Inspection on 16/04/07 for The White House

This inspection was carried out on 16th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The White House 24/04/06

The White House 16/06/05

The White House 02/11/04

The White House 02/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 The White House 74 Reddown Road Coulsdon Surrey CR5 1AL Lead Inspector Barry Khabbazi Key Unannounced Inspection 16th April 2007 8:30am The White House DS0000058633.V336579.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 The White House DS0000058633.V336579.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. The White House DS0000058633.V336579.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The White House Address 74 Reddown Road Coulsdon Surrey CR5 1AL 01737 553 230 01737 553 230 thewhitehouse@govindan.co.uk 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) The White House Megalen Govindan Care Home 9 Category(ies) of Learning disability (9) registration, with number of places The White House DS0000058633.V336579.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The certificate is for 9 service users, adults 18-65 with a variation for 3 older adults. A letter is held on file confirming that, if a double room service user moves on, the remaining service user has the right to refuse to have another service user move into the room. 24th April 2006 Date of last inspection Brief Description of the Service: The White House is a detached two-storey house situated in Coulsdon, Croydon. There are three double and two single bedrooms as well as a dining room, kitchen and lounge. The homes stated aim is to create a home with a warm and friendly atmosphere. There is easy access to local shops, library and places of worship. The home offers care to eight people with learning disabilities, some of whom have additional sensory impairments. The home is not adapted for and is not suitable for people with physical impairments affecting mobility. All residents attend local day resources. The fees are from £460 to £2,100 per month. The White House DS0000058633.V336579.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started early in the day to allow the residents to be met, before they went to their day activities. The manager was interviewed, and records, policies, care plans, and the building were also examined. The home was found to be generally well run with a noticeable improvement in the level of activities and outings, and a increased level staff induction training and staff supervision. One new Standard has been exceeded, ‘supervision’. Some service users talked about recent activities and outings they had attended. Where communication was limited by the service user’s disability, those service users appeared relaxed and contented. Staff were seen to be supportive and responsive to service users’ needs. No areas of serious concern were identified at this inspection. What the service does well: One new Standard has been exceeded, ‘supervision’. The frequency of this now exceeds the 6 sessions per month required by this Standard. The residents have been consistent in their views that they liked their rooms and the meals. Residents commented positively about the home, talking or signing about recent outings, singing activities and visitors. At the last announced inspection the residents chose to stay at the home instead of attending their day centres as they wished to participate in the inspection process. This was supported by the home and additional staffing was provided to facilitate this. The residents all have pressure sore risk assessments. This also meets the Standards for Older People, as required. As the home accommodates only 3 service users over 65, this is seen as good practice for the rest. The bedroom sizes all exceed the minimum standard of 10sqm. Once the condition of registration regarding removing double rooms is implemented, this Standard should be exceeded. See ‘Conditions of registration’. The White House DS0000058633.V336579.R01.S.doc Version 5.2 Page 6 What has 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. The summary of this inspection report can be made available in other formats on request. The White House DS0000058633.V336579.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 The White House DS0000058633.V336579.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement Of Purpose now contains all the information required as set out in Standard 1. This will assist relatives and placing authorities in having a fuller understanding of what the home provides. The service users guide now contains the views of the residents. This is important so that new residents are clear about how other residents feel about living in this home. The home has not had a new service user start for at least 6 years. A completely new placement will need to be made before Standard 2 can be fully assessed. It was therefore not possible to assess Standard 2 fully at this time. The White House DS0000058633.V336579.R01.S.doc Version 5.2 Page 9 EVIDENCE: The home has a Statement Of Purpose and a new Service User Guide. These are clear and well laid out and reflect the changes in ownership. The last inspection report recorded that the Service User Guide did not contain all the elements of Standard 1.2 and 1.4, including the views of the service users. The service users’ views have since been included and this requirement is now therefore met. At the last inspection the range of fees were not available at the home. A new recommendation was therefore set under Standard 1 as follows: The range of fees should be available at the home. These are now readily available and this recommendation is now met. The home has not had a new service user start for at least 6 years. A completely new placement will need to be made before Standard 2 can be fully assessed. It was therefore not possible to assess Standard 2 fully at this time. The White House DS0000058633.V336579.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 8, and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans now cover all the areas required. This is needed so that staff, particularly new staff, know all a resident’s needs. Reviews are now occurring with a satisfactory frequency. This improves the staff’s knowledge of the changing needs of the residents. Although there has been progress in making relevant policies accessible to the residents, more needs to occur in this area so that all residents can access relevant policies Risk assessments contain all the information required as including this information could reduce unnecessary restrictions of liberty for the service users. The White House DS0000058633.V336579.R01.S.doc Version 5.2 Page 11 EVIDENCE: Plans of care were available for all service users and now contain all the elements required under Standard 6.2, namely those set out under Standard 2.3. and in particular educational, training, occupational, social, religious, or cultural needs. Residents reviews of care plans were examined and found to be meeting the required rate of every 6 months and on a monthly basis for those residents over 65. In addition, where care plans had been reviewed, and changes identified, these changes had been transferred to the care plan document. The last inspection report contained the following requirement under Standard 6. Residents must sign care plans and risk assessments to evidence their involvement. Although residents have started to sign care plans and risk assessments to evidence their involvement. This still needs to be implemented in all areas. This requirement remains in force until fully met. The last inspection report contained a recommendation for ‘daily notes’ to be recorded daily and show how the care plan was met on that day. These had improved but still need to be done daily. This recommendation remains. The service users are offered the opportunity to participate in the day to day running of the home and to contribute to the development and review of policies and services through accessible documentation including pictorial versions, regular house meetings and individual discussions with their key workers. The last inspection report recorded that Standard 8.2 requires the home to provide service users with accessible information regarding its policies activities and services, for example pictorial menus and complaints procedures. Although there are now pictorial menus, and pictorial cues to the service user guide, more work needs to be done, for example taped policies to facilitate access to those with a visual impairment. This requirement remains in force. The risk assessment form does contain all the information required under Standard 9.4, in particular details of how training and other options have been explored before any restrictions of liberty are applied, and the involvement of relatives or independent advocates. This had been filled in for all known areas required including restriction of liberty for the protection of the resident. The White House DS0000058633.V336579.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards, 12, 13, 14, 15, 16, and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are now adequately supported to participate in the local community, with the aim of maximum integration and challenging discrimination. Residents are supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. The daily routines and house rules do generally promote residents’ rights, to ensure equality and that all rights are enjoyed by all residents. Residents now receive sufficient access to activities and outings. Residents are supported to continue education, so that they can maximise fulfilment and achievement in their lives. Dietary needs are catered for and a balanced diet is provided, to ensure health and enjoyment of food. The White House DS0000058633.V336579.R01.S.doc Version 5.2 Page 13 EVIDENCE: There was evidence of the home enabling good links with family and friends who can visit and are visited regularly. Family and friends are made aware of the home’s visiting policy and there are few restrictions about when family or friends can visit. Friendships exist within the home. The daily routines and house rules do promote independence and choice. Meals for example can be taken where and when service users want and service users go to bed and get up when they want at the weekends. Service users are able to lock their doors and all have keys to their rooms. The home demonstrated choice in providing extra staff to facilitate the residents’ wish to not attend day services but be present at the home during the inspection to facilitate meeting the inspector. The 2005 inspection report recorded that outings occur every weekend and in the evenings. This was not the case at the time of the last inspection with only one outing per week on average occurring. In addition the placing authority {Croydon} has reduced access to day centres for the service users without increasing placement funding to compensate. For example, four service users now only have access to a day centre for one day a week. These two issues combined have resulted in a significant reduction in access to activities for the service users. The following requirement was therefore set: The home must ensure that service users have access to a range of appropriate activities. Activities have since been increased. Residents now have access to a higher frequency and wider range of appropriate activities. Residents have trips out 2 or 3 times per week and at weekends. These included for example, visits to the park, bowling, the cinema and meals out. Some service users talked positively about recent activities and outings they had attended. At my arrival one resident was colouring in and the rest were watching TV whilst waiting for their transport to day centres etc. By 10am, most of those residents that remained at the home were engaging in table top activities with staff. There are a variety of games, puzzles, and art equipment for the residents to use within the home, as well as equipment for listening to music. The last inspection report contained the following recommendation under Standard 14: Each service user should be offered a seven-day holiday paid for by the home as a part of the contracted price. This had not occurred and this recommendation remains in force. Evidence was provided of residents being supported to attend to continue education. Independent living training occurs at the home and day centre, and is supported by staff and key workers. The White House DS0000058633.V336579.R01.S.doc Version 5.2 Page 14 This was an early inspection and I asked the residents what they had for breakfast. One resident said scrambled egg and another said bread {and cereal when questioned further}. This confirmed that both hot and cold breakfasts were available and the residents concerned confirmed that the breakfast they had had was their stated preference. The service users design their menus with staff and assist in preparation where appropriate, with appropriate support from staff if required. Menus were examined and found to be satisfactory. The service users said they liked the food at the home. Planned menus are recorded. Snacks and drinks are always available. Nutritional needs are reviewed and monitored {including weight} and service users are referred to dieticians through the G.P if required. The White House DS0000058633.V336579.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards- 18, 19, and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ emotional and health needs are met by this home and records of health needs are now better recorded. This ensures that the residents’ emotional health is well maintained and therefore the quality of life experienced is also maximised. Residents’ medication is well managed as staff have had approved and accredited medication administration training to promote safer medication administration EVIDENCE: Encouragement and guidance are provided to support personal care but direct personal care is limited at this home. Evidence has been presented in discussions with staff of them having knowledge of good practice in providing care and support, and this has been confirmed through observation. The White House DS0000058633.V336579.R01.S.doc Version 5.2 Page 16 There are currently no service users with sensory or physical impairments significantly affecting mobility and/ or requiring aids and adaptations such as hoists to be present in the home. The home does not currently provide places for, and is not suitable for, people with a secondary physical or sensory impairment significantly affecting mobility. Healthcare needs were recorded in the residents’ files. The home has actively been promoting regular annual health checks through the GP. Access to audiologists, chiropody, dentists and opticians was demonstrated. Healthcare professionals attend when required and meet service users in private and service users are supported to attend outpatient appointments and other medical appointments. Service users can selfadminister medication subject to risk assessment. Records of action taken when a service user looses significant weight are now recorded. The following evidence of good practice was presented: Service users all have pressure sore risk assessments. This also meets the Standards for Older People, as required. As the home accommodates only 3 service users over 65, this is seen as good practice for the rest. The last report recorded that a new member of staff had been administering medication without having received accredited medication training. The following new requirement was then set: All staff administering medication must have accredited training in the administration of medication. All staff now have accredited training and now also annual updates. This requirement is now met. The White House DS0000058633.V336579.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. On the whole this home manages complaints well and the complaints procedure is now more accessible. The home’s policies and procedures relevant to this Standard currently facilitate protecting service users from abuse. EVIDENCE: There had been no official complaints made to the home or the Commission since the last inspection. The complaints procedure was clear and contained all of the elements required to meet Standard 22 including a minimum response time of less than 28 days. The complaints procedure is also available in a pictorial format. Policies were observed that protected the service users, and records were in good order. The home has a Restraints Policy, a Whistle Blowing Policy, a Gifts/Gratuities Policy, a Bullying Policy and a copy of the Local Authority Adult Protection Procedure on site. The White House DS0000058633.V336579.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards- 24, 26, and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is homely and comfortable and promotes a family-like environment. This environment therefore facilitates the residents’ emotional well-being. Residents’ rooms now contain all of the items listed in Standard 26.2 unless the resident has made a positive choice not to and this is evidenced in their files. This will ensure that all the residents have the furniture they are entitled to and do not have to keep furniture in their rooms just because the Standards require it. The home is clean and hygienic which promotes a pleasant environment, the residents health, and emotional well-being. The White House DS0000058633.V336579.R01.S.doc Version 5.2 Page 19 EVIDENCE: The home’s premises are accessible to the current service user group, in keeping with the local community, and are suitable for their purpose. The premises were clean, and free from offensive odours. There is suitable domestic lighting and ventilation. At the time of the inspection the premises were well furnished and in an appropriate style. There is a regular maintenance programme with records kept. Files samples showed that residents’ rooms now contain all of the items listed in Standard 26.2 unless the resident has made a positive choice not to and this is evidenced in their files. The building was clean and tidy and was generally free of offensive odours, although this was not the case for all bathrooms on this occasion. The manager has put water resistant carpet in the rooms concerned but this is still not fully addressing the situation. It was agreed for the home to write in to the Commission to request a change from carpet to a vinyl covering in the rooms concerned. The home has specific policies covering the disposal of clinical waste, control of infection, use of cleaning materials, hygiene, storage and preparation of food, communicable diseases, disposal of clinical waist, and dealing with spillages. There are Control Of Substances Hazardous to Health data sheets in their own file. Protective clothing was observed to be present. Laundry facilities have easily cleanable non-permeable walls. Washing machines had appropriate programmes over 65 degrees to control risk of infection and a sluicing cycle. The laundry room was positioned so that laundry does not need to be carried through the kitchen. The White House DS0000058633.V336579.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 32, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents are not supported by a staff group where 50 or more have the required qualifications. Achieving this will raise the quality of staff, their knowledge and their practices. The home’s recruitment procedures currently protect the residents through rigorous staff vetting. Staff receive induction and foundation training to ensure that they are appropriately trained. The staff are well supervised and receive supervision above the required level. Standard 36 is therefore exceeded. The White House DS0000058633.V336579.R01.S.doc Version 5.2 Page 21 EVIDENCE: The last inspection report contained the following requirement; 50 of staff should have the NVQ2. Although the staff who work at the home are currently on the NVQ2 course required, none of the staff currently have the required NVQ2. The requirement remains until fully met. The 2004 annual inspection report contained a requirement for the home to implement a new 6-week induction and 6 month foundation training programme, and ensure that this meets Sector Skills Council training specifications. This induction training had occurred by the time of the last inspection but did not then go on to foundation training. By the time of this inspection the required foundation training had begun. This requirement is therefore currently met. The last inspection report contained the following requirement: The manager must draw up a staffing policy which covers staffing levels and includes the home’s proposed reduced staffing numbers where less than 50 of residents are present. This must then be approved by the Commission before implementation. This was in place at this inspection and the requirement is therefore now met. This home has an equal opportunities recruitment policy. Criminal Record Bureau checks, references and proof of identification were checked and were present for all staff. External volunteers are not currently used at this home. The staff files sampled also contained, interview notes, statements of terms and conditions and staff photographs. The staff team receive regular supervision, which is recorded on their files. Staff supervision includes translation of the home’s philosophy into work, monitoring work, support and professional guidance and identification of training needs, as required under Standard 36.4. All staff have an annual appraisal where their training needs are discussed. The 2005 inspection report contained a requirement for staff to receive a minimum of six supervision sessions per year. By the time of the last inspection this had been met and by the time of this inspection the required frequency had been exceeded by almost double. This standard is now therefore exceeded. The White House DS0000058633.V336579.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards, 37, 39, 1nd 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a generally well run home although the manager still needs to complete the registered managers award. Only limited progress has been made with regards to the home implementing a quality assurance system and an annual development plan, with both involving service users. Although this could limit the involvement of the residents and relatives, residents have commented about being involved in decision making in practice. Records to confirm the safety of utilities and the home generally were all available and up to date. The White House DS0000058633.V336579.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager has a level 3 certificate in community mental health care. The registered manager is currently doing the NVQ 4 registered managers award. As the deadline {set under the Standards} for completing this has elapsed, The following new requirement is set. The manager must complete the NVQ 4 registered managers award. To put this in context, the manager has other qualifications, and is currently studying the required NVQ and will have this qualification soon. The last report contained the following requirement: The home must pull together its Quality Assurance tools into a structured Quality Assurance system that makes the service users central to the process. The last report recorded that quality assurance tools currently include service user meetings, user/relatives satisfaction surveys, auditing and a complaints system. Residents and relative satisfaction surveys and an annual development plan were identified as quality assurance tools that were still required. These elements are still needed and so the requirement remains in force. All of the health and safety policies and procedures relevant to this Standard have been seen to be present. Moving and Handling, Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling and Disposal of Clinical Waste policies are all also included in staff induction. The testing of systems required in Standard 42 were all in place. Records for fire fighting equipment testing and fire alarm testing were seen. Records for Portable Appliance Testing, 5-year wiring testing and the gas safety were also readily available. The last report contained the following 2 requirements under Standard 42: 1, Fire doors must be held open with automatic fire door closing devises and any wedges must be removed. 2, The home must confirm the suitability of the fire doors in the home. The home has confirm the suitability of the fire doors in the home and made improvements where required. Expanding smoke resistant strips have been put in doorframes where required and wedges have been replaced with fire responsive do closing devises. Both the requirements under this Standard are now met. The White House DS0000058633.V336579.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 N/a 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 3 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 3 35 2 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 x 2 x x 3 x The White House DS0000058633.V336579.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 12[3] Requirement Residents must sign care plans and risk assessments to evidence their involvement. The home must provide service users with accessible information regarding its policies, activities and services. {Previous timescale of 1/12/2005 not met} The home must pull together its Quality Assurance tools into a structured Quality Assurance system that makes the service users central to the process. The home must also introduce an annual development plan that is open to the service users, to allow measurement of achievement in improving quality.{Previous timescale of 1/4/2005 not met} 50 of staff must have an NVQ2 qualification. The manager must complete the NVQ 4 registered managers award. Timescale for action 01/10/07 2. YA8 12[4]b 01/10/07 3. YA39 24,1,2,3 01/10/07 4. 5. YA30 YA37 18[1]a 9(2) i 01/10/07 01/10/07 The White House DS0000058633.V336579.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA14 YA6 Good Practice Recommendations Each service user should be offered a seven-day holiday paid for by the home as a part of the contracted price. Daily notes should be recorded daily and show how the care plan was met on that day. The White House DS0000058633.V336579.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 The White House DS0000058633.V336579.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!