Inspection on 06/09/06 for New Witheven

This inspection was carried out on 6th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

New Witheven 15/11/05

New Witheven 25/04/05

New Witheven 28/10/04

New Witheven 14/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 New Witheven Jacobstow Bude Cornwall EX23 OBX Lead Inspector Kerensa Livingstone Key Unannounced Inspection 6th September 2006 09:30 New Witheven DS0000009043.V305061.R01.S.doc Version 5.2 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 New Witheven DS0000009043.V305061.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 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. New Witheven DS0000009043.V305061.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service New Witheven Address Jacobstow Bude Cornwall EX23 OBX 01566 781285 01566 781762 new-witheven@btconnect.com 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) Mr Denzil John Phillips Mrs Gillian Margaret Phillips Care Home 8 Category(ies) of Learning disability (8) registration, with number of places New Witheven DS0000009043.V305061.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2005 Brief Description of the Service: New Witheven is a bungalow situated in a quiet rural area. It is the Registered Provider’s home, they live on site and it operates like a family unit. A long narrow lane approaches the home approximately 2 miles from the main A39 at Wainhouse Corner, where there is a hamlet with a shop and public house. The home provides care and accommodation for up to 8 younger adults with a learning disability. At the time of the inspection there were 4 service users living in the home. There has been a new extension built in the last year with six purpose built new rooms with ensuite facilities. One of the existing rooms has been upgraded to incorporate ensuite facilities. The eighth room is being used as an office at this time. There is a new large comfortable lounge and dining room, where service users eat together. There are far reaching countryside views surrounding the bungalow. The Providers own the surrounding area, which creates opportunities for the service users with a variety of animals. There is wheelchair access. Day care is provided separately on site, service users have access to these opportunities depending on their needs. These services are not inspected by the Commission for Social Care Inspection. However the inspector visited and was very impressed with the new ‘chalet’ style facilities that have been provided to replace the previous accommodation. Service users keep in contact with their families and friends and go home at regular intervals. There is an irregular bus service from the main road into Bude, but generally the service users are dependant on transport from the home if they want to go into town e.g. Taxi, Providers transport. New Witheven DS0000009043.V305061.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector conducted this unannounced key inspection over a full day. The inspector had the opportunity to meet all service users and discuss the experiences with three out of the four service users. The Registered Providers were available throughout the day and the inspector was able to talk to staff and look at the environment. Documentation was inspected and case tracking was used. What the service does well: What has improved since the last inspection? Information for prospective service users has improved since the last inspection. New Witheven DS0000009043.V305061.R01.S.doc Version 5.2 Page 6 The standard of accommodation that is available has improved significantly. The three service users the inspector spoke with, were delighted with the improvements and enjoyed spending time in the lounge/dining room too. Policies and Procedures for the home and the recruitment processes have improved since the last inspection. What they could do better: 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. New Witheven DS0000009043.V305061.R01.S.doc Version 5.2 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 New Witheven DS0000009043.V305061.R01.S.doc Version 5.2 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, 4 & 5 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Information for prospective service users has improved since the last inspection. Pre admission information must be gathered prior to the service user moving into the home. EVIDENCE: A comprehensive document to include the information required has been compiled as a combined Statement of Purpose and Service User’s Guide. A copy is provided to any prospective service user and a copy is available in each room. This information may need further development to ensure that it is available in a format that is suitable for the service users for whom it is intended. A copy of the most recent inspection report must be made available to service users and families. Three of the current service users have lived at New Witheven for over nine years. The Registered Providers have developed a care needs assessment form. The inspector was provided with evidence that comprehensive admission information that had been gathered for the newest admission to the home, this information should form the basis of an individual plan being developed and agreed with the service user and staff. This information was provided at the time of admission, not prior to admission. New Witheven DS0000009043.V305061.R01.S.doc Version 5.2 Page 9 The Registered Providers demonstrated an in-depth understanding of service user care needs and capabilities. Service users live a comfortable and active life. The pre assessment information must be gathered prior to the service user moving into the home. Service users should have the opportunity to visit the home to meet service users, staff, have a meal, view the room, see the kinds of records kept about service users and discuss how the home can meet the service user’s requirements. Unplanned and emergency admissions should be avoided. Contracts including written terms and conditions between the service user and the home have been compiled since the last inspection by the Providers. These must be discussed and agreed with the service users. Service users are provided with contracts from Adult Social Care that detail their terms and conditions, although there are often considerable delays in this information being provided the inspector was informed. New Witheven DS0000009043.V305061.R01.S.doc Version 5.2 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, 7 & 9 Quality in this outcome area is adequate. This judgement has been made from evidence gathered during the visit to this service. The Registered Providers have a detailed knowledge of the service users and there is clear evidence that individual needs and choices are met. The Registered Providers need to improve their documentation of care needs, risk-assessment and review. EVIDENCE: As identified at previous inspections, the Registered Providers have been using the care needs assessments as plans of care. As discussed at the time of the inspection, the assessments are used to determine care needs and the Registered Providers must then develop a care plan, which informs the carer about the interventions needed to maintain or improve the service users capabilities and independence. The care plans must be reviewed at least 6monthly with the involvement of the service user, or their representative, where possible. A copy of this plan should be made available in a format the service user can understand and held by the service user unless there are clear recorded reasons not to do so. The need for a comprehensive service user plan must be prioritised. Any restrictions on choice and freedom must be included. New Witheven DS0000009043.V305061.R01.S.doc Version 5.2 Page 11 Risk and hazards are identified in most cases individually, although the inspector and Providers did discuss some key omissions. Personal safety is addressed on an individual basis. Unexplained absences are acted upon promptly. The Registered Providers must ensure that individual risk assessments include risk management strategies; these must be recorded and reviewed. Service Users are encouraged to maintain their independence and are supported to do this. Service users informed the inspector that they were able to make decisions about how they live their lives. The Providers were observed during the inspection to ask a Social Worker about accessing advocacy services and to be supporting the individual’s right to make choices. Service Users attend structured daytime activities or employment for at least four days per week. New Witheven DS0000009043.V305061.R01.S.doc Version 5.2 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): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The service users are able to determine their own lifestyle within the parameters of their own capabilities and risk documentation must clearly reflect what these risks are. The service users are able to choose whether to participate or decline an activity. A balanced and varied diet is provided for the Service Users. EVIDENCE: The service users have a choice of activities such as day centres and work placements, this leaves weekends free for leisure activities. There is a day centre on site, which is available to the service users if they are not otherwise engaged. Leisure activities include shopping, trips to local public houses, takeaway meals, swimming, trips to the beach, and attendance at the Gateway club once a week. Service users are able to assist in feeding the pigs, ducks, ferrets and geese on site. There are plenty of opportunities for local walks and gardening. In June there had been a trip to Centre Parcs and another trip to Germany to visit the Christmas markets is being planned. One service user orders magazines from a local shop. The Registered Providers advised the inspector New Witheven DS0000009043.V305061.R01.S.doc Version 5.2 Page 13 that the service users are able to determine their own lifestyle within the parameters of their own capabilities and risk. The service users said that they like the lifestyle that is offered and the variety of things to do. Service users are encouraged to maintain links with their families. Friends and family are welcome to visit the home. Service users choose who they see and when and are able to receive guests in their room. All service users have locks on their bedroom door with a key provided. Staff knock when they wish to enter and wait for the service user to ask them to come in. Service users informed the inspector that they are able to participate in socialising within the home or spend time alone in their own rooms, without question. The Service Users are provided with a nutritious and varied diet. The menu changes fortnightly, although the Provider informed the inspector due to the size of the home the service users usually accompany the Providers on the weekly shopping trip, so it can be varied. Records must be kept to provide evidence of this. There was evidence that a clear choice for main course and desert is available. ‘The food is good’ one service user commented. There is a large kitchen with a dining area where the Service Users used to eat their meals. Since the last inspection, a new comfortable combined lounge/dining room has been provided with a fridge, microwave and sink to give the service users more privacy and promote independence. A bowl of fruit was available for anyone to help themselves to. The main meals continue to be prepared in the main family kitchen. Two service users informed the inspector that they like to keep their own snacks and drinks in their kitchen facility. Service Users are provided with a packed lunch or given a hot meal when they are attending daytime activities or employment. Personal likes and dislikes are recorded. Service Users should be given the opportunity to contribute to menu planning and meals must be flexible. Since the last inspection the Registered Providers have provided a visitors book and a record of the visitors to the home is being kept. New Witheven DS0000009043.V305061.R01.S.doc Version 5.2 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): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users personal and healthcare needs are supported in an individual way. EVIDENCE: Service users informed the inspector that their privacy and dignity is respected. Guidance and personal support is offered depending on individual need. The Service User plans of care must be reviewed to ensure that they direct care. Service Users make choices about how they live their lives, these choices must be incorporated into the Service User plan. Support and guidance is provided in a sensitive way, whilst continuing to promote independence. The routines within the home are flexible; during the week the Service Users are usually attending structured activities. This allows the weekends free for leisure activities and outings. All Service Users are registered with a General practitioner and have an annual medical check up. Health needs are assessed and specialist interventions would be sought on an individual basis. There is evidence that service users are provided with access to hearing and optical testing. New Witheven DS0000009043.V305061.R01.S.doc Version 5.2 Page 15 The Registered Providers have provided a lockable cupboard for medicines; no service users are currently prescribed any medication. The Providers and Inspector discussed that any service user self administering medication must be provided with a lockable space. The Registered Providers and one other family member have undertaken safe handling of medicines training and would seek advice from their supplying pharmacist when required. On the day of the unannounced inspection, no medicines were kept in the home for service users. Policies and Procedures relating to this area have been commenced. There is no designated drugs fridge or facility for storing controlled drugs. New Witheven DS0000009043.V305061.R01.S.doc Version 5.2 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): 22 & 23 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The Commission has not received any complaints about this home and service users know who to complain to if they are concerned. Adult Protection information must be developed to ensure staff know the action they must take. EVIDENCE: The Commission for Social Care Inspection has not received any complaints or allegations about this home. The Home has a complaints procedure, this must include that the contact details for Adult Social Care and that the complainant may contact them at anytime. This procedure must be made available to all staff and Service Users and a record of all complaints must be kept. The home has a Whistle blowing policy and information is available about the protection of vulnerable adults. The home has a copy of the Department of health document No Secrets. All staff have been or are being provided with training on the Protection of Vulnerable adults. Two staff attended the County Council training provided in January. The inspector and Providers discussed the importance of a clear procedure and policy. As identified at the last inspection the Registered Providers must review the procedure to ensure that it provides clear reference to local procedures and provides contact information, such as telephone numbers for local agencies e.g. Social Services Care Manager as the lead agency and the Commission for Social Care Inspection. New Witheven DS0000009043.V305061.R01.S.doc Version 5.2 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): 24, 25, 26, 27, 28 & 30 Quality in this outcome area is excellent. This judgement has been made from evidence gathered both the visit to this service. New Witheven is in keeping with a family home. However this has been enhanced by the addition of six ensuite rooms in a purpose built extension that meet the new environmental standards. It is very homely and the service users are delighted with their new accommodation. EVIDENCE: The home was observed to be very clean and hygienic on the day of the unannounced inspection. The surrounding land and lane has improved significantly since the building work was completed, the signage to the home was discussed as needing to be replaced. There has been a significant reinvestment in this home over the last year or more. The new extension provides light, airy and very comfortable environment that meets and exceeds the environmental standards. Six new rooms have been finished and one of the existing rooms has been upgraded to provide a sink and toilet. The eighth existing room is being used as an office currently. The service users told the inspector that they were delighted with their new rooms. New Witheven DS0000009043.V305061.R01.S.doc Version 5.2 Page 18 The service users chose the colour of paint for decorating their individual room. All rooms are lockable and the service users have their key. All bedrooms are comfortably furnished, well ventilated and have under floor heating. The Providers have given great consideration ensuring that the rooms have all the required furniture. Rooms are lockable and service users informed the inspector that they like having a key to their room. All rooms must have a lockable space fitted. A portable call bell is provided to each room depending on individual need, this is important as the rooms are sound proofed and the service users need to be able to call for assistance. All rooms have ensuite bathrooms with baths or showers depending on what service users wanted at the time of the building work. The communal bathroom has had the bath removed and a shower put in as it was felt this would be used more. This information must be included in the service user’s guide and arrangements that would be made if someone wished to have a bath. The Registered Providers have their own accommodation. A new comfortable combined lounge/dining room has been provided with a fridge, microwave and sink to give the service users more privacy and promote independence. There are private areas available for consultations and a designated smoking area outside the home. There is an attractive decking area outside where service users can sit, weather permitting with far reaching countryside views. There is parking area to the front and side of the property. Assisted access has been provided to the side of the home. There is a domestic laundry, the need for impermeable flooring was discussed and the Provider plans to replace the domestic washing machine with industrial one with a sluicing facility. There is no sluicing facility in the home, as the Providers do not feel that it is needed at this time. An infection control policy and procedure is required and staff should receive training on this. New Witheven DS0000009043.V305061.R01.S.doc Version 5.2 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): 31, 32, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staff are provided with health and safety practice training, role specific training should be provided for all staff. A robust recruitment procedure is required to safeguard service users. Service users speak highly of the Providers and the staff. EVIDENCE: There are clearly defined job descriptions and it was evident that staff fully understood their roles and responsibilities. Service Users attend a different part of the site for day care and this is staffed separately. One member of staff is studying their LDAF training and one has their NVQ Level 3 training. Staff informed the inspector that they had received First Aid, Fire, Food Hygiene, Moving and Handling, Protection of Vulnerable Adults training. Further training is planned to include training specific to the home. 50 of the care staff must have NVQ level 2. There are no staff employed solely for the home. The Providers and their daughters run the home on a day-to-day basis and the staff from the day service cover for set shifts. A review of the staffing needs has been considered New Witheven DS0000009043.V305061.R01.S.doc Version 5.2 Page 20 if the home was fully occupied. Currently there are two staff on duty or contactable if the home is empty i.e. all the service users attending their day care or employment. There are two staff that sleep in at night. No one under twenty one is left in charge of the home at anytime and no one under the age of eighteen is providing personal care. There is a rolling duty rota and the one available on the day of the inspection was dated the 30th of July. The legality of having an up to date duty rota that reflects accurately the staff on duty was discussed. Service users without exception spoke very positively about the Providers and other staff in the home. Criminal Records Bureau checks have been obtained for all people working in the home. Staff meetings take place informally, the need for there to be evidence that staff contribute to the running of the home was discussed, it was agreed that minutes would be taken. Regular staff meetings (minimum of six a year) were not taking place at the time of the inspection, these have been commenced since and are recorded and actioned. Recruitment Policies and Procedures based on equal opportunities, current legislation and Schedule 2 of the Care Homes Regulations are being developed. Two staff files were examined and found to contain most the required information e.g. application form, references, Criminal Records Bureau checks, induction, job description with the exception of one staff member who did not have two written references and the CRB checks were photocopies. Contracts must be signed by all staff. The Registered Providers and inspector have discussed the requirements for all new staff. The Registered Providers are aware that this is a period of change and of the importance of robust recruitment processes. All the Service Users have resided at the home for many years and have a clear understanding of the roles and responsibilities within the home, however this will change with the introduction of four new Service Users and the appointment of staff. Staff are provided with induction training, the Providers were advised of the new Skills for Care induction standards from this month and the training detailed earlier. New Witheven DS0000009043.V305061.R01.S.doc Version 5.2 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, 39, 40 & 42 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The Registered Providers know the service users very well and the home has functioned effectively for many years. The Registered Providers have recognised that there is a need to prioritise managerial aspects of care with the increase in numbers from 3 to 8 registered, this must be sustained. EVIDENCE: The Registered Providers manage the home on a day-to-day basis. There is evidence of clear leadership within the home; the home is managed on a dayto-day basis by the Registered Providers. There is an open and inclusive atmosphere within the home. This must be underpinned with periodic training and development. No one has undertaken the NVQ Level 4 in Management and Care as required. As identified at the last inspection, an annual development plan must be developed for the home reflecting outcomes and aims of the Service Users. Internal audit would form a part of this with Service Users and other New Witheven DS0000009043.V305061.R01.S.doc Version 5.2 Page 22 stakeholder’s views being sought, at least annually. The results of the Service Users surveys must be published and made available to the Service Users, other interested parties, the Commission for Social Care Inspection and included in the Service Users Guide. A significant number of written policies and procedures have been compiled since the last inspection, the Registered Providers must ensure that all staff working in the home read them, it was recommended that staff sign to say that they have read and understood them, this has been commenced since the inspection. Further Policies and Procedures need to be developed to cover all the topics listed in Appendix 2 of the Care Homes National Minimum Standards for Adults. Staff are provided with training in First Aid, Fire and Moving and Handling of medicines. Records are being kept of Visitors to the home since the last inspection as required. All accidents would be recorded in the home’s accident book. The Fire Officer and Environmental Health Officer visited the home in May 2006, all was found to be satisfactory. Water is regulated to 43 degrees. Emergency lighting is regularly checked and weekly fire tests. All service users have a copy of the fire procedure and have been advised of the action to take if the alarm should go off. The Registered Providers must ensure that environmental assessments are carried out for all safe working practices and risks within the home. New Witheven DS0000009043.V305061.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 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 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 4 25 4 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 3 X 2 X New Witheven DS0000009043.V305061.R01.S.doc Version 5.2 Page 24 No 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 15 Requirement The Registered Providers shall after consultations with the service user prepare a written plan as to how the service user’ needs in respect of his health and welfare are to be me Previous timescales not met 01/08/05. As above The Registered Provider is required to keep food records in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise. Previous timescales not met 14/12/05 The Registered Person shall keep a copy of the duty roster of person’s working at the care home, and a record of whether the roster was actually worked. 19 The registered person shall not & 4 allow a person to work at the care home unless the employer has obtained in respect of that person the information and documents specified in Schedule 2. DS0000009043.V305061.R01.S.doc Timescale for action 15/10/06 2. 3. YA7 YA17 15 17(2), Sch. 4 15/10/06 15/10/06 4. YA32 17(2), Sch. 4 06/09/06 5. YA34 17(2), Sch. 2 15/10/06 New Witheven Version 5.2 Page 25 6. YA37 10(2a) 7. YA39 24 8. YA42 13(4) The Registered Provider is required to undertake such training for example the National Vocational Qualification Level 4 in Management and Care to ensure they have the skills and knowledge required. Previous timescales not met 2005. The Registered Provider must ensure that there is a system for reviewing and improving the quality of care provided in the care home. A report will be provided to the Service Users and the Commission for Social Care Inspection. Previous timescales not met 01/01/06 The Registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. 15/12/06 15/10/06 15/10/06 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 YA23 Good Practice Recommendations For there to be a clear procedure including local contact details, so staff know the action to take if an allegation of abuse was to be made. 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