh are caring and have developed good relationships with those who live at the home; they have an understanding of the needs of individuals and support them appropriately.Staff attend ongoing training courses in order to enable them to meet individual`s needs and ensures that they have the skills needed to support people living at the home. What has improved since the last inspection? Those living at the home, and those considering moving into Westleigh are provided with clear accurate information about the age ranges of people who are able to be supported as the service users guide and the homes statement of purpose have now been updated to include this information. Those living at the home can feel confident that the home have maintained clear and accurate information about their support needs as care plans have been kept under review with them and their family where appropriate. Care plans are dated with full details of changed needs. What the care home could do better: In order that those who are considering moving into Westleigh can be confident that the home will be able to meet their needs it is required that the home obtains full and detailed care management assessments, prior to people visiting and spending the day at the home. In order that those who live at the home can be assured that staff have the appropriate knowledge and skills and are able to perform their duties in a safe manner it is required that staff receive protection of vulnerable adults training. In order to ensure the safety and security of those who live and work at the home it is required that the exit door near the staff room at the rear of the home is repaired or replaced and furthermore the home completes a risk assessment to review the security of the home. A new manager has been appointed at the home, in order that those living and working at the home can be confident that she is able to fulfil the duties and responsibilities of a Registered Manager it is required that the manager submits an application to The Commission in order that an assessment of her `fitness` in undertaken. In order that the home is providing The Commission with full and accurate information it is recommended that the home obtain a copy the new Regulation 37 notification forms. CARE HOMES FOR OLDER PEOPLE Westleigh 17 Summerhill Terrace St George Bristol BS5 8HX Lead Inspector Odette Coveney Key Unannounced Inspection 20 March 2008 08:30 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 Westleigh DS0000036976.V354853.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. Westleigh DS0000036976.V354853.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westleigh Address 17 Summerhill Terrace St George Bristol BS5 8HX Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0117 9031062 0117 9551271 westleigh.eph@bristol.gov.uk Bristol City Council To be appointed Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Westleigh DS0000036976.V354853.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th November 2006 Brief Description of the Service: Westleigh is a local authority care home managed by Bristol City Council and is located in the residential area of St George. It provides accommodation for up to 40 individuals and is registered to provide personal care for older people aged 65 and over. There are a number of communal areas including dining room, small lounges, and garden and patio area. The home is on two floors with lift and is fully equipped to meet the needs of residents. Fees are £451.99 per week and extra charges are made for chiropody, hairdressing etc. Currently this information is initially only provided verbally prior to admission. Westleigh DS0000036976.V354853.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 stars. This means the people who use this service experience Good quality outcomes. This unannounced key standard site visit, it was carried out in one day over an 8-hour period by one inspector for the Commission. The purpose of the visit was to establish if the home is meeting the National Minimum Standards and the requirements of the Care Standards Act 2000 and to review the quality of the care provision for the individual’s living in the home. Prior to the site visit we received from the home a completed an annual quality assurance assessment (AQAA). The annual quality assurance assessment is a new process that is being used for all regulated services from April 2007. An opportunity was taken to view the home and a number of the records relating to the management of the home and plans of care for four individuals were reviewed. 53 comment cards were received prior to the visit, 11 of these were from relatives of those who live at the home, 22 were from individual’s who live at the home, 18 were from staff who work at the home and the 2 other comment cards were from visiting health professionals who visit individuals at the home. Comments made were reviewed during the visit and these, maintaining individual’s confidentiality, were shared with the manager and some have been incorporated within this inspection report. What the service does well: The home has a clear, detailed statement of purpose and service users guide in place; these documents provide sound information about the services and facilities that able to be provided at the home. Good standards of care and service delivery remain at the home. Those spoken with during the inspection said they were happy and enjoyed life at the home. The staff team at Westleigh are caring and have developed good relationships with those who live at the home; they have an understanding of the needs of individuals and support them appropriately. Westleigh DS0000036976.V354853.R01.S.doc Version 5.2 Page 6 Staff attend ongoing training courses in order to enable them to meet individual’s needs and ensures that they have the skills needed to support people living at the home. 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. Westleigh DS0000036976.V354853.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 Westleigh DS0000036976.V354853.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): 1, 2, 3, 5, 6. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Prospective residents have information available to them about the services and facilities provided at Westleigh. The home has an admissions process, however, in order to ensure that they are able to support people it is essential that the home obtain a copy of individuals care management assessments. Prior to people being admitted into the home. EVIDENCE: During the last site visit to the service which was undertaken in November 2006 it was required that the Statement of Purpose and service users guide must be very clear about the age range of people that can be admitted into the home. It was also required that these documents must contain information about the costs of the service. We reviewed these documents during this visit and found that the requirement had been met and the documents had been Westleigh DS0000036976.V354853.R01.S.doc Version 5.2 Page 9 ammended accordingly. Those living at the home are provided with copies of these documents within an information pack that they are given upon admission into the home. This pack also contains information about the philosophy of care provided, information about staff training and qualifications, a copy of the individuals care plan and how to make a complaint about the service. People we spoke with showed us copies of these packs and said that the information given was ‘useful’ and ‘informative’. On the day of our visit a gentleman was visiting with a view to possibly moving into the home, the home had no information about why the man wanted to move from his existing home or what support and care he needed. This is essential in order that the home can be sure they are able to meet this person needs. We spoke with this person who said they he was enjoying his day and the staff were ‘kind and seemed very nice’. It is required that assessments must be obtained by the home as part of the admissions process for people being admitted into the home. All people who live in a care home, whether they are self-funding or not should have a contract in place which outlines their rights and the responsibilities expected of them and of the people who provide the service. We reviewed some contracts whilst we at the home and found they contained all of the required information, they were sufficiently detailed and provide clear information about the terms and conditions of the placement. Intermediate care is not provided at this home. Westleigh DS0000036976.V354853.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, 10. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. People living at Westleigh are well supported with their needs by staff. Care plans reflect individual’s current personal care and health needs. The practices for storage and administration of medication are safe. EVIDENCE: During the last visit we undertook to the home in November 2006 it was required that the home must ensure that care plans are kept under review with the individuals and their family where appropriate. The care and associated documentation for four people were fully examined during this site visit. All care plans reviewed had been well maintained and have been kept under review and showed a clear understanding of individuals’ needs they contained clear guidelines for staff. The home are currently introducing ‘Personal History Profiles’, these are to obtained additional information about those who live at Westleigh in areas such as childhood, adolescence, adulthood, retirement, previous holidays and interests. The manager of the home Lesley Tranter also told us that she is planning to improve the quality of information provided Westleigh DS0000036976.V354853.R01.S.doc Version 5.2 Page 11 within the care plans in order that they are more ‘person centred’ and are written in a way which clearly shows that the resident has been involved in how they are supported with their care. We look forward to reviewing progress in this area at our next visit to the service. All of the people living at the home are allocated a key worker; staff spoken with had a clear understanding of their role and responsibilities in this area. Staff members we spoke with also had full understanding of the needs of those living at the home. Staff clearly identified the values that the home promotes and to be afforded to the individuals living at the home: Dignity, Rights and Privacy. All the care documentation and related information seen promoted good care based on the above values. Risk assessments in respect of activities of daily living had been completed, as had moving and handling assessments. These contained information in order to support those living at the home in a safe way. Two comment cards were received from health professionals prior to the visit at Westleigh, these recorded that the home the home communicates clearly and works in partnership with them, that staff demonstrate a clear understanding of the care needs of residents and that they are satisfied with the overall care provided to residents at the home. Thorough examination of care documentation it evidenced that individuals are well supported with their health care requirements in order to access services. There were records of when individuals have been visited by dentist, optician’s district nurses and general practitioners. Records showed that where there had been concerns about individual’s health the home had made prompt contact with the GP or other services that have been needed, such as end of life care. A comment from an individual who lives in the home was: “If ever I need a doctor he is always here within the day”. All responses from those who live at the home to ‘Have Your Say’ questionnaires said that they “always” receive the medical support they need. Procedures for medication administration, handling, records and storage were assessed. The home had policy and guidelines on medication. A local pharmacy provides medication using a monitored dosage system. A check of the medication packs indicated that medication had been administered as recorded. All medication seen was stored securely. The pharmacy supply printed medicines administration record sheets. Records of administration of medicines were clear. Records are kept of medicines received into the home. Waste medication is recorded and disposed of via the supplying pharmacy. We spoke to a number of individuals about how they felt they were treated by staff specifically whether they felt they were treated with respect: there was very positive response from all we spoke with: “they always treat me as I Westleigh DS0000036976.V354853.R01.S.doc Version 5.2 Page 12 would want to be treated”, “ Yes they do, always knock on my door, very much so”, “ I am given my privacy when I want it and staff listen to my point of view”. During the visit we observed the staff talking and assisting individuals. This was always done in a sensitive, caring and respectful manner. The atmosphere in the home on the day of the visit was relaxed. Staff, the manager and those living at the home were observed to have good relationships. Staff responded to the needs of people in a polite and professional manner. Westleigh DS0000036976.V354853.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, 15. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The arrangements for meeting the social and recreational needs of people living at the home are good and there are opportunities for people to maintain links with family, friends and the local community. The home’s practice and routines are flexible and enable individuals to exercise choice and have control over their lives. The home provides meals, which are balanced and meet the dietary needs of individuals in the home. EVIDENCE: Information we saw showed that the individuals living at the home are provided with a variety of social activities and are able to participate or not. This is dependent on the individual’s choice. On the day of the visit those living at the home told us about the preparations for Easter and the craftwork they had been involved with, people said they had had fun making Easter Bonnets and were looking forward to going to a religious service on Good Friday. People Westleigh DS0000036976.V354853.R01.S.doc Version 5.2 Page 14 were seen playing dominos and appeared to enjoy the social interaction with staff and each other. The home recognises the importance of individuals maintaining contact with family and friends and there is an open visiting policy. In speaking with individuals who live in the home they spoke of how their visitors “are always made welcome” “no problem with people visiting me, always friendly” “staff all very friendly”. All relative responses to the questionnaires, which were sent out to them prior to our visit, said that they were welcomed by staff when visiting the home. Staff we spoke with confirmed that the home would contact individual’s next of kin should they need to be they need to be informed of issues, which affect the well being of an individual living at the home. At a brief walk around the building people were seen spending time in their bedrooms and the communal lounges. Daily records of care showed that those living at the home are able to choose when to get up and retire, what to eat/drink and how they were to be assisted with aspects of their life. There is a bar at the home which is well frequented by those who enjoy a drink at the home, the home also operate a shop in which people can purchase everyday items such as sweets and toiletries. Meetings are held regularly with those who live at the home and the management in order that their views and thoughts about the service, which is provided at Westleigh, can be discussed. At the most recently meeting held in January 2008 it was evident from notes seen that people are listened to and the points they raised are acted upon appropriately. There is a clean, well-stocked kitchen. Individuals are offered choices and individuals special dietary needs are catered for, it was also seen that individuals likes and dislikes were recorded and responded to appropriately. We observed people having their meal at breakfast and at lunchtime. The meals were relaxed and people were given the meals based on the choices they made after consultation on the meals available to them. Of the comment cards received from people who live at the home prior to the visit they said that they enjoyed meals provided at the home and are offered choices and the variety of meals available to them. Westleigh DS0000036976.V354853.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): 16, 17. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home has procedures in place enabling individuals to make a complaint and voice their views about the service they receive and know that they will be listened to and actions taken where necessary. The home makes sure that as far as possible those living at the home are protected from harm by having policies and procedures about the Protection of Vulnerable Adults. EVIDENCE: In talking with individuals who live in the home they were all very positive about their ability to make a complaint and were aware of the complaints procedure, which is included in the home’s Information Pack and displayed in the home. One individual said they had been “given the complaints procedure in writing”. When asked what they would do if unhappy about anything individuals said, “would tell staff”, “would speak to someone” and importantly, “staff listen”, “they listen to you here”. All respondents to the questionnaire said they knew how to make a complaint. No concerns were raised to us during this site visit. The home has a complaints policy and procedure this shows a clear timeline and action to be taken in event of a complaint. It also directs the complainant to the Commission and Bristol City Council Social Services. Westleigh DS0000036976.V354853.R01.S.doc Version 5.2 Page 16 The home has an Adult Protection policy and procedure and there has been some training for staff in the area of Adult Protection. Recently someone attempted to break into the rear of the home. The home responded promptly to ensure the safety and security for those who live at the home. Alarms are in place on exit doors and security sensor lights are also in place. It is required that in order to ensure that nothing further can be done to ensure people are not put at risk it is required that a risk assessment is undertaken to review the security of the home. Westleigh DS0000036976.V354853.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 25, 26. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Westleigh provides a safe, well-maintained and hygienic environment for those who live and work at the home. EVIDENCE: Westleigh is a detached property in keeping with the local neighbourhood. There are shops and local amenities although the shops are not within a close walking distance. The home is situated within fairly close proximity of the Avon Ring Road. There are bus routes near to the home. The home is also within easy reach of local retail and leisure outlets. Accommodation is on two floors with passenger lift in place for those with mobility difficulties. Westleigh DS0000036976.V354853.R01.S.doc Version 5.2 Page 18 There are adaptations in place throughout the Home and specialist equipment including; rise and fall beds, a stand aide, hoists, mobility aids, sensory aids, a passenger lift and bathing aids. There is a spacious dining area and comfortable lounge areas for people to use. Individuals were observed sitting in the lounges, the dining room and going into their rooms, looking very relaxed and comfortable in their environment. The home is ‘homely’ with soft furnishings such as plants, ornaments, footstalls and pictures and photographs, all enhancing the areas within the home. The home has as bar, as previously mentioned, this area has been extended and refurbished making a much-improved area for residents use. The home also has a games room in which there is a pool table and bar skittles for residents to enjoy. The home has sufficient bathroom areas for individuals with both shower and bathing facilities in place. Due to a recent attempted break in at the home the door in which an attempted entry was made a door had been damaged and a temporary repair had been made. It is required that the exit door must be repaired or replaced to ensure that security is maintained. Whilst at the home we saw domestic staff in the kitchen and in the house going about their duties, the home was clean and well maintained with no odours. Westleigh DS0000036976.V354853.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those living at the home are cared for by sufficient numbers of competent staff that are provided with training to fulfil their roles and responsibility, however staff would benefit from protection of vulnerable adults training. EVIDENCE: On the day of the site visit there were sufficient numbers of staff on duty with flexible working by staff in order to meet individual’s needs and aspirations. Staffing provision appeared to be consistent with levels and skills needed due to assessed care needs of the individual’s. The staff team have a varied range of knowledge and skills, they were observed by us to be good listeners, effective communicators and were interested and motivated in meeting the needs of those living at the home. A comment card received prior to the site visit, which had been completed by a relative of someone who lives at the home, recorded that ‘all staff appear to be caring and considerate’. A review of training which has been undertaken by staff evidenced that staff provided with opportunities to develop their knowledge and skills, training which has been undertaken since our last visit to the home has included; first aid, food hygiene and manual handling. It is noted that there are a number of Westleigh DS0000036976.V354853.R01.S.doc Version 5.2 Page 20 staff who have not completed safeguarding of adults training, in order that staff have the information and skills needed to respond appropriately to potential abuse it is required that staff at the home must complete protection of vulnerable adults training National Vocational Qualifications are well promoted within this home and most of staff have achieved or are working towards an NVQ in care practice. The recruitment and selection documents for staff were not reviewed at this visit and there have been no previous concerns in this area during our visits, however this area will be fully examined at our next visit to the service. Westleigh DS0000036976.V354853.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36, 37, 38. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. There are good opportunities for those who live at the home to express their views about the service they receive. The practices of the home help to make sure that the health, safety and welfare of those who live and work art the home are protected. EVIDENCE: The manager of Westleigh, Lesley Tranter has extensive experience over a number of years of caring for older people. Ms Tranter has obtained a National Vocational Qualification, NVQ, at Level 4 in Care management and is also an assessor for NVQ. Individuals we spoke with were all very positive about her approach and how they “could always go and talk to her about anything”; “she is someone we can talk to”. Staff also described her as “approachable”. The Westleigh DS0000036976.V354853.R01.S.doc Version 5.2 Page 22 manager was previously an assistant manager at the home and ‘acted up’ into the manager’s position to cover the absence of the former manager. Ms Tranter was successful in March 2008 in her application to be the permanent manager at the home. Ms Tranter has not yet contacted the Commission formally in order to inform us of her position. It is required that Ms Tranter must submit an application to us in order that her ‘fitness’ to be the Registered Manager of the care home is agreed. A number of records were reviewed as part of this inspection process, these included care documentation, staffing records, health and safety records and policies and procedures, which direct and guide practice at the home. The home is owned and operated by Bristol City Council. The home is one of 13. Meetings have been held recently in order to discuss proposals to possibly close 8 and keep 5 of the care homes, with a focus on the council providing a service for those who have a dementia. No final decision has been reached and consultation with those who live and work at the service is currently ongoing. It is important to note that although this is a difficult and unsettling time for all this does not appear to have impacted on the quality of service provided to those who live at the home and morale, at this time, does not appear to have been affected. There was evidence that the home ensures so far as is reasonably practicable. the health and safety of resident’s staff and visitors. The home has robust policies and procedures in relation to aspect of health and safety. The home underwent a Health & Safety Inspection in October 2007 by an independent corporate advisor, the home are to be commended for achieving 99 compliance. The home has manual handling assessments in place and these outline information about the support needed for those who live and work at the home. The home have kept us informed of incidents which have affected the wellbeing of those who live at the home and have responded appropriately to each situation as and when it occurred, in order that the home are using the correct documentation to report incidences to us it is recommended that the home obtain a copy of the new CSCI Regulation 37 notification. The fire logbook was viewed and was well maintained. The home was completing the appropriate checks on the fire equipments and recording of training and testing of equipments were satisfactory. Staff have attended fire drills to ensure that they have clear knowledge of action to be taken in the event of fire emergency. The home has systems in place for the appraisal of staff performance and supervision in order to manage and guide staff practice. Westleigh DS0000036976.V354853.R01.S.doc Version 5.2 Page 23 Review of the scheme’s Annual Quality Assurance Assessment and discussion with the manager also demonstrated that she is aware of the strengths and areas for improvement within the home and she has a clear vision for how the service provided at Westleigh will develop over the next twelve months. This includes reviewing barriers to improvement, these were identified and recorded how the home have tried to reduce the impact of the barriers and how the home demonstrates it provides value for money. Westleigh DS0000036976.V354853.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 3 3 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 2 3 3 3 3 3 X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X 3 3 3 Westleigh DS0000036976.V354853.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 OP19 Regulation 23 (2) b Requirement The exit door by the staff room must be repaired or replaced to ensure that security is maintained. A risk assessment to be undertaken to review the security of the home. Staff at the home must complete protection of vulnerable adults training. The manager must submit an application to The Commission in order that her ‘fitness’ to be the Registered Manager of the care home is agreed, Assessments must be obtained by the home as part of the admissions process for people being admitted into the home. Timescale for action 20/04/08 2. 3. 4. OP18 OP30 OP31 13 (4) c 13 (6) 8 20/04/08 20/07/08 20/05/08 5. OP3 14 (1) a 20/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Westleigh DS0000036976.V354853.R01.S.doc Version 5.2 Page 26 No. 1. Refer to Standard OP38 Good Practice Recommendations The home to obtain a copy of the new CSCI Regulation 37 notification. Westleigh DS0000036976.V354853.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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