Care Home: Westy Hall

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What the care home does well Westy Hall is a busy home with a friendly and welcoming atmosphere that changed throughout our visit from relaxed and sociable in the daytime to buzzing with activity and fun in the evening. The people who live at the home have good relationships with staff and enjoy a range of activities so they are kept occupied and enjoy a good quality of life. People who live in the home are involved in developing their own care plans so they receive care and support in the way they prefer. Our observations of the way staff interacted with the people who lived at the home showed us that care is usually provided in a sensitive, considered and compassionate way. We saw examples of good practice where staff responded to difficult situations calmly, creatively and with respect for the person. For example we saw one staff member respond to a person who was confused and agitated in a way that helped them to understand where they were and that they were safe so they were able to settle and relax within the home. The staff had received training in the care of people with dementia and demonstrated considerable skill and dedication to their work. Effective quality assurance and quality monitoring processes that involve the people who live at the home make sure that the home is managed in their best interests. The accommodation is clean, well maintained and comfortably furnished so people feel at home. All the people who we spoke to said the food was good so they enjoyed their meals. What has improved since the last inspection? CLS has effective quality assurances arrangements and works to make sure that the accommodation, services and the standards of care are continually improved so the changing needs of the people who live at the home are met. The system to audit the giving and recording of medicines had been improved so errors are identified and action can be taken to make sure people are safe. Parts of the home have been redecorated, new carpets have been laid in some of the corridors and new furniture has been provided in some rooms so people live in pleasant surroundings and are comfortable and safe. More than 50% of staff have or are working toward a nationally recognised qualification in care so the people who live at the home are in safe hands. CARE HOMES FOR OLDER PEOPLE Westy Hall Marsden Avenue Latchford Warrington Cheshire WA4 1UB Lead Inspector David Jones Unannounced Inspection 29 and 30 July 2008 03:45 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 Westy Hall DS0000027014.V369176.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. Westy Hall DS0000027014.V369176.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westy Hall Address Marsden Avenue Latchford Warrington Cheshire WA4 1UB 01925 637948 01925 651420 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) www.clsgroup.org.uk CLS Care Services Limited Janice Helen Johnson Care Home 39 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (10), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (1), Old age, not falling within any other category (29) Westy Hall DS0000027014.V369176.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1 The home is registered for a maximum of 39 service users to include: * Up to 29 service users in the category of OP (old age not falling within any other category). * Up to 10 service users in the category DE(E) (dementia over the age of 65) may be accommodated. * Up to 2 service users in the category DE (dementia over the age of 55) may be accommodated. * Up to 1 named service user in the category MD(E) (mental disorder over the age of 65 years) 13 June 2007 Date of last inspection Brief Description of the Service: Westy Hall is a care home located in Latchford, a residential area of Warrington. It is close to bus routes, local shops and other public amenities. It is registered to provide personal care for up to 39 older people and is run by CLS Care Services, a not for profit organisation that runs a number of homes in the North West of England. The home is divided into two parts. One part of the home provides personal care for up to 29 older people whose needs are associated with old age and the other section of the home, known as the Hollies, is for ten older people with a diagnosed dementia. The home is a purpose built two-storey property with access between the floors provided by one passenger lift and three stairways. Accommodation includes 39 single bedrooms, all having hot/cold water washbasins and door locks fitted. Communal facilities include seven separate lounge areas, two dining rooms and one quiet room. There are four bathrooms, one shower room and 12 WCs. There are also kitchen and laundry facilities on the ground floor, and the home has its own hairdressing salon. The home is set within its own grounds. Information about Westy Hall including copies of the most recent inspection report is made available to each resident and can be acquired by contacting the home on the telephone number given above. Fees range from £440 to £470 per week for accommodation, board and care, depending on assessment of need. There are no additional charges other than hairdresser, toiletries, newspapers and other sundry items charged at cost. Westy Hall DS0000027014.V369176.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating for this service is 2 stars. This means that the people who use the service experience good quality outcomes. This key inspection was unannounced. The visit to the home took place over two days and took 10 hours and 5 minutes in total. It started at 3:45 pm on the first day. This visit was just one part of the inspection. Before the visit, the manager was asked to complete a questionnaire to provide detailed information about the home and how it is meeting the needs of the people who live there. CSCI questionnaires were made available for the people who use the service, their families and the staff and their views about the home have been taken into account. Because people with dementia are not always able to tell us about their experiences, we have used a formal way to observe people in this inspection to help us understand. We call this a Short Observational Framework for inspection (SOFI). This involved us observing five people who live in the home for two hours and recording their experiences at regular intervals. This included their state of well being, and how they interacted with staff members, other people who use the service and the environment. Records for three of the people who live at the home were checked to see the care they receive. Some people were spoken with and their views taken into account. Staff recruitment and training records were examined. Some of the home’s policies and procedures were also checked. What the service does well: Westy Hall is a busy home with a friendly and welcoming atmosphere that changed throughout our visit from relaxed and sociable in the daytime to buzzing with activity and fun in the evening. The people who live at the home have good relationships with staff and enjoy a range of activities so they are kept occupied and enjoy a good quality of life. People who live in the home are involved in developing their own care plans so they receive care and support in the way they prefer. Our observations of the way staff interacted with the people who lived at the home showed us that care is usually provided in a sensitive, considered and Westy Hall DS0000027014.V369176.R01.S.doc Version 5.2 Page 6 compassionate way. We saw examples of good practice where staff responded to difficult situations calmly, creatively and with respect for the person. For example we saw one staff member respond to a person who was confused and agitated in a way that helped them to understand where they were and that they were safe so they were able to settle and relax within the home. The staff had received training in the care of people with dementia and demonstrated considerable skill and dedication to their work. Effective quality assurance and quality monitoring processes that involve the people who live at the home make sure that the home is managed in their best interests. The accommodation is clean, well maintained and comfortably furnished so people feel at home. All the people who we spoke to said the food was good so they enjoyed their meals. What has improved since the last inspection? What they could do better: The service users guide should be revised to confirm that it could be made available in other languages so all people who are interested in moving to home would know that the information could be made available in their first language. Steps should be taken to make sure that all people who have recently moved into the home have a review meeting some weeks after they move in so they can review their care with the support of their representatives, if they wish, and consider whether the home is suitable is a permanent place for them to live. Westy Hall DS0000027014.V369176.R01.S.doc Version 5.2 Page 7 Managers and staff need to make sure that care plans and risk assessments are reviewed and updated when the needs of the individual change so they can be sure care staff will always have the information they need to give care in a safe and appropriate way. Records of the medicines given in the home must be accurate so people are safeguarded from medication errors and their health care needs are always met. 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. Westy Hall DS0000027014.V369176.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 Westy Hall DS0000027014.V369176.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 and 6 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who are interested in moving to Westy Hall receive information and can visit so they are able to make an informed choice about the home before they move in. They have their needs assessed so they know their needs can be met at the home. EVIDENCE: People who are thinking of moving to Westy Hall are invited to visit the home so they can find out more about it and make an informed choice about moving in. They are given an information pack, which sets out the aims and objectives of the home, and includes a service users guide. The pack provides clear information on the home’s facilities and services including details about activities, food, accommodation and staffing. It is available in large print so it is easy to read. Most of the people who responded to our survey told us they received enough information to help them with their decision-making. Westy Hall DS0000027014.V369176.R01.S.doc Version 5.2 Page 10 The manager told us that the service users guide would be made available in other languages on request. The information pack should be updated to confirm this so all people who are interested in moving to Westy Hall would know that the information could be made available in their first language. All people living at the home had a contract, if they were paying privately, or a statement of terms and conditions if their local authority supported them, so they knew their rights and responsibilities. Records show that people have their needs assessed by qualified and experienced staff before they move in so they are sure that the home is suitable to meet their needs. Meetings are normally arranged with the individual and their representatives six weeks after they move in so they can review their care and decide whether the home is suitable for them as a permanent place to live. However, the records for one person had no evidence of the “six week review” taking place. The manager told us that this was an oversight. The person had lived at the home for 18 months and decided that they wanted to move to live nearer to their relatives. Arrangements were being made with social services to help them find another home. All of the people who responded to our survey told us their care and support needs were always or usually met and all made positive comments about the home. For example one person told us they had settled in well. They said they had moved in at the same time as another person who had helped them and they had become friends. Other people spoken with during the inspection told us they were happy at the home and were well looked after. Westy Hall does not provide intermediate care so standard 6 does not apply. Westy Hall DS0000027014.V369176.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 and 10 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Arrangements for health and personal care are based on each person’s individual needs and the principles of respect, dignity and privacy are put into practice so people receive care in the way they prefer. EVIDENCE: Our observations of the interactions between the people who lived at the home and staff showed us that care is usually provided in a sensitive, considered and compassionate way. We saw examples of good where staff responded to potentially difficult situations calmly, creatively and with respect for the person. For example we saw one staff member respond to a person who was confused and agitated in a way that helped them to understand where they were and that they were safe. This resulted in positive outcomes for the person who was then able to settle and relax within the home. The staff member had received training in the care of people with dementia and demonstrated considerable skill and dedication to their work. Westy Hall DS0000027014.V369176.R01.S.doc Version 5.2 Page 12 Another staff member, who was not a permanent member of the team, did not have the same level of training was observed to be well meaning but on occasion responded in ways that had poor outcomes for the person. For example, their response to a person who was anxious was ill considered and caused the person to be more agitated. On another occasion they unintentionally insulted another person when they responded to their affection in a dismissive and demeaning way. This highlights the importance of effective training for staff working with people who have dementia. The manager told us that these issues would be addressed through supervision. This poor practice was the exception and the overall standard of care was good. All of the people who live at the home have a care plan that has been agreed with them or their representatives. Care plans are written in plain language, are easy to understand and cover most areas of the individual’s life, including health and personal care needs and personal preferences. Some of the care plans needed to be improved because they did not always say how the individual’s needs are to be met. For example, the care plan for one person did not say how their needs in respect of their epilepsy would be met or what staff would need to do in the event of a seizure. Another person’s care plan did not provide sufficient information on how staff should respond when the person’s behaviour became difficult to deal with. Information in a risk assessment suggested that staff should try to stop this person if they tried to force their way through the door but did not say how they would be expected to do this. Care plans must be are reviewed and where necessary revised when the needs of the individual change so care staff always have the information they need to provide care in a safe and appropriate way. People living at the home told us that they always or usually received the care and support they needed and all said their health care needs were always met. A visiting district nurse told us staff were helpful and a social worker told us that the home provides a good standard of care. The manager had recently attended a meeting with social services and other agencies to explore how all professionals could work together to improve falls prevention. This and the home’s records showed us that the manager and the staff work in partnership with health and social care professionals to make sure that the health care needs of the people who live at the home are met. The manager told us that there had been a number of occasions where staff had made errors in giving out medication. In each instance staff had taken appropriate action to ensure the well being of the individual by informing health care professionals and acting on their recommendations. The manager had put an action plan into practice to make sure that the home’s systems for the administration and recording of medication were safe. The system to audit the giving and recording of medicines had been improved but a random sample of one person’s records found that some medicines were not recorded appropriately. Westy Hall DS0000027014.V369176.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Suitable activities are available and people who live at the home have choice so they enjoy a good quality of life that always or usually reflects their needs and expectations. EVIDENCE: Westy Hall is a very busy home. It has friendly and welcoming atmosphere that changed throughout our visit from relaxed and sociable in the daytime to buzzing with activity and fun in the evening. All of the people who responded to the survey told us that suitable activities are always or usually available. There is an activities co-ordinator who is very well thought of by the people who live at the home. One person said she is excellent. A range of activities and entertainers are booked from time to time to perform in the home. During the visit a Tea Dance was held in the main dining room. People from a neighbouring care home had been invited to attend along with relatives and friends of the people who lived at Westy Hall. The evening was a great success; all the people there were enjoying themselves. Westy Hall DS0000027014.V369176.R01.S.doc Version 5.2 Page 14 Staff were observed to be caring, sensitive and skilled in their approach. They respect people’s wishes regarding rising and retiring and try to promote choice in all aspects of daily living. Staff working with people with dementia where seen to offer timely prompts to help them complete tasks or join in activities. People were playing dominoes, enjoying manicures, reading magazines or exploring other areas of the home. Most of the people who returned survey questionnaires and all those spoken with said the food is always or usually good. Special dietary needs are catered for and menus confirm that a varied and nutritious diet is provided. People are asked about the quality of meals and menus are discussed at “Residents meetings” so people can influence the range of choices on offer. Westy Hall DS0000027014.V369176.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 and 18 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. There are complaints and adult safeguarding procedures for the home so the people who live there are able to express their concerns. They are listened to and are safeguarded from abuse and neglect. EVIDENCE: People who live at the home are able to express their concerns and have access to an effective complaints procedure so they are listened to and their concerns are acted upon. Most people responding to the survey told us that they know how to make a complaint and staff listen to and act on what they say. The home’s complaints records show that two complaints had been received and acted upon since our last inspection. Appropriate records of each complaint were made and included details of action taken to resolve the complaint. This shows us that complaints are welcomed and are acted upon by the management of the home. Procedures for responding to suspicion or evidence of abuse or neglect are in place, including whistle blowing policies. There have been six adult safeguarding referrals from the home since our last inspection. Managers and staff have worked in partnership with other professionals to make sure that vulnerable people were safe and protected from harm. Westy Hall DS0000027014.V369176.R01.S.doc Version 5.2 Page 16 Staff training records show that most of the staff had received training on adult safeguarding procedures in 2006. Further staff training is being arranged on adult safeguarding so all staff know what to do in the event of any suspicion or evidence of abuse. Westy Hall DS0000027014.V369176.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 and 26 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who live at the home have well-equipped and well-maintained accommodation, which meets their needs and expectations so they are safe, comfortable and feel at home. EVIDENCE: Westy Hall is located in Latchford, a residential area of Warrington with good access to the local shops and general amenities nearby. The home is well maintained with good quality furnishings and fittings and is clean and hygienic with no offensive odours. It is set within its own grounds. People have access to pleasant gardens and a new patio area has been created so people can enjoy the gardens and a breath of fresh air. All of the people who responded to the survey told us the home is always clean and all spoken with during the inspection told us that they are comfortable. Westy Hall DS0000027014.V369176.R01.S.doc Version 5.2 Page 18 New carpets have been fitted in the main corridors on the ground floor and various other parts of the home have been redecorated and new furniture has been provided in some rooms. Maintenance records show that electrical and gas installations; hoists and fire prevention equipment are serviced regularly so people are safe Westy Hall DS0000027014.V369176.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 and 30 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Staff are trained, skilled and employed in sufficient numbers to meet the changing needs of people who live at the home. Staff recruitment procedures are thorough to make sure that staff are suitable to work with vulnerable people. EVIDENCE: The home’s recruitment procedures are thorough so people who live at the home are safe and protected from harm and abuse. People who live at the home are involved in the staff selection process so they can have a say in who provides their care and support. All of the people who returned survey questionnaires told us that staff were always or usually available when they wanted them. However some staff members who returned survey questionnaires raised concerns about staffing levels and the day-to-day management of the Hollies. This is the part of the home where people with dementia live. Observation of staff interactions with people who live on the Hollies over a two-hour period confirmed that there were enough staff on duty to meet each person’s health, personal and social care needs. Westy Hall DS0000027014.V369176.R01.S.doc Version 5.2 Page 20 Staff rosters and information provided by the manager confirmed that there had been a few occasions when the home had been short staffed. The manager told us this happened when staff went absent but had not informed the home until it was to late to find a replacement. However on these occasions managers had worked on care so the needs of the people who lived at the home were met. All staff spoken with during the inspection told us they were happy with staffing levels and the general management of the home. Overall good standards of care were observed with positive outcomes for the people who lived at the home. Management encourage staff members to undertake nationally recognised qualifications beyond the basic requirements, and recognise the benefits of a skilled, trained workforce. Information provided indicates more than 50 of the current staff team have an NVQ in care at level 2 or above or are working toward the qualification. There is a comprehensive staff-training programme that includes “Skills For Care” staff training standards. Staff benefit from an annual appraisal and all have personal development plans. Westy Hall DS0000027014.V369176.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, 35, 36 and 38 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Effective management and quality assurance systems make sure that the people who live at Westy Hall are involved in the management of the home so it is run in their best interests. EVIDENCE: The manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Senior care staff and care staff continue to speak highly of her leadership abilities and appreciate her support and guidance. Westy Hall DS0000027014.V369176.R01.S.doc Version 5.2 Page 22 Effective quality assurance and quality monitoring processes that involve the people who live at the home and their relatives and other representatives are in place. These include care plan audits, medication audits, customer feedback forms, effective complaints procedures and annual “Residents and Relatives” and health and social care professionals survey questionnaires. The home had received a good response to the latest quality survey with nine health and social care professionals’ questionnaires returned. Eight care professionals made positive comments about the home. All agreed that the standard of care provided by the home was high. Other comments included: “Staff appear very friendly and helpful”; and “Very good service the home meets all patient care needs”. The result of this work is to be published in the service users guide so people know their views are taken seriously and acted upon. The manager ensures that people are able to control their own money, except where they state that they do not wish to or they lack capacity and other arrangements are made. They may deposit small amounts of money with the home for safekeeping. The home services manager maintains appropriate records and receipts. Information provided by the manager and staff indicates that most staff have had a recent formal supervision meeting with their respective line manager. The frequency of supervision meetings every 3 months has not been met because the manager has been off work. The organisation seeks to ensure the health and safety of all employees and residents. Risk assessment and risk management is central to the conduct of the home so people are safe. However a risk assessment for one person needed revising because it was out of date and had not kept pace with the individual’s changing needs. Information provided indicates that fire precautions are in place and routine maintenance checks of gas and electrical systems, hoist, electrical appliances, lift, fire alarms, extinguishers and emergency lighting systems are undertaken and are up to date. Westy Hall DS0000027014.V369176.R01.S.doc Version 5.2 Page 23 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 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Westy Hall DS0000027014.V369176.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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 Refer to Standard OP1 Good Practice Recommendations The service users guide should be have information to confirm that it could be made available in other languages so all people who are interested in moving to Westy Hall would know that the information could be made available in their first language. All new people moving into the home should have a review meeting some weeks after they move in so they can review their care with the support of their representatives, if they wish, and consider whether the home is suitable as a permanent place for them to live. 2 OP4 Westy Hall DS0000027014.V369176.R01.S.doc Version 5.2 Page 25 3 OP7 Care plans should record all needs presented by the individual and confirm how their needs are to be met so staff always have the information they need to provide care in the way the person prefers. Records of the administration of medication should always be accurate so people are not at risk of medication errors and their health care needs are met. Risk assessments should be kept under review and where necessary revised when circumstances change so appropriate arrangements are made and put in place to make sure they are safe. 4 OP9 5 OP38 Westy Hall DS0000027014.V369176.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North West Region Unit 1, Level 3 Tustin Court Port Way Preston PR2 2YQ 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 Westy Hall DS0000027014.V369176.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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