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Inspection on 06/03/07 for The White House

Also see our care home review for The White House for more information

This inspection was carried out on 6th March 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

This home provides a clean, comfortable and homely environment for the service users, and the individual bedrooms are furnished with personal belongings that reflect personal life histories. All service users are fully assessed, and have the opportunity to visit the home prior to being offered a permanent placement, so they can be sure of the quality, facilities and suitability of the home. The assessments are being reviewed regularly to ensure changes in needs were being efficiently addressed. Health and personal care needs are clearly set out in individualised care plans for all service users. The three service user files that were inspected all contained very thorough care plans. These had been generated from the initial assessments that had been carried out pre admission.Care practices and interactions between staff and service users were observed during the inspection, and relationships appeared friendly, familiar and respectful. Assistance and encouragement was being offered in a dignified manner appropriate to the service users individual needs This home does not act as appointee for any of the service users finances, however most of the service users have an account held in the home for daily spending. Three service user accounts were selected at random and the records were checked. In all cases the records corresponded correctly with the funds remaining, and all transactions appeared to be clearly recorded and supported by receipts. The daily life and social activities in this home, allow service users to exercise control and choice over their lives, and satisfies their social, cultural, religious and recreational needs. The chef at this home had been in post for several years, and clearly enjoys her work. She had produced a four- week menu plan, which included a variety of dishes to satisfy all tastes. Service users spoke very positively about the food, one lady said "The food is absolutely marvellous".

What has improved since the last inspection?

Consent forms were appropriately completed and in place for the use of bed rails where necessary. Beds that had previously been placed against walls, and may have compromised safety whilst moving and handling, have now been moved. Fluid and food intake charts were in place for service users where a risk had been identified, or where assessments were ongoing.

What the care home could do better:

The recording of the administration of medication that is prescribed as variable doses requires clear guidelines to ensure service users are protected. Supervision of staff is in place, however not all staff are receiving it as regularly as is expected. Due to the level of capacity of the service users that were tracked during this inspection, it was difficult to confirm that service users always received, and had access to a Statement of Purpose and Service User Guide. Consequentlythe manager discussed placing copies of these documents on display in the entrance hall, to ensure they were always accessible. Quality assurance has not been formally addressed since the last inspection, however the manager stated that questionnaires are due to be issued to service users and their representatives in the near future. The results of this exercise must be used to formulate an annual quality review report / plan. It was noted that not all falls, particularly those less serious, are not reported to the CSCI, however they have been very well documented and follow up action from GP or hospital interventions is very clearly logged. The manager was reminded that CSCI should be made aware of all incidences through the regulation 37 notices. Some minor maintenance and housekeeping issues were in need of address. Curtains in the main lounge required attention and one bedroom in particular appeared rather cluttered.

CARE HOMES FOR OLDER PEOPLE The White House High Street Eggington Leighton Buzzard Bedfordshire LU7 9PQ Lead Inspector Mrs Louise Trainor Unannounced Inspection 6th March 2007 09:00 X10015.doc Version 1.40 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 DS0000054000.V304657.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 Older People. 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 DS0000054000.V304657.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The White House Address High Street Eggington Leighton Buzzard Bedfordshire LU7 9PQ 01525 210322 01525 211925 knjanes@supanet.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Janes Care Homes Ltd Miss Tracey O`Hara Care Home 23 Category(ies) of Dementia (23), Old age, not falling within any registration, with number other category (23) of places The White House DS0000054000.V304657.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service users over the age of 65 years not falling within any other category (OP) 23 Service users over the age of 65 years with dementia DE(E)) 23 The maximum number of service users that the home can accommodate at any time must not exceed 23 The home can accommodate service users of either sex Date of last inspection 22nd February 2006 Brief Description of the Service: The White House was registered to provide for 23 older people who may also have dementia. The Home was located in an attractive semi-rural setting in Eggington Village, a short distance by road from the town centre of Leighton Buzzard. The premises were set back from the road and approached via a driveway and large front garden given over mainly to parking but affording a seating area for service users with views over pleasant shrubbery borders. Further parking spaces were situated to one side of the home. The accommodation was distributed over three floors that were accessed via staircases and a shaft lift. Seventeen single bedrooms and three double bedrooms were provided. One single room had an en suite toilet facility. Other rooms had washbasin fixtures. All rooms were connected to the call bell system. Toilet and bathing facilities were located for convenient access throughout the building. Communal accommodation was located on the ground floor and comprised two lounges and a dining room. Kitchen, laundry and office facilities were also situated on the ground floor. The fees for this service range from £450.00 to £480.00 per week. The White House DS0000054000.V304657.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first Key Inspection for this year for this home. Regulatory Inspector Mrs Louise Trainor carried it out on the 6th of March 2007 between the hours of 09:30 and 16:00 hours, and the homes’ manager was present throughout the day to assist. As this was this inspectors’ first visit to the home, a full tour of the premises was conducted. Both communal areas and individual’s bedrooms were visited. Three service users were picked at random by the inspector to case track. This involved the inspection of personal care documentation, including care plans and risk assessments, informal discussions with the individual service users, where appropriate, and observations of care. Other documentation relating to staff training, supervision, service users finances, accident / incident reporting, complaints, medication administration and recruitment were also inspected. The inspector also had the opportunity to speak with three members of staff and sample the midday menu. The inspector would like to thank everyone involved for their assistance and support throughout the day. What the service does well: This home provides a clean, comfortable and homely environment for the service users, and the individual bedrooms are furnished with personal belongings that reflect personal life histories. All service users are fully assessed, and have the opportunity to visit the home prior to being offered a permanent placement, so they can be sure of the quality, facilities and suitability of the home. The assessments are being reviewed regularly to ensure changes in needs were being efficiently addressed. Health and personal care needs are clearly set out in individualised care plans for all service users. The three service user files that were inspected all contained very thorough care plans. These had been generated from the initial assessments that had been carried out pre admission. The White House DS0000054000.V304657.R01.S.doc Version 5.2 Page 6 Care practices and interactions between staff and service users were observed during the inspection, and relationships appeared friendly, familiar and respectful. Assistance and encouragement was being offered in a dignified manner appropriate to the service users individual needs This home does not act as appointee for any of the service users finances, however most of the service users have an account held in the home for daily spending. Three service user accounts were selected at random and the records were checked. In all cases the records corresponded correctly with the funds remaining, and all transactions appeared to be clearly recorded and supported by receipts. The daily life and social activities in this home, allow service users to exercise control and choice over their lives, and satisfies their social, cultural, religious and recreational needs. The chef at this home had been in post for several years, and clearly enjoys her work. She had produced a four- week menu plan, which included a variety of dishes to satisfy all tastes. Service users spoke very positively about the food, one lady said “The food is absolutely marvellous”. What has improved since the last inspection? What they could do better: The recording of the administration of medication that is prescribed as variable doses requires clear guidelines to ensure service users are protected. Supervision of staff is in place, however not all staff are receiving it as regularly as is expected. Due to the level of capacity of the service users that were tracked during this inspection, it was difficult to confirm that service users always received, and had access to a Statement of Purpose and Service User Guide. Consequently The White House DS0000054000.V304657.R01.S.doc Version 5.2 Page 7 the manager discussed placing copies of these documents on display in the entrance hall, to ensure they were always accessible. Quality assurance has not been formally addressed since the last inspection, however the manager stated that questionnaires are due to be issued to service users and their representatives in the near future. The results of this exercise must be used to formulate an annual quality review report / plan. It was noted that not all falls, particularly those less serious, are not reported to the CSCI, however they have been very well documented and follow up action from GP or hospital interventions is very clearly logged. The manager was reminded that CSCI should be made aware of all incidences through the regulation 37 notices. Some minor maintenance and housekeeping issues were in need of address. Curtains in the main lounge required attention and one bedroom in particular appeared rather cluttered. 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 DS0000054000.V304657.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The White House DS0000054000.V304657.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All service users are fully assessed, and have the opportunity to visit the home prior to being offered a permanent placement, so they can be sure of the quality, facilities and suitability of the home EVIDENCE: This service has an appropriate Service User Guide and Statement of Purpose, which are issued to prospective service users and their representatives enabling them to make an informed choice about whether or not this home can fully meet their needs. Due to the level of capacity of the service users that were tracked during this inspection, it was difficult to confirm that this did always happen, consequently the manager discussed placing copies of these documents on display in the entrance hall, to ensure they were always accessible. The White House DS0000054000.V304657.R01.S.doc Version 5.2 Page 10 There was evidence in all the service users files that confirmed they had been fully assessed by the manager or the deputy prior to being offered a place in this home. These were detailed documents that included information relating to past and present physical and mental health conditions, the level of assistance required to meet the needs of the individual, and personal likes and dislikes which were also included in the individual care plans that were generated from these assessments. The assessments were being reviewed regularly to ensure changes in needs were being efficiently addressed. This home promotes an open visiting policy, and although there was one of two visitors present during the inspection, none were interviewed on this occasion. There are presently no service users residing in this home for intermediate care. The White House DS0000054000.V304657.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health and personal care needs are clearly set out in individualised care plans for all service users so that needs are fully met. The recording of the administration of medication that is prescribed as variable doses requires further guidelines to ensure service users are protected. EVIDENCE: The three service user files that were inspected all contained very thorough care plans. These had been generated from the initial assessments that had been carried out pre admission. It was refreshing to see such detailed documents that contained so many personal idiosyncrasies that would ensure care was delivered safely, with continuity and in a way that was preferred by the service user. Consent forms were appropriately completed and in place for the use of bed rails where necessary. The White House DS0000054000.V304657.R01.S.doc Version 5.2 Page 12 One service user’s care plans contained care instructions for; communication, mobility, personal safety, continence, unpredictable mood swings, diet, social interactions and medications. It contained a full list of medications including how they should be given and an allergy warning. Personal choices and preferences were also clearly identified in this documentation. Reviews were being carried out each month and any changes were clearly documented. Another service users file clearly identified goals and objectives with instructions of how these goals should be achieved. Pressure relieving equipment had been identified in line with the risk assessment and care plan, and was in place. This service users plan also included personal lifestyle choices, such as “……. Likes two spoonfuls of wine before going to bed”. These details made a positive impact on the quality of life for this service user, as this was a continuation of his preferred lifestyle prior to admission. Two of the service users that were tracked were diabetics, and documentation confirmed that blood sugars were closely monitored daily, and the district nurses visited to support this process and administer the insulin. All the Medication Administration Record Sheets (MAR sheets) were examined, and appeared in good order, with signatures and omission codes clearly completed. The only criticism with the medications was that some prescriptions were written as variable doses, and staff were not clearly indicating exactly what dosage had been administered, therefore reconciliation of these medicines was very difficult. Care practices and interactions between staff and service users were observed during the inspection, and relationships appeared friendly, familiar and respectful. Assistance and encouragement was being offered in a dignified manner appropriate to the service users individual needs. The White House DS0000054000.V304657.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The daily life and social activities in this home, allow service users to exercise control and choice over their lives, and satisfies their social, cultural, religious and recreational needs. EVIDENCE: The atmosphere in this home was very relaxed, and some service users appeared to be ‘pottering around’ doing their own thing, without any interference from staff. Some service users were in their rooms, and others were involved in activities such as artwork and puzzles, and there was a game of bingo in progress, which some service users appeared to be enjoying. One service user was very proud of artwork she had done with sea- shells and pasta. Some of this work was displayed in the dining room. These activities were not compulsory, and although service users were encouraged to participate, they had a choice. There were posters around the home advertising a clothes sale that was planned for the near future. Previously a similar event had been a successful. The White House DS0000054000.V304657.R01.S.doc Version 5.2 Page 14 Staff appeared to be making time to spend talking to service users on a one to one basis, and relationships appeared friendly and mutually respectful. The chef at this home had been in post for several years, and clearly enjoys her work. She had produced a four- week menu plan, which included a variety of dishes to satisfy all tastes. There was no repetition on this menu except for the fish on Fridays, and there was a choice of two hot meals each day. There were presently no special dietary requirements in the home, however the chef was undoubtedly prepared for whatever choices may be requested. Service users spoke very positively about the food, one lady said “The food is absolutely marvellous”. The inspector sampled the midday menu, which was of a very high standard. The White House DS0000054000.V304657.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There had been no formal complaints relating to this home in the last year. EVIDENCE: There is a complaints policy in place for this home, which clearly details how concerns and complaints will be addressed within specified time frames. There had been no formal complaints to this service since the last inspection. There had been one informal concern to the manager and this had been clearly documented and details of the investigation logged. The manager has a suggestion box in the entrance hall. This allows any service users or visitors to the home, to make any anonymous comments/ suggestions if they so wish. However it was reported that this rarely used. All staff under- go POVA awareness training, and interviews with staff indicated that staff are well informed and have a clear understanding of this subject. They are aware of what actions they should take if they witnessed or suspected anything which may constitute abuse within the home. The White House DS0000054000.V304657.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 23, 24, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This home provides a safe, comfortable and homely environment, so that service users can live comfortably with their own possessions around then. However there are some areas of maintenance, which require attention. EVIDENCE: As this was the first visit to this home for this inspector a full tour of the premises took place. Communal areas were clean, comfortable and homely, although the small lounge did appear a little crowded and the inspector had to perch on a table in the corner to observe care practices during the visit. Individual bedrooms were decorated in a homely way, and some service users had clearly brought some furniture into the home with them. Ornaments, photographs and other personal assets that reflected individual life histories were also very evident in this home. The White House DS0000054000.V304657.R01.S.doc Version 5.2 Page 17 One service user had paintings that she had done herself, framed and displayed on her wall, and another had ‘Big Band Orchestra’ records and a record player in her room. The home is presently going through a period of refurbishment, which on completion will enhance and improve the kitchen and bathroom / shower facilities in the home. It was noted that the flooring of the doorway leading to the dining room had not yet been made even. This was a requirement from the previous inspection and still requires attention. It was also notice that the curtains in the main lounge were hanging off the rails. This was a minor detail, but gave the impression that daily maintenance issues could be addressed more efficiently. Whilst visiting one service user in their bedroom, it was noted that the room was a little over crowded and cluttered. It containing two different hoists and a commode, as well as general bedroom furniture. It was felt that this could result in a compromise of both staff and service users safety during moving and handling procedures. The White House DS0000054000.V304657.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff in this home are trained sufficiently to perform their roles in a competent manner, so that service users are in safe hands. EVIDENCE: This home is staffed by a small team that appear dedicated to the service users. Agency staff are rarely required. During the daytime there are four care staff, (including at least one senior) on duty, supported by the manager and the deputy manager. At night there are two staff on duty, this also includes a senior carer, and they are supported by an on call service provided by the manager and the deputy. Separate staff are employed for the laundry, maintenance and kitchen duties. Three staff files were picked at random during the inspection and examined. One of these had been very recently recruited and was still working through her induction program, for which there was a progress log. All files contained the appropriate recruitment documentation, which included; fully completed application forms, interview feedback sheets, two appropriate references, Criminal Records Bureau check, photograph identification, passport The White House DS0000054000.V304657.R01.S.doc Version 5.2 Page 19 and home office documentation where appropriate, and contracts clearly signed and dated. There is a lengthy and varied training programme in place, and certificates indicated that staff are attending a variety of training ranging from the mandatory subjects to care planning, care of the dying and challenging behaviour. Two care staff were interviewed during this inspection and both presented as competent and confident in their jobs. Both were able to discuss at length the service users that the inspector was tracking, and both were fully aware of the service users needs and the content of the corresponding care plans. Both of these staff had attended training in; moving and handling, fire safety, death and dying, Protection of Vulnerable Adults (POVA), medication administration, and health and safety. In addition to these mandatory subjects they had both attended other more specialist sessions such as dementia. The White House DS0000054000.V304657.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of this home promotes a good standard of care with the service users independence, health and well- being as the main focus. EVIDENCE: The manager for this home, has been in her present role for the past year, but has worked in the home for eleven years, progressing to this position. She is clearly very committed to the service users. She has worked hard with her team to ensure care plans and assessments are working documents, and are of a high standard, that provide a prescriptive guidance for continuity of individualised care. The White House DS0000054000.V304657.R01.S.doc Version 5.2 Page 21 Quality assurance has not been formally addressed since the last inspection, however the manager stated that questionnaires are due to be issued to service users and their representatives in the near future. The results of this exercise must be used to formulate an annual quality review report / plan. This home does not act as appointee for any of the service users finances, however most of the service users have an account held in the home for daily spending. Three service user accounts were selected at random and the records were checked. In all cases the records corresponded correctly with the funds remaining, and all transactions appeared to be clearly recorded and supported by receipts. Staff interviews revealed how well supported they feel by the management. Staff stated how much they enjoyed their work and “what a bright and happy atmosphere” there is in the home. Systems are in place to ensure all staff receives supervision. However records indicated that this might require some attention to assure some staff receives it more regularly. One senior member of staff presently has her supervision with the area manager. These arrangements are presently being reviewed to increase its frequency. Staff are kept fully informed of any changes in procedures and care, by staff meetings and memos, and those that were interviewed were confident and knowledgeable when discussing individual service users and their needs with the inspector. Records of accidents and incidents were inspected; two specific accidents were cross-referenced with the daily record sheets and corresponded correctly. It was noted that not all falls, particularly those less serious, are not reported to the CSCI, however they have been very well documented and follow up action from GP or hospital interventions is very clearly logged. The manager was reminded that CSCI should be made aware of all incidences through the regulation 37 notices. The White House DS0000054000.V304657.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 2 2 2 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 The White House DS0000054000.V304657.R01.S.doc Version 5.2 Page 23 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 OP19 Regulation 13(4)(a) (c) Requirement The flooring of the doorway leading through to the corridor to the dining room must be made even. Previous timescale unmet 31/03/06 The registered person must ensure that the layout of individual rooms is appropriate for the service users needs to be met safely, in particular where specialist equipment is required. A report that includes an action plan must be prepared as part of an annual quality review process, which has involved consultation with the service users. Previous timescale unmet 31/03/06 The registered person must ensure all staff are appropriately supervised. Timescale for action 31/08/07 2. OP23 23 (2)(f) 30/04/07 3. OP33 24 31/08/07 4 OP36 18(2) 31/05/07 The White House DS0000054000.V304657.R01.S.doc Version 5.2 Page 24 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 OP1 Good Practice Recommendations The manager should consider placing a Statement of Purpose and Service User Guide in the entrance hall, where they are always accessible to service users and their representatives. Service users should be provided with information to enable them to contact advocacy services. 2. OP14 The White House DS0000054000.V304657.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 DS0000054000.V304657.R01.S.doc Version 5.2 Page 26 - 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!