Inspection on 20/05/08 for The White House

This inspection was carried out on 20th May 2008.

CSCI found this care home to be providing an Adequate service.

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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The White House 21/11/05

The White House 23/05/05

The White House 03/12/04

The White House 21/07/04

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 28/09/2008.

CARE HOME ADULTS 18-65 The White House 39a Shaftesbury Avenue Feltham Middlesex TW14 9LN Lead Inspector Sarah Middleton Key Unannounced Inspection 20th May 2008 09:25 The White House DS0000057847.V362078.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 DS0000057847.V362078.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 DS0000057847.V362078.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The White House Address 39a Shaftesbury Avenue Feltham Middlesex TW14 9LN 020 8890 3020 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) white.house@craegmoor.co.uk www.craegmoor.co.uk Parkcare Homes Ltd Veronica Valery Govia Care Home 6 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1) of places The White House DS0000057847.V362078.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th September 2006 Brief Description of the Service: The White House is a detached house in a quiet residential area near to Feltham and Bedfont. The Hounslow shopping centre can be reached by public transport and there are leisure facilities at Feltham and Bedfont. The home is registered for six people with learning disabilities. All the current residents are male. The house is owned and managed by Craegmoor, trading at Parkcare Homes. There are six single bedrooms. Two are on the ground floor, one of which leads into the lounge. One of the first floor bedrooms has a full en suite, with a bath. The remaining five have washbasins. There are two bathrooms; the one on the ground floor is an assisted shower room, which meets the needs of one particular person. There are three toilets in the home. The communal facilities are a lounge/dining room, which has French doors to the garden. There is also a small room, where there is a telephone for residents to talk in private. This is close to the office, laundry room and kitchen. The Registered Manager has a small office on the first floor. The staff team consists of the Registered Manager and day/night support workers. At night there is one waking night staff and the Registered Manager is on call in the event of an emergency. The staff provide support with personal care, practical tasks, day services and leisure activities. Staff also receive training to support people with disabilities. There is a large rear garden and there is parking at the front of the home. The fees range from £934-to £1,200 per resident per week. The fees are reviewed on a regular basis and vary depending on the specific needs of the resident. The White House DS0000057847.V362078.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection and the inspection visit to the home was from 9.25am-5.50pm. We spoke with 4 residents and one member of staff. Postal surveys were sent out and three residents, one health professional and one relative completed these. Residents were supported to complete the surveys with a member of staff. We looked at documentation, such as, resident files, medication systems and health and safety records. The Manager assisted with the inspection process and had completed an Annual Quality Assurance Assessment for this year. Five of the previous requirements had been met and eleven new requirements were made. All of the National Minimum Standards had been assessed. What the service does well: What has improved since the last inspection? What they could do better: The White House DS0000057847.V362078.R01.S.doc Version 5.2 Page 6 The home’s environment needs updating in certain areas, such as the kitchen, bathroom and the garage roof needs replacing. Medication systems need to be more robust in order to protect the welfare of the residents. The health and safety of the residents need to be considered at all times, including providing door releasing equipment for those doors needing to be kept open. The fire risk assessment must be reviewed and updated and be relevant to the home. Information about the residents needs must be detailed and relevant to the individual resident. Sufficient staff must be working at any one time in the home. The Manager must have time to continue to settle into the role as Manager of the home and be able to carry out her managerial duties. She should not be carrying out excessive care and support duties, please see body of the report, Standard 33 for further details. Any significant incidents or issues must be reported to the Commission. 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 DS0000057847.V362078.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 DS0000057847.V362078.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are assessed prior to moving into the home. EVIDENCE: The previous Manager had assessed the most recently admitted resident prior to their admission. A completed pre-admission assessment was viewed and this was mainly a checklist, outlining the needs and abilities of the prospective resident. The Manager confirmed there is a process in place to obtain information about a prospective resident before a decision is made. Prospective residents and their relatives or friends would be encouraged to make several visits to the home to ensure it is deemed to be a suitable place. The White House DS0000057847.V362078.R01.S.doc Version 5.2 Page 9 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): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents would benefit from having their current needs clearly recorded onto care plans and risk assessments. Residents are supported to make daily decisions about their lives. EVIDENCE: We discussed with the Manager how the home is meeting the needs of the residents. Two residents need funding for one to one staff support. This has only been obtained for one of these residents and the Manager said she has tried where possible to provide extra staff support until funding is agreed for the other resident. On many of the morning shifts the Manager is the third member of staff working with the residents, (see Standard 33 with regards to staffing levels). The White House DS0000057847.V362078.R01.S.doc Version 5.2 Page 10 One resident spoken with, described how they were “frightened of another resident”. The Manager is aware of some of the concerns residents have and is considering how to address this issue. We discussed with the Manager the need to ensure the home can meet the needs of all the residents and to consider the feelings and safety of all the residents. A sample of care plans and risk assessments were viewed. Although these outlined some of the resident’s needs, aspects of the care plans were inaccurate, for example stating that a resident would see a dentist or chiropodist to maintain good health, when in fact it is likely they would refuse to have full treatment from these professionals. Other parts of the care plans were very general and overall the information recorded would not give a member of staff full details of how to care for the resident or indicate what the resident can do for themselves. This was brought to the attention of the Manager and a requirement was made for this to be addressed. Those risk assessments viewed were also general. Information about each resident should be easily accessible for staff and record the identified needs of the resident. The files viewed contained a lot of documentation and it is advised that the information in all the files are reviewed to ensure only relevant and accurate information is kept. A moving and handling risk assessment had not been reviewed since 2006. A re-stated requirement was made for risk assessments to be reviewed, and relevant to the individual resident. The residents living in the home do not have an advocate. Some residents have input from relatives. The Manager is aware that an independent advocate would benefit some of the residents and is looking into this as a possible additional form of support. Residents are not able to manage their own finances. However they are supported to make choices and staff confirmed they listen to what residents ask for. Residents said they have input into the food they eat and the activities they wish to take part in. The White House DS0000057847.V362078.R01.S.doc Version 5.2 Page 11 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): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall residents have the opportunity to take part in activities both in the home and in the community. Residents are encouraged to maintain social relationships with family and friends. Residents’ rights are respected in the home. The meal provision offers choice and healthy options. EVIDENCE: Two residents attend day centres five days a week. The other residents then spend time with staff doing tasks both in the home and going out in the community. There are ongoing issues with some residents who do not like going out with other residents or choose to spend time in the home. The White House DS0000057847.V362078.R01.S.doc Version 5.2 Page 12 The Manager is aware that the staff team need to explore further the opportunities that are available for residents. Although the home has a car, residents are encouraged to walk and use public transport as a means to access places. One resident used to attend church services, but due to a change in their needs this has not been occurring. We discussed with the Manager the possibility of finding out if a person from the church would visit the resident in the home. Residents have the option of going on holiday each year and a holiday is planned for later in the year. If residents have relatives or friends then they are able to visit the home. The Annual Quality Assurance Assessment states that the home is looking to provide an alternative place for residents to meet with their relatives. Some contact is maintained through telephone calls. One resident is able to receive their own post, as they can read. Those residents asked said that staff spend time talking with them. The needs of the residents are varied and staff recognise that some residents are able to make informed choices and decide what they wish to do each day. We spent time with residents at lunchtime and some residents make their own breakfasts and lunches, with staff making the main evening meal. It was noticed that the lunch one resident made did not appear to be healthy. This was brought to the attention of the Manager who commented that the home aims to balance resident choices along with ensuring residents eat a healthy meal. It is acknowledged that residents should have options of meals they wish to eat and to be able to eat foods they like. However staff need to continuously monitor the meal provision to meet the health needs of the residents. Residents have input into the weekly menus and meals actually eaten by the residents are recorded. Food that had been opened was dated in the fridge. Fridge and freezer temperatures are taken on a regular basis. The environmental officer who visited the home recently had made several recommendations about the kitchen, (Standard 24 for similar findings on this visit). The Manager is acting on these findings. Those residents asked said they enjoyed the food in the home. The White House DS0000057847.V362078.R01.S.doc Version 5.2 Page 13 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): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents receive personal support in their preferred way. Overall residents’ health needs are being met. The medication shortfalls identified at this inspection could place residents’ health and welfare at risk. EVIDENCE: Three residents need assistance with personal care. Some residents have a preference in gender care and this should be noted on their care plans. Those residents asked said they got up and went to bed when they wanted to. The Manager had recently devised a check for staff to use for a resident who had particular needs. The White House DS0000057847.V362078.R01.S.doc Version 5.2 Page 14 All residents have a GP and a record is made when residents attend health appointments. The home also has a form that is used if a resident seeks medical treatment and is usually used in an emergency. Aspects of this form could be more detailed to ensure relevant details about the resident is passed on to the medical professional, such as how the resident communicates. Feedback from the dentist, via the postal survey, commented that advice given by the dentist to staff to maintain the residents oral hygiene is not always followed. One suggestion from the dentist was for the home to “improve protocols for assisting residents with their oral hygiene routines”. Although it was acknowledged by the dentist that the problems could be due to the varying needs and difficulties in supporting residents with complex needs, this will need to be monitored. A relative also commented in a postal survey about the difficulties there had been in accessing appropriate health services to investigate a resident’s possible health issues. The Manager, during the inspection, also confirmed there were ongoing issues in identifying appropriate healthcare. This matter, should if it continues, be taken up both by the home and Social Services with the local Primary Care Trust. Residents have various needs that healthcare professionals need to be able to address, with the assistance and guidance from staff and relatives. We were satisfied that the staff team were doing everything they could to try to resolve this issue. A sample of medication was viewed. New staff shadow existing staff and complete a workbook that is sent through from the local Pharmacist. We could not check one resident’s medication, as the quantity had not been written onto the Medication Administration Record. This particular resident had been discharged from hospital and the medication was in boxes and bottles. Regardless of whether medication was from hospital or the Pharmacist, all medication entering the home must be recorded onto the Medication Administration records. Another resident’s medication seen was not recorded on the Medication Administration record and staff could not say why this medication was in the home. It was agreed that this medication would be returned to the Pharmacist. A gap was noticed on the Medication Administration record where a staff signature should have been and staff had also signed for several days in the wrong place. The above errors were discussed with the Manager, as staff need to be aware that there are serious implications if correct procedures are not followed. Poor record keeping makes it very difficult to carry out a detailed and accurate count of any medication and makes it unclear exactly what medication has been administered. A requirement was made for records to be accurately maintained. The White House DS0000057847.V362078.R01.S.doc Version 5.2 Page 15 A requirement was also made for all medication, including those in boxes and bottles to be counted and recorded on a regular basis. Clear audits carried out can pick up on medication errors and action can then be swiftly taken. Although the home currently does not have any controlled drugs, due to recent changes in legislation, all homes should now have appropriate separate storage in the event that controlled drugs might be prescribed for a resident. It was recommended for the home to purchase a secure lockable unit for controlled drugs. Overall the residents’ safety and welfare needs to be a priority and the above errors shows that this had not been the case. The White House DS0000057847.V362078.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to make a complaint and to voice their concerns. Systems are in place to protect residents from abuse. EVIDENCE: There had been three complaints since the last inspection visit. These had been from staff and a relative and all three had been looked at and responded to appropriately. Those residents asked knew how to make a complaint and who to talk to if they had a concern. The complaints policy is freely available, although only one resident can read. There had been one abuse allegation made since the last inspection visit. This had been swiftly responded to and there was no evidence to uphold the allegation. Abuse training is available for all staff and policies are in place from the Local Authority. The Annual Quality Assurance Assessment also stated that the Provider has various policies in place to safeguard residents from abuse. We observed a sample of resident’s personal money being counted. This is checked three times a day at handover meetings. No errors were noted. The White House DS0000057847.V362078.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents would benefit from a well maintained home. The home is clean and free from unpleasant odours. EVIDENCE: A tour of the home and outside was carried out. The kitchen is in need of updating. Many cupboard doors and tiles had peeling paint. In one place the worktop was badly marked and the kitchen window had condensation trapped in it. A requirement was made for this room to be addressed, as it looked unappealing for the residents. The garage roof out in the garden could place the residents at risk and needs removing and replacing with safer material. A requirement was made for this work to be carried out. The White House DS0000057847.V362078.R01.S.doc Version 5.2 Page 18 Although the first floor bathroom had been painted, the radiator was very rusty and the ceiling was marked. A requirement was made for this to be made a more pleasant room for residents to use. The Manager is aware of areas needing attention and is keen for the home to look welcoming and inviting for the residents. The staff team, along with the residents, keep the home clean. On the day of the inspection the home was clean and tidy. Residents are supported to do their personal laundry, with assistance from staff. The White House DS0000057847.V362078.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A trained and competent staff team support the residents. Residents would benefit from sufficient numbers of staff working in the home. Residents are protected by the recruitment checks carried out on staff. The staff team are trained in order to meet the varied needs of the residents. EVIDENCE: Overall feedback from residents about the staff team was positive. The relative in the postal survey commented, “staff are well informed and helpful”. Staff receive support and information about specific needs of the residents, such as how to manage challenging situations. Over 50 of staff are studying for an NVQ in care. The White House DS0000057847.V362078.R01.S.doc Version 5.2 Page 20 The rota was viewed, although many shifts have three members of staff working, often during the week in the morning there are two members of staff and the Manager. Although two residents go to the day centre during the week, we were concerned that the Manager’s focus is sometimes on direct care duties and supporting the residents in the morning and not on managerial duties. It is recognised that the Manager should take part in various tasks relating to residents, in order to build and develop relationships and to see how the care staff work on a shift. However, as the Manager needs to manage the home effectively and to address the shortfalls identified at this inspection a requirement was made for another member of staff to work as the third person in the mornings. It is then the Manager’s decision, once she feels the home is running smoothly, to review the numbers of staff needed on shift in order to meet the needs of the residents. Staff meetings are held monthly and those staff asked said the team work well together. A shift plan is completed so that staff are aware of their duties each day. The staff team is a mix of gender, race and experience. Some of the staff members are new to working in the home and are supported by the more long-standing members of staff who are familiar with the residents and the home. Two staff employment files were viewed regarding new members of staff. Completed application forms were seen, although a discussion took place with the Manager, as the application forms did not record full details of the applicant’s employment histories. Where possible, it is good practice to request full details of employment histories, including requesting information on any gaps in employment. One file had no health declaration completed and this needs to be done and stored on the file. One Criminal Record Bureau check was seen and a POVA first check on the other member of staff, who does not work unsupervised. Two references were seen. It is important to make a record if references need to be sought from other sources that are not noted on the application form, so that there is a clear audit trail. Training and induction for new staff was seen. New staff work through a detailed book that takes several weeks to go through. This covers a wide range of subjects relating to care. Once the Manager is happy that the induction has been completed this is then signed by both the new staff member and the Manager. Those staff asked said they had been through a detailed in house induction, which had included reading about residents and shadowing experienced members of staff. We viewed an overall training record. This recorded the training the whole staff team had attended. Staff were up to date with core training, such as food hygiene and moving and handling. Staff had also received training on sexuality and relationships. It is worth noting that many of the training provided to staff is only for two hours, with many subjects being covered in one day. This practice should be monitored to ensure the quality and contents of the training meet the needs of the staff team and consequently the residents. The White House DS0000057847.V362078.R01.S.doc Version 5.2 Page 21 We also discussed with the Manager the benefit in devising individual training records as different staff might have different training needs. Devising these forms will also make it easier to quickly identify the training each member of staff has attended. These can then be looked at with staff during one to one supervision and annual appraisals. The White House DS0000057847.V362078.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): 37, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a home that is well managed. Residents’ views need to be sought and included in a report when assessing the quality of the care in the home. The health and safety shortfalls could place the residents at risk of harm. EVIDENCE: The Manager joined the home in October 2007. She is currently studying for the Registered Managers Award. Feedback from staff and residents about the new Manager was positive, with staff saying the Manager was “approachable”. She has dealt professionally with some difficult situations, since working in the home and is aware of the shortfalls needing to be addressed. The White House DS0000057847.V362078.R01.S.doc Version 5.2 Page 23 The home has various ways in which to monitor the care being offered in the home. Residents and relatives complete surveys about the home. The Manager looks at different areas each month and completes a report commenting on such things as, health and safety. Resident meetings are held and evidence was seen of the last recorded meeting held in March 2008. Residents are encouraged to contribute to these meetings. An overall report that would give a summary of the work the home had been doing the past year and aims and objective of the forthcoming year had not been developed. This report needs to evidence how the home has made improvements and note where there are still issues to be addressed. This must then be made available for residents and for inspection. A requirement was made for this to be completed. Maintenance records were viewed. Fire drills had been held at different times and evidence was sent that risk assessments had been completed on each resident with regards to their response to fire practices. The fire risk assessment had been completed in 2005, this must be reviewed and updated and a requirement was made for this to be addressed. Other records were up to date, such as Gas Safety Record, Test for Legionella and Portable Appliance test. We discussed testing the temperature of the water in all areas and recording this, as evidence was only seen that bath water had been tested. A resident had been discharged from hospital with pressure sores but we had not been informed of this event. A requirement was made that any significant incident or event that affects the welfare of a resident should be recorded and the Commission be notified. It was noted that one fire door had been propped open and it was later identified that other residents either need or like their bedroom doors to be kept open. Appropriate door releasing equipment needs to be fitted to these doors in order to fully protect the welfare of the resident and staff. A requirement was made for this to be actioned. The White House DS0000057847.V362078.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 x 2 3 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 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 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 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 3 x 2 x x 2 x The White House DS0000057847.V362078.R01.S.doc Version 5.2 Page 25 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. 2. Standard YA6 YA9 Regulation 15(1) Requirement Timescale for action 30/06/08 30/06/08 In order to meet residents’ needs, detailed care plans need to be in place. 12(1)&13(4)(b)(c) Risk assessments must be completed and be relevant to the individual resident. These must then be reviewed and updated on a regular basis. (Previous timescale 31/10/06 not met) 13(2) In order to protect the health and safety of residents, Medication Administration Records need to be correctly and accurately completed. Regular medication checks and counts on all medication in the home must be carried out in order to protect the welfare of the residents. For the home to be safe and welcoming the garage roof in the garden must be replaced with safe materials. 3. YA20 20/05/08 4. YA20 13(2) 23/05/08 5. YA24 13(4)(a) 23(2)(b) 29/08/08 The White House DS0000057847.V362078.R01.S.doc Version 5.2 Page 26 6. YA24 23(2)(d) 7. YA24 23(2)(b)(d) 8. YA33 18(1)(a) 9. YA39 24(2) 10. YA42 13(4)(c) 23(4)(a) 11. YA42 (23)(4)(a)(b) The home needs to be welcoming for residents, therefore, the first floor bathroom radiator needs replacing and the ceiling needs to be painted. The kitchen cupboards and worktops need updating and replacing, in order to provide a clean, hygienic and welcoming home to live in. In order to meet the needs of the residents and to manage the home effectively, the Manager should not undertake excessive amounts of care duties that might inhibit her role as the Manager. In order to ensure residents live in a home that reviews the care being offered and continuously makes improvements, a report must be devised and completed to evidence the home reflects on its care practice. This report needs to be made available to residents and the Commission. In order to protect the residents, an up to date and detailed fire risk assessment must be completed. To protect the welfare of the residents, doorreleasing equipment must be fitted to all fire doors that need to be kept opened. The Commission must be informed of any significant incident or concern 29/08/08 30/09/08 31/07/08 31/08/08 30/06/08 09/06/08 12. YA42 37(1)(c) 20/05/08 The White House DS0000057847.V362078.R01.S.doc Version 5.2 Page 27 regarding a resident. 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 YA20 Good Practice Recommendations A separate and lockable controlled drugs cupboard and register should be obtained. The White House DS0000057847.V362078.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 DS0000057847.V362078.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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