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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
VDAN-B9MRL5

FACILITY NAME
Westminster House
SERVICE TYPES
125 Substance Use
FACILITY LICENSE #
2582023
FACILITY ADDRESS
228 7th St
FACILITY PHONE
(604) 524-5633
CITY
New Westminster
POSTAL CODE
V3M 3K3
MANAGER
Susan Hogarth

INSPECTION DATE
February 22, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.5
ARRIVAL
09:00 AM
DEPARTURE
01:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
10

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSP). Evidence for this report was based on the Licensing Officer’s observations, review of the facility records and information provided by the facility staff at the time of inspection.
The following areas were reviewed:
· Licensing
· Physical Facility
· Staffing
· Polices & Procedures
· Care & Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records and Reporting
As part of the routine inspection a Facility Risk Assessment Tool is completed and a copy is provided. The Risk Assessment includes non-compliance identified during the routine inspection and a 3 year “historical” review of the facility’s compliance and operation.
Visit the CCFL website at www.fraserhealth.ca/residentialcare for:
· Additional resources and
· Links to the Legislation (CCALA & RCR)
If you have any questions regarding this report feel free to contact me at 604 918 7526
or valerie.dairon@fraserhealth.ca

Contraventions
Previous Inspection - Contraventions observed on FIR #KBOI-ASMSLC have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: The sanitizing product used for surfaces, did not demonstrate evidence of any bactericidal capability.
Corrective Action(s): Please provide a plan to ensure that products used to sanitize the facility are bactericidal and appropriate instructions for use are clearly labelled.
Date to be Corrected: March 7, 2019

POLICIES AND PROCEDURES: 33220 - RCR s.85(1)(a) - A licensee must do all of the following: (a) have written policies and procedures for the purposes of guiding staff in all matters relating to the care and supervision of persons in care.
Observation: The residents do not carry Westminster House identification when off-site.
Corrective Action(s): Please ensure that residents carry identification as described above.
Date to be Corrected: March 7, 2019

RECORDS AND REPORTING: 39090 - RCR s.77(2)(c) - Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer.
Observation: The non-reportable incident records were reviewed. One record documented an injury to a resident that required medical intervention. This incident should have been reported to licensing. A review of the type of incidents requiring reporting, and the specific circumstances. Using the Licensing officer as a resource, if there is doubt about the reportability of an incident is also encouraged. Resources were provided to the manager.
Corrective Action(s): Please provide a plan that will assure that incidents that require reporting are reported in a timely manner.
Date to be Corrected: March 7, 2019


Comments

It was identified that there were several staff whose First Aid and CPR had expired. Manager ensured writer that every shift was covered with staff who were current with First Aid and CPR. Manager also stated that the licensee is organizing a group certification for renewal of first Aid/CPR and that this will be imminent.
Please provide writer with the date for the first aid renewal completion by Mar.7, 2019.

This house appears to be of 1940-50's design. There have been some inspired renovations to make this facility very homey while providing maximum function as a facility. It is clean, and well organized. the residents appear very comfortable in their space and were seen to interact in a relaxed manner with the staff.
Thank you to the residents and staff for assistance in this inspection.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingNo action required
Due Date
Mar 07, 2019

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Click here for a description of each "Category" of violation displayed.