Inspection on 03/03/06 for 72 Milton Road (Welcome House)

This inspection was carried out on 3rd March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 42 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

72 Milton Road (Welcome House) 08/10/07

72 Milton Road (Welcome House) 20/06/06

72 Milton Road (Welcome House) 06/12/05

72 Milton Road (Welcome House) 14/12/04

72 Milton Road (Welcome House) 10/08/04

72 Milton Road (Welcome House) 08/01/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 72 Milton Road (Welcome House) 72 Milton Road Gillingham Kent ME7 5LW Lead Inspector Sarah Montgomery Announced Inspection 3rd March 2006 09:30 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 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 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 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 Adults 18-65. 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. 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 72 Milton Road (Welcome House) Address 72 Milton Road Gillingham Kent ME7 5LW 01634 574644 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) Dr Toqeer Aslam Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th December 2005 Brief Description of the Service: 72 Milton Road is a registered care home for three adults with mental health problems. It is one of nine homes owned and managed by the Welcome House Group. At present two service users live at the home. The home offers a support package, which comprises the sharing of 56 staff hours with 3 other service users living in two homes nearby. Staff are not on duty in the evening or overnight. During these times service users have access to an on-call staff member. The home is situated in a residential area with easy access to public transport and local shops. Gillingham town centre is approximately one mile away. 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted by Sarah Montgomery (Regulation Inspector) and John Walker (Regulation Manager). Evidence was gathered by speaking with a service user and the home manager, and by reading a selection of documents relating to provision of care and services offered by the home. What the service does well: What has improved since the last inspection? What they could do better: The inspection process evidenced non-compliance in a number of areas. Significant shortfalls were identified with the statement of purpose and service user guide; service user assessment; care planning; risk assessment; staffing numbers; medication, overall senior management of the home, and lifestyle choices for service users. There was insufficient evidence to suggest that service users needs were correctly identified or met, and outcomes for service users are poor. 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 6 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. 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Service users are unable to make an informed choice about where to live. Service user care may be compromised due to insufficient assessment of needs and skills. Service users cannot be sure that the home they choose will meet their needs and aspirations. EVIDENCE: In January this year, the sister homes to 72 Milton Road were inspected. The inspector found that the Statement of purpose and service user guide for all three homes (66, 68 and 72) were not only the same, but contained inaccurate and misleading information. The registered person was required to change these documents, and produce a statement of purpose and service user guide which were both specific to individual homes, and contain information relevant to the services currently offered. This has not been done, and inspection of the service user guide and statement of purpose for 72 Milton Road evidenced that prospective and current service users are given information about services and facilities at the home, which do not exist. The registered persons attention is again drawn to the following Regulation and Standard: Standard 1 clearly states; ‘The registered person produces an up-to-date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities, and terms and conditions; and provides each service user with a service users’ guide’. Regulation 6 talks about review of the statement of purpose and service user’s guide and states; ‘The registered person shall keep under review and, where appropriate, revise the statement of purpose and the service users guide’. 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 9 Inspectors looked closely at the home’s philosophy of care, which states; ‘Our care philosophy is to support and encourage all of our residents to lead as normal a life as possible and to reach their full potential. This is achieved by offering guidance and assistance with every day living skills and by encouraging residents to participate in the planning of their own care’. Little evidence could be found to support the above statement. The service users are not guided or assisted with every day living skills, nor are they involved in planning their own care. The manager informed inspectors that the service users had no motivation to cook or clean. Although no formal assessments were available, the manager indicated that the service users ‘probably could’ do more in terms of independent living, but would require a much higher level of staffing input to firstly motivate the service users, and teach them such skills. The manager presented inspectors with a draft document (written by the registered provider) intended as an addition to the statement of purpose to clarify Welcome House’s aims and objectives. The inspectors read the draft and considered it was not entirely suitable for inclusion. Some of the language used was regarded as inappropriate, for example ‘you will be loved’. Pre assessment documentation for both service users was requested. Although pre assessment documentation was available on individual files, the documentation provided evidenced neither service user was assessed prior to admission. One service user who was admitted to the home in September 1999, did not have the pre assessment documentation completed until June 2000. Another service user had all the pre assessment documentation completed on the day of admission. No evidence could be found that either admission was conducted in a planned way, with regard to assessing whether the home could meet the individual’s needs or aspirations. No follow up assessments regarding suitability of placement, or assessments of continuing support needs were evident. Documents viewed, and discussion with the manager and a service user evidenced that current and prospective service users cannot have confidence that the home will meet their needs and aspirations. 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9. Service users do not know if their assessed and changing needs and personal goals are reflected in their individual plan. Service users cannot be confident that they will be supported to take risks as part of an independent lifestyle. EVIDENCE: Care plans of both service users were inspected. Alongside care plans is a care plan review record. The inspectors noted regular review of care plans, but it was evidenced that care plans for one service user have not changed since 2003. This indicates that the service user is not being supported appropriately to realise goals. The home also undertakes monthly keywork reports. These were inspected. Information contained within the reports is considered too general. Keyworker reports are not linked to outcomes in care plans, nor do they record any changes in risk assessments. While the inspectors agree that such reports are good practice, the current report format requires more direction and involvement from service users. Care plans inspected contained insufficient information. An example of this is a care plan for supporting a service user with independent living skills. It states 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 11 the need as ‘everyday living skills’, and the method as ‘staff to assist (service user) with making light meals and to encourage with personal care’. The care plan does not indicate the service user’s current skills and strengths in this area, nor does it contain any information regarding specific support needs. Furthermore, the absence of staffing in the home (‘staff to assist’) makes the care plan redundant, and is perhaps an indicator as to why the service user’s care plan has not changed since 2003. The manager was asked how service users were supported to achieve goals set in their care plans. Inspectors were informed that service users received no support, and that care plans were not adhered to. The manager explained that she is the only full time member of staff, and is responsible for supporting six service users in three care homes. She is supported by two other members of staff – one who comes in two hours per day, Monday to Friday, and another who comes in for 3 hours on Saturday and Sunday. These staff undertake cooking duties. The manager acknowledged that in order for service users to receive support to enable them to realise goals recorded within care plans, staffing levels would need to be raised. Without this, service users receive minimal support and cannot be assisted to work towards gaining increased independence. Risk assessments were inspected. It was evidenced that information in the risk assessments is too brief, and does not contain sufficient information to be considered an effective tool. Furthermore, areas of concern identified during the inspection are not included in risk assessments. An example of this is a service user has a history of violence and alcohol abuse. There is no risk assessment in place to manage this, nor is there a risk assessment in place to protect the other service user from potential harm. 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11. Service users cannot be confident that they will be supported or offered opportunities for personal development. EVIDENCE: As previously evidenced, service users are not supported to maintain or develop independent living skills. Care plans pertaining to addressing the support needs of service users are not followed, and inadequate staffing levels in the home mean that service users currently receive limited support, which amounts to being provided with a meal at lunchtime, and being given their medication. The service at 72 Milton Road is described by Welcome House as a ‘semiindependent living home’, and is considered to be a stepping-stone to independent living. The evidence seen suggested that service users are not only being denied opportunities to learn skills necessary for independent or semi independent living, but it is likely that they have lost skills previously gained, and are in a situation where they are unmotivated and deskilled. The evidence indicates that Welcome House is failing to meet the needs of its service users, and is not demonstrating compliance to minimum standards, 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 13 Regulation, its own statement of purpose, or the Welcome House mission statement. 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20. Service users cannot be confident that medication is administered appropriately. EVIDENCE: Both service users receive prescribed medication. Neither retain their medication, and rely on staff to administer it on a daily basis. One service user has a letter from a care manager which states; ‘(service user) does need to be monitored taking his medication’. A risk assessment regarding medication states; ‘ (service user) is given his medication on a daily basis, which he takes in the evening. (Service user) is given his medication about 6pm and is then responsible to take his medication at this time. Staff to monitor (service user) on a daily basis. Staff to monitor any changes’. Inspectors were informed that the service user is not monitored taking his medication. Nor is the medication given at the time stated on the Medication Administration Record. Medication is given based on availability of staff. The manager informed inspectors that another service user has ‘a history of non-compliance with medication’ and stated that ‘he should not self medicate, he is not capable’. On several occasions the manager has found tablets in the service users bedroom. This service user has medication for 9pm at night. The 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 15 home is required to ensure that the service user is supported to take his medication at this time, and that the 9pm medication is given at that time by a member of staff. This is an immediate requirement. 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected. EVIDENCE: 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26, 28 and 30. Service users would benefit if communal areas and bedrooms were clean and did not have unpleasant odours. Service users would benefit from fire training. EVIDENCE: The communal areas and one bedroom was inspected. The following was noted: The hot water tap in the kitchen and bathroom was tested. On both occasions the water was tepid. The manager was asked to check the hot water supply, and if necessary, arrange for the boiler to be serviced. The one towel in the bathroom could be a cause of cross infection. The manager is required to ensure that service users use their own towels. The lounge furniture appeared shabby. Wallpaper was peeling off the wall. The lounge did not present as homely and welcoming. The bedroom inspected had a strong and unpleasant odour. Both service users smoke. There are no smoking signs in the house, and the service users have been asked to smoke outside. The manager agrees that this 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 18 is not enforceable, and knows that service users smoke in all areas of the house. Ashtrays have not been provided, and service users have not received any fire training. The manager was required to ensure that appropriate measures regarding equipment and training for service users were put into place. The toilet does not flush properly. 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33. Service users are not supported by an effective staff team. EVIDENCE: From information gathered and the observations made during the inspection, staffing is not adequate to meet the present needs of the current service users in the home. Based on figures from the residential forum, this home should have 72.66 support hours per week. The present support hours are significantly less, with 56 support hours for 6 service users in 3 care homes. Welcome House must address these staffing shortfalls as a matter of urgency, and ensure that 72 Milton Road is appropriately staffed to enable service users to receive the support required. The statement of purpose, service user guide, care plans and risk assessments are all documents to which no evidence could be found to support their texts. All areas inspected had significant shortfalls, and indicate that an increase in staff, coupled with training needs of staff being addressed, would significantly improve the service, and produce a likelihood of positive outcomes for service users. The manager informed the inspectors that she is frustrated by the low staffing numbers, and indicated that the service users living at the home are not receiving an acceptable service. 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 20 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38 and 43. Service users benefit from having a home manager who is committed and professional. Service users cannot be confident that the home is well run, or that the overall management of the service is competent. EVIDENCE: At present, managers of Welcome House care homes are required by the registered provider to sign a ‘managers registration fee disclaimer’ form. This form states ‘this is to confirm that should I (name) fail to obtain or withdraw my application for registration, for whatever reason, I agree to and give authority for Welcome House to deduct the total fee from my next wages. Should I terminate my employment with Welcome House within 36 months from the date of registration, I agree to and give authority for Welcome House to deduct the total fee from my next wages’. In the experience of the Commission this is considered unusual practice and are concerned that managers are required to sign this disclaimer. This ‘agreement’ discourages managers to seek registration, and it is noted that the 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 22 manager of the home has not done so, informing the inspectors that should she leave, she could not afford to lose £518. Given that all staff are not paid to attend training courses either, and also have to sign a disclaimer form saying they will pay back the cost of training should they leave, inspectors conclude that staff are not given sufficient encouragement or incentive to further their knowledge and training, and are not valued. Outcomes for service users at 72 Milton Road are considered to be very poor, and inspectors cannot envisage the situation improving if the constraints on staffing numbers and the current practice of senior management remains unchanged. The home manager presented as competent, professional, committed and knowledgeable about her role and responsibilities. She has developed a management style and approach, which is open, fair and welcoming. She clearly works hard in trying to ensure the home is run smoothly, and that service users are cared for in line with current care plans and company policies and procedures. However, the inspectors could not conclude that the home is well run. Evidence in the majority of standards inspected indicates non-compliance with standards and regulations. Service users have not been adequately assessed, their care plans do not reflect their support needs, staff numbers are unacceptably low, and service users do not receive adequate support in developing or maintaining a semi-independent lifestyle. 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 1 2 1 3 1 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 1 27 X 28 1 29 X 30 1 STAFFING Standard No Score 31 X 32 x 33 1 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 X X 1 X LIFESTYLES Standard No Score 11 1 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 1 X 1 1 X X X X 1 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 24 Yes. Are there any outstanding requirements from the last inspection? 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 YA6 Regulation YA6YA6 Requirement 15.—(1) Unless it is impracticable to carry out such consultation, the registered person shall, after consultation with the service user, or a representative of his, prepare a written plan (the service user’s plan) as to how the service user’s needs in respect of his health and welfare are to be met. OUTSTANDING REQUIREMENT FROM PREVIOUS INSPECTION OF DECEMBER 6TH 2005. 13.—(6) The registered person shall make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. OUTSTANDING REQUIREMENT FROM PREVIOUS INSPECTION OF DECEMBER 6TH 2005. 18.— (1) The registered person shall, having regard to the size of the care home, the DS0000028998.V274730.R01.S.doc Timescale for action 06/03/06 2. YA23 YA23YA23 06/01/06 3. YA33 YA33YA33 06/01/06 72 Milton Road (Welcome House) Version 5.1 Page 25 statement of purpose and the number and needs of service users— (a) ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users; OUTSTANDING REQUIREMENT FROM PREVIOUS INSPECTION OF DECEMBER 6TH 2005. 4. YA37 YA37YA37 9.—(1) A person shall not manage a care home unless he is fit to do so. (2) A person is not fit to manage a care home unless— (b) having regard to the size of the care home, the statement of purpose, and the number and needs of the service users— (i) he has the qualifications, skills and experience necessary for managing the care home; OUTSTANDING REQUIREMENT FROM PREVIOUS INSPECTION OF DECEMBER 6TH 2005. The registered person shall compile in relation to the care home a written statement (in these Regulations referred to as “the statement of purpose”) which shall consist of – (a) a statement of the aims and objectives of the care home; a statement as to the facilities and services which are to be provided by the registered person for service users; The registered person shall DS0000028998.V274730.R01.S.doc 06/03/05 5 YA1 4(1)(a) 4(1)(b) 30/04/06 6 YA1 4(1)(c) 30/04/06 Page 26 72 Milton Road (Welcome House) Version 5.1 7 YA1 4(2) 8 YA1 4(3)(a) 4(3)(b) 9 YA1 5(1)(a) 5(1)(b) 10 YA1 5(1)(c) 5(1)(d) compile in relation to the care home a written statement (in these Regulations referred to as “the statement of purpose”) which shall consist of – (c) a statement as to the matters listed in Schedule 1. The registered person shall supply a copy of the statement of purpose to the Commission and shall make a copy of it available on request for inspection by every service user and any representative of a service user. Nothing in regulation 16(1) or 23(1) shall require or authorise the registered person to contravene, or not to comply with – (a) any other provision of these Regulations; or the conditions for the time being in force in relation to the registration of the registered person under Part 2 of the Act. The registered person shall produce a written guide to the care home (in these Regulations referred to as “the service user’s guide”) which shall include – (a) a summary of the statement of purpose. The terms and conditions in respect of accommodation to be provided for service users, including as to the amount and method of payment of fees; The registered person shall produce a written guide to the care home (in these Regulations referred to as “the service user’s guide”) which shall include – (c)A standard form of contract for the provision of services and facilities by the registered provider to service users; 30/04/06 30/04/06 30/04/06 30/04/06 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 27 11 YA1 5(1)(e) 5(1)(f) (d) The most recent inspection report; The registered person shall produce a written guide to the care home (in these Regulations referred to as “the service user’s guide”) which shall include – A summary of the complaints procedure established under regulation 22; (f) The address and telephone number of the Commission. The registered person shall supply a copy of the service user’s guide to the Commission and each service user. Where a local authority has made arrangements for the provision of accommodation, nursing or personal care to the service user at the care home, the registered person shall supply to the service user a copy of the agreement specifying the arrangements made. The registered person shall – (a) keep under review and, where appropriate, revise the statement of purpose and the service user’s guide; and (b) notify the Commission and service users of any such revision within 28 days. The registered person shall not provided accommodation to a service user at the care home unless, so far as it shall have been practicable to do so – (d) the registered person has confirmed in writing to the service user that having regard to the assessment the care home (e) 30/04/06 12 YA1 5(2) 30/04/06 13 YA1 5(3) 30/04/06 14 YA1 6(a) 6(b) 30/04/06 15 YA2 14(1)(d) 15/04/06 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 28 16 YA3 14(1)(a) 14(1)(b) 17 YA3 14(1)(c) 18 YA6 15(1) 19 YA6 15(2)(a) 15(2)(b) 20 YA6 15(2)(c) 15(2)(d) is suitable for the purpose of meeting the service user’s needs in respect of his health and welfare. The registered person shall not provided accommodation to a service user at the care home unless, so far as it shall have been practicable to do so – (a) needs of the service user have been assessed by a suitably qualified or suitably trained person; the registered person has obtained a copy of the assessment; The registered person shall not provided accommodation to a service user at the care home unless, so far as it shall have been practicable to do so – (c) there has been appropriate consultation regarding the assessment with the service user or a representative of the service user; Unless it is impracticable to carry out such consultation, the registered person shall, after consultation with the service user, or a representative of his, prepare a written plan (“the service user’s plan”) as to how the service user’s needs in respect of his health and welfare are to be met. The registered person shall – (a) make the service user’s plan available to the service user; (b) keep the service user’s plan under review; The registered person shall – (c) where appropriate and, unless it is impracticable to carry out such consultation, DS0000028998.V274730.R01.S.doc 15/04/06 15/04/06 15/04/06 15/04/06 15/04/06 72 Milton Road (Welcome House) Version 5.1 Page 29 21 YA6 12(1)(a) 12(1)(b) 22 YA9 13(4)(b) 13(4)(c) 23 YA11 12(1)(b) 24 YA20 13(2) 25 YA28 23(2)(d) after consultation with the service user or a representative of his, revise the service user’s plan; and (d) notify the service user of any such revision. The registered person shall ensure that the care home is conducted so as – (a) to promote and make proper provision for the health and welfare of service users; (b) to make proper provision for the care, and where appropriate, treatment, education and supervision of service users. The registered person shall ensure that – (b)any activities in which service users participate are so far as reasonably practicable free from avoidable risks; and unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. The registered person shall ensure that the care home is conducted so as – (b) to make proper provision for the care and, where appropriate, treatment, education and supervision of service users. The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The registered person shall having regard to the number and needs of the service users ensure that – DS0000028998.V274730.R01.S.doc 15/04/06 15/04/06 15/04/06 03/03/06 30/04/06 72 Milton Road (Welcome House) Version 5.1 Page 30 26 YA30 16(2)(k) 27 YA33 18(1)(a) 28 YA37 10(1) 29 30 YA43 YA43 7(1) 7(2)(ii) 31 32 YA43 YA43 7(3)(a) 21(1) (d) all parts of the care home are kept clean and reasonably decorated. The registered person shall having regard to the number and needs of the service users ensure that – (k) keep the care home free from offensive odours and make suitable arrangements for the disposal of general and clinical waste. The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users – (a) ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. The registered provider and the registered manager shall, having regard to the size of the care home, the statement of purpose, and the number and needs of the service users, carry on or manage the care home (as the case may be) with sufficient care, competence and skill. A person shall not carry on a care home unless he is fit to do so. A person is not fit to carry on a care home unless – (ii) that individual satisfies the requirements set out in paragraph (3) The requirements are that – (a) he is of integrity and good character This regulation applies to any matter relating to the conduct of the care home so far as it may affect the health or welfare of DS0000028998.V274730.R01.S.doc 20/03/06 20/03/04 20/03/06 20/03/06 20/03/06 20/03/06 20/03/06 72 Milton Road (Welcome House) Version 5.1 Page 31 service users. 33 YA43 21(2) The registered person shall make 20/03/06 arrangements to enable staff to inform the registered person and the Commission of their views about any matter to which this regulation applies. A contravention or failure to 20/03/06 comply with any of the provisions of regulations 4, 5, 11, 12(1) to (4), 13(1) to (4) and (6) to (8), 14, 15, 16(1), (2)(a) to (j) and (1) to (n) and (3), 17 to 26 and 37 to 40, shall be an offence. 34 YA43 43(1) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 72 Milton Road (Welcome House) DS0000028998.V274730.R01.S.doc Version 5.1 Page 32 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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