Care Home: Westwood

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What the care home does well The service provides personal care for older people within homely surroundings.Residents said the staff are friendly and very helpful and that the manager is always cheerful. Visitors are welcome at any time and those visiting the home that day said that they were ` very pleased with the home and have recommended it to others, their relative comes in regularly for short stay visits and is always well looked after`. There is a pleasant garden, which is accessible to residents, and a patio area with seating is provided. On the day of the inspection residents were seen enjoying this. What has improved since the last inspection? There have been many improvements across all areas since the last inspection. The standard of care planning has improved, although there are still some areas that need addressing. The manager is now more aware of the need to thoroughly assess prospective residents and to move people to care homes with nursing when their needs exceed the level where personal care only is insufficient. The home has had new carpets in the corridors, stairways and some resident`s rooms, and the lounge and corridors have had items that were no longer in use removed. New dining and lounge chairs have been purchased, as have new beds for most rooms. Disposable towel holders are now sited in bathrooms, toilets and other areas thereby reducing the risk of cross infection. Staff training has improved with over 50% of the staff having attained their National Vocational Qualification level 2 or 3 in care. All staff have now received updating in the mandatory health and safety training including moving and handling, safeguarding adults and fire safety CARE HOMES FOR OLDER PEOPLE Westwood 9 Knoyle Road Brighton East Sussex BN1 6RB Lead Inspector Elizabeth Dudley Unannounced Inspection 10:00 22nd May 2008 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 Westwood DS0000014260.V363472.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. Westwood DS0000014260.V363472.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westwood Address 9 Knoyle Road Brighton East Sussex BN1 6RB 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) 01273 553077 Mr Mohamed Saber Sadek Mrs Sadek Mr M S Sadek Mrs Somaya Sadek Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Westwood DS0000014260.V363472.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The number of service users accommodated must not exceed twentynine (29) The service users will be aged sixty-five (65) or over on admission Date of last inspection 12th July 2007 Brief Description of the Service: Westwood is a privately owned residential home, registered to provide personal care for 29 older people. The building consists of two semi-detached properties converted for its current use. Accommodation is presented across three levels, ground, first and second floors, accessed by a shaft lift. This includes seventeen single and three double bedrooms, seventeen of these 20 rooms having en-suite facilities. The home has communal facilities that include a lounge/dining room and an attractive garden that has access for wheelchairs. Situated in a residential area on the outskirts of Brighton, it is close to a main bus route and local parks. Although there is no car parking facilities at the home, all adjoining roads have unrestricted parking. Current fees charged range between £314 to £550 per week; this information was received from the provider on the 22nd May 2008. Extra services not included in the fees include hairdressing and chiropody, details of the charges for these can be obtained from the home. Westwood DS0000014260.V363472.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star, this means the people who use this service experience good quality outcomes. This unannounced key inspection took place on the 22nd May 2008 over a period of six and a half hours and was facilitated by Mr M Sadek, owner and registered manager. Methods used to collect information about the home included examination of documentation in the home, observation of staff working with residents, the serving of lunches and conversations with residents, staff and visitors to the home. All residents were spoken with during the inspection, and six residents were spoken with in depth and gave their views on life in the home. Documentation examined included care plans, personnel files, staff training and supervision records, catering records and health and safety files. Prior to the inspection questionnaires were sent out to relatives and residents. Of these five were returned from relatives and residents. These gave information about the daily life in the home and helped to inform the judgements made in this report. Thanks are extended to those people who responded. Comments from these surveys included ‘The food is always good’. ‘The owner is very pleasant and approachable and always speaks to you in private’ ‘ The rooms are cleaned daily and the staff are very helpful’. The Annual Quality Assurance Assessment, required by the CSCI, which gives an overview of what has been achieved in the home and issues to be addressed, was received by the CSCI prior to the inspection. This reflected the current status of the home. This was used as part of the inspection process. Over the past few months there have been many improvements made to the home, in the environment, the documentation and care of the residents, and in staff training. The CSCI will expect these improvements to be sustained in order to justify the current quality rating, and continual further improvements, as discussed at inspection, must take place. What the service does well: The service provides personal care for older people within homely surroundings. Westwood DS0000014260.V363472.R01.S.doc Version 5.2 Page 6 Residents said the staff are friendly and very helpful and that the manager is always cheerful. Visitors are welcome at any time and those visiting the home that day said that they were ‘ very pleased with the home and have recommended it to others, their relative comes in regularly for short stay visits and is always well looked after’. There is a pleasant garden, which is accessible to residents, and a patio area with seating is provided. On the day of the inspection residents were seen enjoying this. What has improved since the last inspection? What they could do better: There have been several issues over the past year with the home, which have lead to improvements being made. The manager should ensure that all staff receive formal supervision at intervals directed by the National Minimum Standards and that new staff undertake a Westwood DS0000014260.V363472.R01.S.doc Version 5.2 Page 7 thorough induction course which is in line with the recommended ‘Skills for Care’ induction programme. It would benefit the residents and home if the manager undertakes recognised management training and care training to National Vocational Qualification level 4 in care. Some of the staff are being encouraged to undertake this advanced qualification. Empty rooms would benefit from the replacement of furniture and being kept in a condition ready for use. The manager must ensure that the CSCI receives Regulation 37 notices (Notices informing the CSCI of any incident that affects a resident) and a requirement has been made about this. The manager should ensure that a quality monitoring system is in place, which gains the opinions of stakeholders in order to maintain and improve the quality of services delivered by the home. During the tour of the building it was noted that in one room the window restrictors were broken, the manager gave assurances that these would be repaired, therefore no requirement has been made. 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. Westwood DS0000014260.V363472.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westwood DS0000014260.V363472.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6. People who use the service experience good quality outcomes in this area. Prospective residents receive full information about the home and have a comprehensive preadmission assessment to ensure that the home is able to meet their needs. This is followed by written confirmation that the home is able to admit them This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has produced a Statement of Purpose and Service User Guide, which meet the regulations and have been reviewed on a regular basis. The Service User Guide has been produced in a suitable format for the residents in the home. All residents are given a copy of this. Westwood DS0000014260.V363472.R01.S.doc Version 5.2 Page 10 Residents receive a Contract and Statement of Terms and Conditions on their admission to the home; these documents comply with the regulations. Prospective residents and their representatives are encouraged to visit the home prior to admission and all prospective residents are assessed by the manager or his deputy to ensure that the home can meet their needs. Three recent preadmission assessments were seen and these contained sufficient detail to inform the staff about the care the resident required. Three preadmission assessments were seen and these were satisfactory and had sufficient information to inform the care plans. Written confirmation is given to the residents regarding whether the home can meet their needs. There was evidence that social service care plans and assessments are used to inform the current care plans. The home admits residents for respite care but not for intermediate care. Westwood DS0000014260.V363472.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. People who use the service experience good quality outcomes in this area. The present standard of care planning generally safeguards the residents and ensures that their personal, health and social care needs are being met. Not all residents are familiar with the contents of their care plan. Residents are safeguarded by the standard of medication administration in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four care plans were examined in depth, generally there is much improvement in the amount of information contained in the care plan, the regularity of the reviews and the recording of visits from health and social care professionals. There is still some scope for improvement and this includes the following: Westwood DS0000014260.V363472.R01.S.doc Version 5.2 Page 12 Evidence that the care plans are produced following consultation with the residents is required. Any residents whose risk assessment identifies that they are at risk of pressure damage requires a specific care plan to address the ways of minimising pressure damage including reference to how often changes of position are required, the home should access a health care professional for advice over this Continence care plans must include the type of continence aid used and how often the resident needs assistance with visits to the toilet or other to help maintain continence. Instructions received from health care professionals must be included in the main body of the care plan. When residents have returned from hospital a complete review of the care plan is required. Results of assessments by health care professionals must be put into the main body of the care plan and instructions for carrying these out included. Where instructions for regular exercises are given these must be identified and recorded when they are carried out. The manager has contacted the CSCI since the inspection and states that the staff are in the process of addressing the above. When bedrails or other equipment is used, risk assessments in line with the advice issued by the Medical Devices Agency must be put in place, regardless of whether this equipment is put in by health care professionals. Since the inspection the manager has informed the CSCI that this has been attended to. Where electric pressure relieving beds or other equipment is provided, staff must receive training on how to use this equipment safely and how to ensure the equipment is working satisfactorily. Staff have attended moving and handling training and moving and handling aids are in place. The provider/ manager is aware of the need to continually assess the moving and handling practices undertaken in the home. Use of a key worker system was discussed with the manager, this would ensure that care plans are kept up to date and fully reflect any changes to care required. Westwood DS0000014260.V363472.R01.S.doc Version 5.2 Page 13 Social care plans require to be expanded to fully reflect the residents past and present interests. Residents appeared well cared for and several residents said that they thought that the care was good, and that Doctors and district nurses were called in as required. Those residents spoken with said ‘ the staff are real gems’, ‘ we can do what we want to do and the staff are really good’, ‘ I’m only here for a few weeks, it’s a nice place everyone very helpful, I need to go home as I can look after myself really with some help and I shall get a care agency coming in’. The standard of medication administration was generally good; the majority of staff have undertaken medication administration training. Controlled drug records require to have their total brought to zero when returned to the dispensing pharmacist, the risk assessment for a resident who self medicates needs to be reviewed to ensure safety of other residents. The manager has contacted the CSCI since the inspection and states that the above issues have been addressed. The home uses a system of pre-packed medication administration, the main drawback of this system is that all drugs to be given in a session are not prepacked separately therefore there is no way that the staff can identify any drug that is discontinued, the manager states that at present the entire drug pack is sent back to the dispensing chemist, he was advised to discuss alternative methods with the chemist. Staff must ensure that two people sign changes to medicine prescriptions and that indications for giving as required medication are listed on the MAR charts. Westwood DS0000014260.V363472.R01.S.doc Version 5.2 Page 14 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 People who use the service experience good quality outcomes in this area. Residents are enabled to make choices in the activities of daily living and over how they wish to spend their time Residents are satisfied with the choice of menus; the quality and quantity of the food served and are able to have snacks and drinks as they wish. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Weekly activities programmes have not been put in place on a sustained basis by the staff, but records of activities provided showed that, on the majority of days, a reasonable variety of activities are taking place. These include musical afternoons, films, newspaper reading and various board games. Staff have plans to take residents on outings during the better weather and at present take residents out to the shops etc on an individual basis. There is some scope to improve the activities offered to those residents who wish to stay in their rooms, this may be take the form of one to one conversation or helping them Westwood DS0000014260.V363472.R01.S.doc Version 5.2 Page 15 in small ways and staff must ensure that these residents have information regarding the activities offered. It was noted that one resident who has always on previous inspections complained of being ‘bored’ said at this inspection: ‘ There is always plenty going on here’. Residents can make their own choices around activities of daily living including what time they rise and retire. One resident said ‘ yes you just do what you like, say when you are ready to go to bed or when you want to get up, and if you don’t want to get up you can stay in bed’. The CSCI will expect this improvement to be sustained. Residents can have visitors at any time and two visitors present in the home on this day said that they were very satisfied with the care the home provides, their relative comes in regularly for respite care and another relative was in the home prior to this. They have always been satisfied. Arrangements are made for ministers of religion to visit the home. The menu is varied and now provides choices at all meals. The daily menu is displayed in the lounge and residents spoken with said that they enjoyed the food. Fresh fruit and vegetables are offered and homemade cakes are provided at times. Residents said that they ‘look forward to Thursdays as pancakes are on the menu’. Staff are aware of cultural and religious diets and ensure if these are required, they are provided. The presentation of meals has improved since the last inspection. All staff involved in catering have the food hygiene course and the documentation required in the kitchen was in place. The home has recently commenced the hazard analysis documentation as required by Environmental Health Authority and staff received training in this. A recent Environmental Health Authority inspection awarded the home 2 stars on their scores on doors initiative. Westwood DS0000014260.V363472.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): 16,18. People who use the service experience good quality outcomes in this area. The manager addresses any complaints in an open and transparent manner and residents said that they were confident that any complaints they may have would be dealt with. Staff have received safeguarding adults training and the manager has shown that the home will co-operate with the safeguarding adults team and make efforts to improve situations leading to issues in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure and residents spoken with were aware of this and aware of to whom to make a complaint. There has been one minor complaint during the past year and records of how this was addressed were in place. There have been three safeguarding adults issues over the past eight months, these were substantiated and during this time the manager worked with social services to prevent any reoccurrence and procedures in the home have improved. Westwood DS0000014260.V363472.R01.S.doc Version 5.2 Page 17 There is comprehensive abuse and whistle blowing policy and during the inspection the manager made arrangements to obtain copies of the latest safeguarding adult reporting protocol. All staff have received training in the safeguarding of the people in their care. Westwood DS0000014260.V363472.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): 21,22,24,25,26 People who use the service experience adequate quality outcomes in this area. General maintenance and redecoration, which have taken place over the past year, have improved the home for the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Over the past two years the provision of ongoing maintenance and decoration has lead to improvements throughout the home. New carpets are now in place in corridors, stairs and in some rooms and new lounge and dining chairs have been purchased. Westwood DS0000014260.V363472.R01.S.doc Version 5.2 Page 19 The majority of the beds have been replaced. The garden is well maintained and provides a seating area, which residents can enjoy in clement weather. Residents’ rooms are generally comfortable and the manager intends to purchase new bed covers and curtains this year. Residents are able to bring in their own possessions and information regarding whether the residents wish to have a key to their rooms is available in the care plans. Residents would benefit from the replacement of some furniture in their rooms. The monitoring of the hot water temperatures in residents outlets continues to be checked on a regular basis and records showed that these were in line with the recommended parameters. The window restrictors in one room were broken and the provider said that he would address this. The CSCI has received information since the inspection that these have been repaired, therefore no requirement has been made. There is an infection control policy in place but this needs reviewing to reflect current knowledge. The home was generally clean but there were some commode pots, which were stained and required replacing. The manager has since informed the CSCI that this has been addressed. It is recommended that curtains on portable screens receive regular laundering to prevent infection. The home now provides paper towel dispensers and there were no particular issues that could compromise the spread of infection. Westwood DS0000014260.V363472.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): 27,28,29,30. People who use the service experience good quality outcomes in this area. There are sufficient staff employed to provide the care currently required by residents in the home. The majority of staff have received sufficient training to offer the care required by residents currently in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rota and conversations with staff showed that there are sufficient staff on duty to meet the needs of the residents currently in the home. Should residents needs increase or residents with higher dependency be admitted to the home the ratio of staff will need to be increased. Six members of staff (55 ) have either the National Vocational Qualification level 2 or 3 in care and two more are in the process of attaining this. The home is currently encouraging two members of staff to undertake National Vocational Qualification level 4 in care and the manager says he may take this also. Westwood DS0000014260.V363472.R01.S.doc Version 5.2 Page 21 All staff have undertaken recent updates in mandatory training, which includes moving and handling, fire training and health and safety. Two members of staff have first aid and all have received adult safeguarding training. Some staff have infection control training and this is being put in place for all staff. Whilst all staff have the homes local induction training not all staff have received the ‘Skills for Care’ or a similar nationally approved induction course, was identified in the Annual Quality Assurance Assessment as being a plan for the coming year, and the provider will be expected to address this. All staff have a copy of the General Social Care Code of Conduct. Three personnel files belonging to recently recruited staff were examined and found to contain all documentation as required by the regulations. Personnel files of existing staff have been examined over previous inspections and found to be in order. Westwood DS0000014260.V363472.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): 31,32,33,35,36,37,38. People who use the service experience good quality outcomes in this area. The management systems in place enable the home to meet the expectations of the residents. Lack of formal supervision of staff may affect the care of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The provider/ manager has owned the home for a number of years. The management of the home, whilst currently ensuring a reasonable service is provided for residents, would be improved by the manager undertaking Westwood DS0000014260.V363472.R01.S.doc Version 5.2 Page 23 relevant training which includes the Registered Managers Award, although he has many years experience in the care field. Residents living in the home have always stated their satisfaction with the home saying ‘ Its nice here and I am happy’, ‘ The manager is nice and the staff are very good’. There generally a low staff turnover, which ensures that residents know and feel comfortable with the staff on duty. The manager now has an annual development plan in place and surveys have been sent to residents and relatives, this should be continued. The Annual Quality Assurance Assessment accurately reflected what was happening in the home and the manager must ensure that he reviews the goals he set in the Annual Quality Assurance Assessment. Surveys and conversations with residents showed that the home is meeting their expectations. The home acts as appointee for four residents and holds money for other residents, records were in order. Not all staff have received supervision over the past few months, although prior to this they were receiving it regularly. The manager has stated that he will be recommencing this and it is required to ensure that residents receive care, which meets their expectations, and that staff are helped to achieve their own goals. Reg 37 reports (reports required by regulation of any incidents affecting residents) have not been sent to the CSCI in the past few months and a requirement will be made around this. There was evidence that there has been regular servicing of utilities and equipment and that staff have received mandatory training. Westwood DS0000014260.V363472.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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 2 2 2 x 2 3 2 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 3 3 2 x 3 2 3 3 Westwood DS0000014260.V363472.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 Reg 23(2)(b)( d) Requirement Timescale for action 06/01/09 2 OP26 2 OP38 That an ongoing programme of repair and refurbishment is maintained and that this is adhered to Reg 13 That the infection control policy 01/09/08 (3) is reviewed to reflect current research in infection control issues, and that staff receive regular infection control training. Reg 37 That reports are sent to the CSCI 22/05/08 (1)(a)(b)( regarding any incidents c)(d)(e)(f) adversely affecting service users (g) (2) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP30 OP31 Good Practice Recommendations That newly appointed staff undertake a recognised induction course That the manager undertakes the National Vocational Qualification level 4 in care and Registered Managers Award DS0000014260.V363472.R01.S.doc Version 5.2 Page 26 Westwood 3 4 OP33 OP36 That the quality monitoring process includes the views of stakeholders including health and social care professionals That staff undergo regular formal supervision at the timescales required by the National Minimum Standards Westwood DS0000014260.V363472.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 Westwood DS0000014260.V363472.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!