Care Home: Westvilla (MPs) Ltd

What the care home does well People living at Westvilla find the lifestyle they experience, matches their expectations and preferences. They exercise choice and control over their lives and they receive a wholesome and balanced diet in pleasant surroundings. People who live at the service and their relatives are confident that any complaints or concerns will be listened to, taken seriously and acted upon. The management and staff ensure people are safeguarded from harm. People`s financial interests are safeguarded. People are consulted about the running of the home and their views are taken into account when any decisions are being made that may affect them. Quality Assurance Systems are in place to record and capture these views. Westvilla offers the people who live there a clean and well-maintained environment. The atmosphere in the home is welcoming and homely and it is furnished and decorated to a high standard. Care plans are in place and provide a lot of information about what people do and don`t like, about their routines and their families. This told us that the staff promote choice about how people live their lives and treat people with dignity and respect. We found that people`s religious and cultural needs are met at the home and the activities provided for people are varied according to need, choice and ability. Some people we spoke with said they enjoy their own company and this is respected. Family and friends are welcomed into the home, and told us they are pleased with the care being provided. What has improved since the last inspection? Westvilla is registered as a new service as it was purchased by the current owners in August 2009. A programme of refurbishment has commenced and will continue until the new owners achieve the standard of accommodation they are striving to provide. Staff training is under review and a new training matrix is being developed to ensure that all staff receive mandatory training as well as additional training to enable them to provide a high standard of care and support to people. A number of policies and procedures are also being revised to ensure best practice at Westvilla. What the care home could do better: This inspection did not identify any areas that need improvement but throughout discussion with the management of the home, it was evident that they will continue to strive to improve all areas of their service through further development of quality assurance systems and staff training. The new owners of Westvilla assured us that they will continue their programme of refurbishment and then maintain the home at a high standard. Staff files and training will continue to be reviewed and kept up to date.Security in the clinical room would benefit from being improved. Key inspection report Care homes for older people Name: Address: Westvilla (MPs) Ltd Westfield Road Retford Notts DN22 7BT     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Angela Starr     Date: 1 4 0 1 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 28 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: Westvilla (MPs) Ltd Westfield Road Retford Notts DN22 7BT 01777701636 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Westvilla (MPS) Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: care home 35 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 past or present alcohol dependence dementia old age, not falling within any other category physical disability Additional conditions: The registered person may provide the following categories of service only Care home with nursing Code N to service users of the following gender Either whose primary care needs on admission to the home are within the following categories Older persons code OP The maximum number of service users who can be accommodated is 35 Date of last inspection Brief description of the care home Situated in the market town of Retford in Nottinghamshire, Westvilla is a privately owned Care Home that currently provides for up to 35 people. The home was purchased by the present owners in 2009. They have a commitment to ongoing refurbishment and improvement, including the purchasing of new furniture, Care Homes for Older People Page 4 of 28 0 0 0 0 Over 65 0 0 35 0 Brief description of the care home fittings and re-decoration. They have plans to enhance the use of the current accomodation. The bathrooms have already been re-fitted to a high standard and there are plans to provide a dedicated hair salon. Westvilla is able to provide Nursing and Residential care to people with varying needs and abilities on an individual basis. The fees start at £366.00 per week, rising to £652.00 for people with extensive nursing needs. Care Homes for Older People Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The focus of Inspections undertaken by the Care Quality Commission is upon outcomes for people who use the services and their views on the service provided. This process considers the providers capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. We ask managers to fill in a questionnaire called an Annual Quality Assurance Assessment, which tells us about how well their service provides for the needs of the people who use it and how they intend to improve their service. We received this back from the manager within the required timescale and the form was completed in a satisfactory manner, providing us with information to assist in planning our visit and deciding what areas to look at. We also reviewed all the information we have received about the service since we last visited and we considered this in planning the visit and deciding what areas to look at. Care Homes for Older People Page 6 of 28 The main method of Inspection we use is called case tracking which involves us selecting a number of people who use the service and looking at the quality of the care they receive by speaking with them, observation, reading their records and asking staff about their needs. We also sent Have Your Say questionnaires to a random selection of people who use the service and some staff members. The information provided in the replies we received, was also a contributory factor in the focus of our inspection visit. We spoke with three members of staff, three people who use the service and two relatives to form an opinion about the quality of the service being provided. We read documents as part of this visit and medication was inspected to form an opinion about the health and safety of people who use the service. Care Homes for Older People Page 7 of 28 What the care home does well: What has improved since the last inspection? What they could do better: This inspection did not identify any areas that need improvement but throughout discussion with the management of the home, it was evident that they will continue to strive to improve all areas of their service through further development of quality assurance systems and staff training. The new owners of Westvilla assured us that they will continue their programme of refurbishment and then maintain the home at a high standard. Staff files and training will continue to be reviewed and kept up to date. Care Homes for Older People Page 8 of 28 Security in the clinical room would benefit from being improved. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 28 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who want to live at the service have their needs assessed and can be assured these will be met. They receive good quality information about the service to enable them to make an informed choice about living there. The service does not have provision for intermediate care so this standard was not assessed. Evidence: The information provided to us by the acting manager of Westvilla told us Prior to admission, service users have a pre-admission assessment completed which enables us to determine if we can meet their needs and therefore offer them a place. Potential residents are encouraged to view the home unannounced so they can view first hand, meal times and any other activities which are occurring in the home. There are no restrictions on visiting. We explain the services that the home provides and have a copy of the latest inspection report available for them to view. Details of the potential Care Homes for Older People Page 11 of 28 Evidence: client are taken, fee prices are explained and a service user guide is given. We currently advise prospective service users and their families of the changes we plan to make and show them around all areas of the home. People considering living at the service are seen by a senior member of staff and a full pre-admission assessment is completed to ensure that each persons needs can be met. Where it is appropriate, a persons relatives and any other relevant party are involved in this process. As part of our case tracking process, we looked at files for three people who currently live at Westvilla and all three contained documentation to support the above statements. Before undertaking the inspection visit, we sent questionnaires to people who live at the service and to members of staff. The completed surveys we received told us that people were given good and sufficient information to assist them with their decision to move to Westvilla. Staff told us that they were given enough information about peoples assessed needs to enable them to provide care in the most appropriate way, whilst further developing the care plans. We saw a copy of the statement of purpose and the service user guide and both contained comprehensive, useful and relevant information. Care Homes for Older People Page 12 of 28 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Personal and healthcare needs are assessed and provided for in a way which shows respect for the privacy and dignity of people living at the service whilst meeting their identified needs. Evidence: As part of our case tracking process we looked at files for three people and all contained thorough and up to date care plans that had been regularly reviewed with some involvement of the person and/or their relatives. One person told us I am very well aware of the areas where I need help and how I want that help to be given. I was able to tell staff this. The care plans included the initial assessment that identified the individuals areas of need and each had been developed on an on-going basis to reflect the persons current and changing needs. Risk assessments were seen and they addressed a wide area of identified risks, such Care Homes for Older People Page 13 of 28 Evidence: as Mobility, Moving and Handling, Nutrition and Risk of developing pressure sores. Files also contained evidence of visits from Doctors, District Nurses, Optician, Dentist, Chiropodist etc. The relating records were clear and concise. People we spoke with told us that they see a doctor whenever necessary and only need to ask staff for this to be arranged. Staff we spoke with told us that they would always call a doctor if there were any concerns about a persons health. We received three completed questionnaires from professionals who are involved in the care for people living at Westvilla. Two were from visiting GPs who told us that they feel peoples health care needs are well catered for by staff at Westvilla. Another questionnaire indicated that the home operates good practice around issues of infection control. We looked at the Medication Administration Records for the people we case tracked and we did indentify gaps where staff had not signed to say they had observed people taking their medication. We checked the stocks and storage of medication to ensure that the correct doses had been administered. During this inspection visit the Manager spoke with the staff responsible for these errors and arranged for further training to be undertaken as soon as possible. We were satisfied that the manager had followed the correct procedures to ensure that these errors do not continue to occur. There are currently no people at Westvilla who are responsible for administering their own medication but we did see evidence in care plans that this had been considered. One person said I prefer the staff to look after this and then I dont have to worry about it. Peoples care plans made reference to peoples privacy and dignity and we observed staff treating people with respect, throughout our visit. People told us that staff always knock on doors before entering a persons room and said they consider the staff to be respectful at all times. People told us They are lovely. Always treat me properly. Relatives told us that they have never seen anyone being treated in an inappropriate way. Care Homes for Older People Page 14 of 28 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People enjoy a range of activities and a flexible menu that meets their needs and wishes. Evidence: The information provided to us by the acting manager tells us There is an activity programme in place to suit the needs of the service users at the home. There are links with the community such as shopping expeditions, reflections cafe and the home held its summer fare at the time we acquired the home. This was a great success and enabled us to introduce ourselves to the service users, relatives and the local community. The service users enjoy visits from the local ministry and members of all faiths are encouraged to visit. We saw evidence that confirmed regular visits are made by the local ministry and people we spoke with confirmed that they are able to attend religous services as they wish. On the day of the inspection visit, we observed the activities co-ordinator working with individual people on a one to one basis. One person was engaged with making a bread and butter pudding which was eaten at lunchtime by a number of people. Later in the Care Homes for Older People Page 15 of 28 Evidence: day, another person made trifles for everyone. This person told us that she had told staff that she used to enjoy cooking and was now able to partake in this activity on a regular basis. We spoke with people living at the service and some relatives and we were told that there is usually something being organised for them to get involved in if they wish. However, some people said that they prefer to spend time in their own rooms and watch TV, read or listen to music. One person said they enjoy shopping and go out regularly. Visitors are always welcome at the home and relatives we spoke with confirmed that they are made welcome at any time. We also looked at the menus for a four week period and found them to be varied and provide choice to people. Fresh fruit and vegetables are provided by a local supplier and high quality meat by a local butcher. We looked at a recent Nutrition report and it told us that meal times are flexible and people may eat in their own rooms if they prefer to. Meal times are protected to allow sufficient staff to assist people who require support or encouragement. We observed people having lunch and saw that staff assisted people where necessary in a discreet and respectful manner. People we spoke with told us that the food is very good and there is plenty of variety and choice. One person said she likes to have particular foods such as salmon and this is provided for her. The acting manager said that if someone asked for fish and chips from the local shop, someone would fetch them. Comments we received told us The food is very good. Plenty of it and well cooked. I have everything I want and there is always a choice if you dont like something. Care Homes for Older People Page 16 of 28 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People know how to complain and are confident that any concerns would be acted upon and responded to. People living at the service are safeguarded from harm and abuse by an experienced staff team who adhere to robust policies and procedures. Evidence: The information provided to us by the acting manager tells us Any complaints received will be dealt with in the recommended timescale. The complaints and whistleblowing procedures are in the policy file and staff are made aware of these. Copies of the complaints and adult safeguarding booklet are available in the reception area for everyone to look at. On arrival at the service we saw a copy of the complaints procedure clearly displayed in the entrance hall. The files we looked at also contained copies of the complaints procedure and some people we spoke with could recall seeing it. During our visit, we spoke with three people who all told us that they felt confident to complain about anything they felt was wrong. They added that they believe any complaints or comments would be listened to and appropriate action taken. Relatives we spoke with also said they would not hesitate to complain if something Care Homes for Older People Page 17 of 28 Evidence: was wrong. We received ten completed questionnaires from people living at the service and all tell us that people know how to complain and have someone they could talk to about any concerns. We received five completed questionnaires from staff and all tell us that they know what to do if someone makes a complaint to them or shares matters of concern. We looked at the staff training records and observed that staff have received training in Safeguarding Adults and Whistle Blowing. We spoke with three staff members and all demonstrated a good level of knowledge and understanding of the Safeguarding Adults policies and procedures. (Safeguarding Adults is a process of identifying and reporting suspected or potential abuse of vulnerable people and provides a framework of consistency to protect those individuals at risk.) Staff we spoke with were also aware of the homes policy about Whistle Blowing. (Whistle Blowing is a means for staff to feel supported to report anything of concern that they may witness.) We looked at records of complaints that have been received by the service since the new owners took over the running of the home. One had been recorded and the records told us that this had been thoroughly investigated within the timescale and the outcome shared with the complainant. The acting manager told us that anyone who has a concern is listened to and action is taken immediatley to avoid people feeling that they need to make a formal complaint. Care Homes for Older People Page 18 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a clean, safe and comfortable environment which is well maintained and equipped to meet their needs. Evidence: The information provided to us by the acting manager tells us The home has a cleaning schedule in place. The home is clean and odour free and people comment about this when they visit the home. We continue to buy equipment for the home to ensure these standards are maintained including a carpet cleaner and new cleaning trolleys. We have purchased new curtains and profiling beds in some of the bedrooms. A quiet office and lounge area has been refurbished to provide an area where we can take relatives when private discussions are needed. We undertook a partial tour of the home where we looked at communal areas including the lounges, dining rooms and bathrooms. We also looked at the laundry, the kitchen and some peoples bedrooms. We observed the home to be clean and comfortable throughout providing a safe and homely environment for people. The bedrooms we looked at were furnished in a suitable and comfortable manner. Peoples personal items such as pictures and small pieces of furniture were present in Care Homes for Older People Page 19 of 28 Evidence: their rooms and at least one person had their own fridge to store drinks and snacks of their choice. Some beds have been replaced with profiling beds and many of the rooms have been decorated and new soft furnishings provided. The new owners have begun a refurbishment of the home and some of the bathrooms have already benefitted from this, providing excellent bathing facilities for people to enjoy. We discussed this with the owners who told us of their plans with the refurbishment of the home. The lounge and dining areas are to be changed around to provide larger rooms for people to sit and enjoy views of the gardens and to partake in any activities. A maintenance programme is in place and staff communicate any requirements to the maintenance person for his attention. On the day of our visit, a local contractor arrived to conduct annual safety checks on all the equipment used for the moving and handling of people. He was able to assure us that there were no problems with any of the items and he would be issueing new certificates to confirm this. Care Homes for Older People Page 20 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported and protected from harm by trained and experienced staff, in sufficient numbers to meet their needs. Evidence: The information provided for us by the acting manager tells us Since acquiring the home on 26-08-09 we ensure that when we recruit staff they have references and Criminal Records checks in place prior to commencement of employment. We are still recruiting more staff so that we can run on seven staff during the day. We are currently checking staff records to determine what training they have received prior to 26-08-09 and have compiled a matrix of their training needs especially for mandatory training. We are compiling a staff training plan to reflect this need. Most staff have National Vocational Qualifications levels 2 or 3 and this also includes the domestic staff. We are looking at further training for staff including distance learning courses on Safe handling of Medicines, Infection Control etc, Phlebotomy training for Nurses and NVQs for new staff. As part of our case tracking processes we looked at files for three members of staff, including the latest recruit and one qualified nurse. We observed that they all contained the necessary paperwork and information to tell us that the recruitment policies and procedures are safe and are being strictly adhered to. We saw that staff had provided a minimum of two references and the required Criminal Record Bureau Care Homes for Older People Page 21 of 28 Evidence: and Protection of Vulnerable Adults checks had been completed before staff commenced employment. We also saw evidence that staff receive an induction when they start work and staff we spoke with confirmed this. We looked at training records and saw that all mandatory training, such as moving and handling, fire safety etc, is in place. Additional training is provided for staff and includes Safeguarding Adults, Dementia Awareness and Palliative Care. Staff told us that they have access to training that is useful and relevant and equips them with the skills they need to do their work. One member of staff said The training is brilliant. I have been able to do courses about a great number of things including Palliative Care, End of life pathway and I am going to do Phlebotomy. Staff told us that they feel valued and supported and have regular supervision enabling them to discuss any matters they wish with their line manager. They also told us that the acting manager is very approachable as are the new owners. Staff told us that they believe there are usually enough staff on each shift to enable them to provide care and support to people. They also said that the most of the staff work very well as a team and this adds to the positive atmosphere around the home. They also said there are times when they have felt short of staff but the management always listen and increase numbers appropriately. People we spoke with who live at the service told us The staff are lovely. They listen to me and I know they will always do their best. We can have a bit of fun with the staff. You need to be able to have a laugh now and then. Nothing is too much trouble. One or two people we spoke with said there are times when they have to wait for help because the staff are busy and at these times there could be more staff on a shift. The acting manager and the owners continue to review staff numbers according to the assessed needs of the people living at Westvilla and strive to provide the right numbers on each shift. Care Homes for Older People Page 22 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed and is being run in the best interests of the people who live there. Evidence: The Annual Quality Assurance Assessment that was completed and returned to us by the person responsible for the service tells us The previous manager left our employment on 08-09-09 and the Responsible Individual has been running the service since then. We have recruited a new matron from within the care group who was a home manager and we are applying for her registration for the home. We are currently reviewing all areas of the home and introducing changes in practice such as a new admission pack which we feel is in the best interests of the service users. We plan to continue to undertake audits for drugs, the care plan system and random checks of other areas to maintain standards of good practice. The acting manager has been in post since September 2009 and is in the process of applying to the Care Quality Commission to become registered. She has had Care Homes for Older People Page 23 of 28 Evidence: considerable previous experience of working in care and managing a care home. This means that people who live at the service benefit from a knowledgable manager who understands the needs of older people. People living at the home, relatives and staff that we spoke with all told us that the manager is very approachable and that she actively seeks their views about the service provided. One staff member said Matron is very good. She always follows things up. Another said If anything was wrong, I would always be able to approach Matron. People living at Westvilla told us There have been big improvements since the new owners and new manager took over It has been marvellous here. A relative told us I have no worries. They look after my relative very well and Im happy because they have settled. The service is developing an internal Quality Audit System whereby people will complete questionnaires to provide feedback about their experience. Regular meetings are planned with people living at Westvilla and their relatives. Some of these have already taken place and any issues that were raised have been responded to and relevant actions taken. Health and safety measures are in place to ensure that people living and working at Westvilla are protected. This is evidenced by the implementation of a Health and Safety policy which clearly identifies the roles and responsibilities of management and staff. We looked at the records of accidents and/or incidents that have been recorded since the new owners took over. Nine entries had been made and the records showed us that in each event, the appropriate actions had been taken. There had been a previous concern about the safety of a hoist following a person falling whilst being transferred, but during this inspection visit, the company responsible for maintaining and servicing the lifting equipment did their annual visit. They assured us that the hoist in question is in perfect working order and all straps etc are safe. A certificate will be issued to confirm this. We looked at the relevant safety certificates for servicing and maintenance of equipment and services and saw that they were up to date. The fire safety equipment Care Homes for Older People Page 24 of 28 Evidence: and testing was also up to date. Some peoples monies are looked after by the service and records we saw showed us that these were correct and being managed safely. Care Homes for Older People Page 25 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 9 The clinical room would benefit from additional security at the window. Care Homes for Older People Page 27 of 28 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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