Inspection on 24/04/06 for The White House

This inspection was carried out on 24th April 2006.

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

Other inspections for this house

The White House 16/04/07

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 24th April 2006 8:00am The White House DS0000058633.V291202.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The White House DS0000058633.V291202.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The White House DS0000058633.V291202.R01.S.doc Version 5.1 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 5 Category(ies) of Learning disability (8) registration, with number of places The White House DS0000058633.V291202.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The certificate is for 8 service users, adults 18-65 with variations 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. 16th June 2005 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 White House DS0000058633.V291202.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 8.00 a.m. An early ‘breakfast time’ inspection was selected following a concern being raised that the service users were being given water on their cereal instead of milk. This was not the case on the day of the inspection, and service users confirmed that they had milk with their cereal if they wanted cereal and when desired, hot milk. During this inspection all the service users were met and comments from residents are included in this report. At this inspection the manager/owner was interviewed. Records, policies and care plans, and the building were examined, as were the residents’ bedrooms. No previous requirements had been met since the last inspection. 6 new requirements were set at this inspection. Concerns regarding unmet requirements were also raised in the last report. The manager agreed to a six week plan to meet six key requirements identified as priority requirements. Please see requirement section for details. The progress in these areas will be assessed over the next six weeks and if that progress is not satisfactory further action will be taken to ensure compliance. What the service does well: 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, 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.V291202.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The Service Users Guide is still not fully satisfactory, as it does not contain the views of the residents. This is important so that new residents are clear about how other residents feel about living in this home. Care plans do not contain all the information required under the standards. This could affect the staffs’ knowledge of the needs of the residents. Reviews are not occurring with a satisfactory frequency. When reviews do occur, identified changes in need are not included in the care plans. This could affect the staffs’ knowledge of the changing needs of the residents. Although there has been progress in making relevant policies accessible to the service users, more needs to occur in this area so that all service users can access relevant policies. Restrictions of liberty or pre-planned restraints are occuring without being fully recorded and evidenced, this could allow unnecessary restrictions of liberty for the residents. Service users do not have access to a wide range of appropriate activities. Each service user should be offered a seven-day holiday paid for by the home as a part of the contracted price. This would facilitate more funding and additional holidays for service users. All staff administering medication do not have accredited training in the administration of medication. This could put the service users health at risk. Although there has been progress in implementing the induction training programme, the home has not completed staff foundation training within Sector Skills Council training specifications and timescales. This could also affect the home’s ability to meet all of a resident’s needs. Only limited progress has been made with regards to the frequency of staff supervision. This area therefore remains unsatisfactory. The White House DS0000058633.V291202.R01.S.doc Version 5.1 Page 7 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. 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 White House DS0000058633.V291202.R01.S.doc Version 5.1 Page 8 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.V291202.R01.S.doc Version 5.1 Page 9 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 and 2. 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 is still not fully satisfactory, as it does not contain the views of the residents. This is important so that new residents are clear about how other residents feel about living in this home. EVIDENCE: The home has a new 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 also 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 were still not present and this requirement remains. 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.V291202.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, and 9. Care plans do not cover all the areas required . This is needed so that staff, particularly new staff, know all a resident’s needs. Reviews are not occurring with a satisfactory frequency. This could affect 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 Restrictions of liberty or pre-planned restraints are occuring without being fully recorded and evidenced, this could allow unnecessary restrictions of liberty for the residents. EVIDENCE: The White House DS0000058633.V291202.R01.S.doc Version 5.1 Page 11 Plans of care were available for all service users but they did not all record all of a service user’s needs and how these are to be met. For example educational and training needs and family/social contact. The following requirement is now set: Care plans must 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. This has been set as a Priority requirement for completion within 6 weeks. The last inspection report contained the following requirement: Residents care plans must be reviewed every 6 months and this must occur on a monthly basis for those residents over 65. This had not occurred for all residents and the requirement therefore remains. This has been set as a Priority requirement for completion within 6 weeks. In addition, where care plans had been reviewed and changes identified, these changes had not been transferred to the Care plan document. The following new requirement is set: When care plans are reviewed and changes are identified, the care plans must be updated accordingly. This has been set as a Priority requirement for completion within 6 weeks. Daily notes were not recorded daily and did not reflect the care provided. The following recommendation is set: Daily notes should be recorded daily and show how the care plan was met on that day. 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 last inspection report recorded that the risk assessment form does not contain 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 not been fully implemented by the time of this inspection and this requirement therefore remains in force. This has been set as a Priority requirement for completion within 6 weeks The White House DS0000058633.V291202.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, and 17. Residents are not adequately supported to participate in the local community, with the aim of maximum integration and challenging discrimination. Residents are well 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. Service users do not 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.V291202.R01.S.doc Version 5.1 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 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 last inspection report recorded that outings occur every weekend and in the evenings. This was not the case at the time of this 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 uses 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 manager does however have plans to appoint a member of staff specifically to provide activities for the service users. The following new requirement is now therefore set: The home must ensure that service users have access to a range of appropriate activities. It was ascertained at the last inspection that service users are not offered a 7day holiday, paid for by the home as a part of the contracted price. The recommendation set at that time has not yet been met and remains in force. The White House DS0000058633.V291202.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, and 20 Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ emotional health needs are met well by this home but records of health needs could be 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 not well managed to ensure maximised good health. 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. Healthcare needs were recorded in the residents’ files. However one service user had dropped from 45kgs to 40 kgs representing a significant loss of weight. The manager was not able to show records of any action taken or assessment of whether any action was required to remedy this. The following new requirement is therefore set: Records of action taken when a service user looses significant weight must be recorded. This has been set as a Priority requirement for completion within 6 weeks The White House DS0000058633.V291202.R01.S.doc Version 5.1 Page 15 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. 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, is seen as good practice for the rest. The new member of staff had been administering medication without having received accredited medication training. The following new requirement is now set: All staff administering medication must have accredited training in the administration of medication. This has been set as a Priority requirement for completion within 6 weeks The White House DS0000058633.V291202.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. On the whole this home manages complaints well. Although the complaints procedure is now more accessible, further developments would facilitate better access to the complaints system for the residents. 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 at or 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. 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.V291202.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, and 30. The home is homely and comfortable and promotes a family-like environment. This environment therefore facilitates the residents’ emotional well-being. The home is clean and hygienic which promotes a pleasant environment, the residents health, and 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. 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. The White House DS0000058633.V291202.R01.S.doc Version 5.1 Page 18 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. 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 White House DS0000058633.V291202.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, and 36. Not all staff are appropriately trained. This may affect how effective staff are in their work with service users. Service users are protected by the home’s recruitment procedures and practices Although there has been progress in implementing the induction training programme, the home has not completed staff foundation training within Sector Skills Council training specifications and timescales. This could also affect the home’s ability to meet all a resident’s needs. Only limited progress has been made with regards to the frequency of staff supervision. This area therefore remains unsatisfactory. EVIDENCE: Although the manager and provider who both work at the home are appropriately trained, none of the staff have the required NVQ2. The following recommendation is therefore set: 50 of staff should have the NVQ2. 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 The White House DS0000058633.V291202.R01.S.doc Version 5.1 Page 20 specifications. This induction training had occurred by the time of this inspection but did not then go on to foundation training. This requirement will remain in force until fully met. This home has an equal opportunities recruitment policy. Criminal Record Bureau checks were checked and were present for all staff. External volunteers are not currently used at this home. The staff files sampled also contained references, interview notes, statements of terms and conditions and staff photographs. The 2004 inspection report contained a requirement for staff to receive a minimum of six supervision sessions per year. Although this had started there was still a shortfall at this inspection. One staff member had monthly supervision in 2005{which is to be commended}, but no supervision was recorded for 2006. The existing requirement will remain in force until fully met. This has been set as a Priority requirement for completion within 6 weeks The White House DS0000058633.V291202.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Service users benefit from a generally well run home and appropriately qualified management. 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 not available. 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. The White House DS0000058633.V291202.R01.S.doc Version 5.1 Page 22 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. Although questionnaires have now been developed they still need to be sent out and the information included an annual development plan where applicable. The existing requirement remains until fully met. 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 recently sent to the commission following a requirement last year. This requirement is therefore now met. 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 not readily available. The following requirement is set to address this: The Portable appliance testing certificate, The gas safety certificate and the 5 year wiring test certificate must be sent into the Commission. The White House DS0000058633.V291202.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 x 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 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 2 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 3 x 2 x x 2 x The White House DS0000058633.V291202.R01.S.doc Version 5.1 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 12[3] Requirement Timescale for action 24/04/06 2. YA6 3. YA8 4. YA9 The Service User Guide must contain the views of the service users. {Previous timescale of 1/3/2005 not met} 15[2]b Residents care plans must be reviewed every 6 months and this must occur on a monthly basis for those residents over 65. {Previous timescale of 1/12/2005 not met} Priority requirement 12[4]b The home must provide service users with accessible information regarding its policies, activities and services. {Previous timescale of 1/12/2005 not met} 17[1]a 13[7] Specific risk assessments must be produced where any restrictions of liberty or preplanned restraints are assessed as necessary for the protection of service users. These risk assessments must contain details of how training and other options have been explored and the involvement of relatives or independent advocates. {Previous DS0000058633.V291202.R01.S.doc 06/06/06 24/04/06 06/06/06 The White House Version 5.1 Page 25 5. YA35 18[1] 6. YA36 18[2] 7. YA39 24,1,2,3 8. YA14 16[2]m 9 YA6 15 10 YA6 152b timescale of 1/10/2004 not met} Priority requirement The home must now implement its foundation training programme and ensure that this meets Sector Skills Council training specifications. [35.3] {From the June 2003 inspection} Recorded supervision must occur at least 6 times per year. {Previous timescale of 1/10/2005 not met} Priority 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 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} The home must ensure that service users have access to a range of appropriate activities. {New requirement} Care plans must 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. {New requirement} Priority requirement When care plans are reviewed and changes are identified, the care plans must be updated accordingly. {New requirement} Priority requirement 24/04/06 06/06/06 24/04/06 01/07/06 06/06/06 06/06/06 The White House DS0000058633.V291202.R01.S.doc Version 5.1 Page 26 11 YA19 12[1]a Records of action taken when a service user looses significant weight must be recorded. {New requirement} Priority requirement All staff administering medication must have accredited training in the administration of medication. {New requirement} Priority requirement The Portable Appliance testing certificate, the gas safety certificate and the 5 year wiring test certificate must be sent into the Commission. {New requirement} 06/06/06 12 YA20 13[1]2 3[c] 06/06/06 13 YA42 12[1]a 01/07/06 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. 2 3 Refer to Standard YA14 YA6 YA32 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. 50 of staff should have the NVQ2. The White House DS0000058633.V291202.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The White House DS0000058633.V291202.R01.S.doc Version 5.1 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!