Inspection on 23/08/06 for The White House, Falmouth

This inspection was carried out on 23rd August 2006.

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

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

Other inspections for this house

The White House, Falmouth 12/03/09

The White House, Falmouth 25/03/08

The White House, Falmouth 11/10/07

The White House, Falmouth 06/06/07

The White House, Falmouth 20/03/06

The White House, Falmouth 04/01/06

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE The White House The White House 128 Dracaena Avenue Falmouth Cornwall TR11 2ER Lead Inspector Diana Penrose Unannounced Inspection 23rd August 2006 10:15 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 DS0000065484.V299723.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 DS0000065484.V299723.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The White House Address The White House 128 Dracaena Avenue Falmouth Cornwall TR11 2ER 01326 318318 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) Mrs Helen Judith Christopher Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places The White House DS0000065484.V299723.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th March 2006 Brief Description of the Service: The White House is situated in Falmouth on the main route into the town. The home provides personal care for up to seventeen elderly people. Accommodation is provided on two floors and there are stair-lifts to access the first floor. Residents have their own bedrooms that are fitted with hand washbasins. There are sufficient toilets and assisted bathing facilities are provided. Meals are prepared in the kitchen on the ground floor and served in the lounge diner. Residents can choose to eat in their individual bedrooms if preferred. The home has small gardens at the front and rear with patios accessible to residents. Some areas are suitable for wheelchairs. The front access to the home is on a slope and limited parking space is available. There is a flexible visiting policy and residents can see their visitors in private. Information about the home is available in the form of a residents’ guide, which can be supplied to enquirers on request. A copy of most recent inspection report is available in the home. Fees range from £295 to £400 per week; this information was supplied to the Commission by the registered provider, on 31/08/06. Additional charges are made in respect of private healthcare provision, hairdressing and personal items such as newspapers, confectionary and toiletries. Mrs Christopher became the owner of the home in December 2005 and has made a great deal of improvements since then. She is responsible for the dayto-day running of the home and employs a team of care assistants and domestic staff. Care is provided in a relaxed friendly atmosphere. The White House DS0000065484.V299723.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector visited The White House Care Home on the 23 August 2006 and spent six hours at the home. This was a key inspection and an unannounced visit. The purpose of the inspection was to ensure that residents’ needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus was on ensuring that residents’ placements in the home result in good outcomes for them. It was also to gain an update on the progress of compliance to the requirements identified in the last inspection report dated 20/03/06. All of the key standards were inspected. On the day of inspection 15 residents were living in the home. The methods used to undertake the inspection were to meet with a number of residents, relatives, staff and the registered provider to gain their views on the services offered by The White House. Records, policies and procedures were examined and the inspector toured the building. This report summarises the findings of this inspection and any includes relevant information received by the Commission. Residents and relatives expressed satisfaction with the care and services provided at the home. Overall the home is providing an adequate quality of care to the residents placed there, with notable improvements over the past year. What the service does well: The registered provider has a very positive and enthusiastic attitude to improving The White House. Staff and residents spoke positively regarding her management style and the amount of effort she has put in to change the ethos of the home. The home provides a clean, comfortable, homely environment for residents that is free from offensive odours. There is a rigorous plan to improve the décor and furnishings in the home and the rooms already refurbished are a vast improvement. Prospective residents are visited by the registered provider and a thorough assessment is undertaken to ensure the home can meet their needs. Each resident has an individual care plan, which is compiled with them, or their representative and relevant risk assessments are undertaken. The plans direct staff in the care to be provided. There is a suitable system in place for medications and staff receive appropriate training in this area. Residents say that their healthcare needs are met and they are treated with respect. The White House DS0000065484.V299723.R01.S.doc Version 5.2 Page 6 Visitors are welcome and can be received in private. Residents say they have control over their lives and their individual preferences are appreciated. A varied menu is on offer with fresh fruit and vegetables included. Beverages and snacks are available at anytime. Sufficient staff are on duty and staff interact very well with residents. The atmosphere is relaxed and friendly. Residents say the staff are kind and caring and they each have a ‘special carer’ (key worker). All care staff undertake NVQ training and 77.7 are qualified to at least level 2. What has improved since the last inspection? What they could do better: Facilities, furniture and fittings need upgrading. The registered provider recognises this, and it is appreciated this process will take time as financial resources become available. Facilities for staff must be improved as follows: • An office facility • A suitable room for staff sleeping in at night • Secure storage for staff belongings The White House DS0000065484.V299723.R01.S.doc Version 5.2 Page 7 Although extensive work has been undertaken in respect of risk assessments there are areas to be addressed and the registered provider is aware of this. Mrs Christopher is providing training for staff; food hygiene training must be the next priority for staff that handle food. More work needs to be done to provide social and recreational facilities that suit individual residents needs. Residents should be aware of what is on offer and when. Some of the records and documents Mrs Christopher has put in place have not yet been used or have only recently been implemented, for example the induction programme, recruitment system and care planning system. The next inspection should ascertain if these systems are working to an appropriate standard. 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 DS0000065484.V299723.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 DS0000065484.V299723.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (6 is N/A) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are only admitted to the home following an assessment of their needs to ensure the home can provide appropriate care. EVIDENCE: Evidence was provided in the form of records and discussion with the registered provider. The registered provider said she visits new residents prior to admission and information is obtained from the resident, relatives and any other appropriate party. There is a specific document used for the assessment of residents, which is regularly reviewed. Records for one new resident were thoroughly completed and discharge information from the hospital was on file. The White House DS0000065484.V299723.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans are generated for each resident; they inform and direct staff in the care provision but staff need time to understand and become efficient in the use of them. Residents have access to health care services as necessary to ensure their assessed needs are met. There are suitable systems and policies in place for dealing with residents medicines and assure residents safety. Systems are in place to ensure that residents are respected and their privacy is upheld at all times. EVIDENCE: Evidence was provided in the form of documentation, records, observation, and discussion with residents, relatives, staff and registered manager. The registered provider has developed a new care planning system and she has implemented it for all residents. The plans inform staff in the care to be provided and staff are beginning to get used to the new way of working. Although comprehensive the registered provider said she intends to improve the system further when staff become proficient with the current system. At present the registered provider is supervising staff and providing appropriate The White House DS0000065484.V299723.R01.S.doc Version 5.2 Page 11 support. Relevant risk assessments are undertaken, for example Waterlow scoring nutrition, moving and handling and Barthel scoring. Daily records are maintained and are becoming more informative. All of the plans inspected were reviewed on a monthly basis; the registered provider said that six monthly reviews of residents needs are also taking place with input from relatives and Adult Social Care. Some residents said they have been involved in the care planning process with the registered provider. Doctors and other healthcare professionals visit residents as appropriate and records are kept. The home has sufficient equipment for moving and handling and pressure relief. Residents are weighed regularly according to their individual requirements. The registered provider said she has someone who will provide exercises for residents soon and the home has a musical chairs video that residents enjoy. The pharmacist was doing her audit during the inspection and it was satisfactory. There is a policy and system in place for dealing with resident’s medicines. The policy needs some additions and needs to refer to The Royal Pharmaceutical Guidelines for the Administration of Medicines in Care Homes; this was discussed with the registered provider who said she would do this. A monitored dosage system (MDS) of medication is used in the home. Records of the receipt, administration and disposal of medicines are maintained and there is a photograph of each resident with his or her medication chart. Handwritten medicine details or instructions on the medication charts are few but are witnessed with two signatures recorded. There are no controlled drugs in the home. The registered provider said she would ensure that patient information leaflets are obtained and retained in the home for medicines in use. Staff have received training in the administration of medicines and the pharmacist is going to provide a staff training pack. The arrangements for ensuring privacy and dignity are specified in the statement of purpose. Staff were observed to respect residents privacy during the inspection and residents said this is always so. Residents said they could see their visitors in private if they wished. The White House DS0000065484.V299723.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides some activities but more needs to be done to offer a lifestyle that meets individual residents needs. Links with family, friends and the community are good and allow residents the opportunity to socialise. Residents are helped to maintain control over their lives and staff respect their individual preferences and choice. Dietary needs of residents are catered for with a selection of food available; more could be done to ensure that it meets their taste and preference. EVIDENCE: Evidence was provided in the form of documentation, records, observation, and discussion with residents, relatives, staff and the registered provider. The registered provider said that staff provide activities for residents in the afternoons and these include one to one chats, bingo, cake baking and manicures. A musician visits the home each month and is popular with the residents. Residents said they enjoy the activities provided in particular the bingo. One resident said it is difficult to have group activities as there are quite a few who are unable to participate. The registered provider has purchased a ‘people carrier’ to transport residents on outings and they have enjoyed this during the summer months. Church services take place in the home and some The White House DS0000065484.V299723.R01.S.doc Version 5.2 Page 13 residents go out to church, some go to the local evangelistic church for cream tea afternoons. The registered provider acknowledges that more socialising and recreational activities should take place and is working on this. Activities are optional and residents can spend time in their own bedrooms if they wish. Residents do not know when activities are taking place and there is no activities schedule. Staff were observed to remain in the reception area in the afternoon and they were not involved in activities. There is a record of visitors to the home and there were visitors in the home during the inspection. Residents said they could receive visitors in private and at any time. Visitors spoken with said they are made welcome in the home and can call in when they like. Residents said they could go out with their friends and relatives if they wish. Residents said they have control over their lives. They said they are given choices in respect of food, clothes to wear, daily routines and so on. They also said they are addressed by their preferred name. Residents meetings take place and residents said that the registered provider discusses their individual preferences with them. Several said they have been involved in choosing the decoration and furnishings for the home in particular their own bedrooms. All residents have their own possessions in their rooms. There is a varied menu with fresh vegetables and fruit available. The menu is displayed on the dining tables. Residents said cakes or biscuits are available at teatime, sometimes cakes are homemade. Staff said that drinks and snacks are available as requested at any time. There was plenty of water and fruit juice available in the lounge for residents. Meals are served in the dining area at one end of the lounge or individual bedrooms if residents prefer. The dining tables have tablecloths and special cutlery is supplied for those who need it. Some residents said the food is good but most said it is variable depending on who is cooking. Residents said they have a cake on their birthday and there are special celebrations at Christmas and Easter, and so on. The White House DS0000065484.V299723.R01.S.doc Version 5.2 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure that ensures complaints are listened to and acted upon. Arrangements are in place for the protection of residents safeguarding them from harm or abuse. EVIDENCE: Evidence was provided in the form of documentation and discussion with staff and the registered provider. There is a suitable complaints policy in the home and a method for recording complaints, the action taken and the outcome. There have been no complaints since the last inspection. Thank you letters and cards are kept. The home has an adult protection policy and the registered provider explained appropriately the procedure she would follow. She said she needs to obtain a copy of the Local Authority procedures and will try to obtain the Adult Social Care training video. Staff said they have attended abuse training provided by the registered provider. None have yet attended the Adult Social Care “No Secrets” study days; this is recommended for all care staff. A recent adult protection investigation regarding a member of staff in the home was unfounded. The White House DS0000065484.V299723.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a reasonable environment for residents and staff and essential work is taking place; the home will be better suited when the refurbishment programme is complete and an office and a suitable sleeping in facility has been provided for staff. The home is clean and free from offensive odours and work is underway to make it a more pleasant place to live in. EVIDENCE: Evidence was provided in the form of records, observation and discussion with residents, relatives, staff and registered manager. The home is warm and comfortable. Heating and lighting are suitable, low energy bulbs are being replaced; this is particularly necessary where instant light is required. Grab rails and raised toilet seats are provided in toilets and there are two stair lifts to access upstairs. Residents have their own bedrooms; the double is not shared at the moment. Some of the downstairs rooms have doors leading to the garden; the windows in these rooms do not have The White House DS0000065484.V299723.R01.S.doc Version 5.2 Page 16 restrictors fitted. The registered provider must undertake risk assessments for the doors and windows taking into consideration the individual residents and their safety. Residents have their personal possessions around them and some said they have some of their own furniture. All bedrooms can be locked from the inside with accessibility for staff if necessary. One resident said she has been offered a key to her room and is thinking about this facility. Residents said they are happy with the accommodation provided and it meets their needs. Residents share a large lounge diner where a majority of them spend their time. There is a budgerigar in a cage in the lounge and new tank with tropical fish has been provided for residents to enjoy. A great deal of re-decoration and refurbishment has taken place since the last inspection and is still in progress. Seven bedrooms have been totally refurbished and one more has been started. The registered provider said there is a rolling programme to replace the furniture in the home. All of the bathrooms and toilets are being upgraded and she intends to purchase a new assisted bath. The wooden ceiling in the lounge is being painted white to make the room brighter and new lights are being installed. The lounge carpet is to be replaced and new armchairs provided. New dining tables and chairs have already been purchased. There is no office in the home staff utilise the reception area this is not acceptable for confidentiality and the registered provider acknowledges this. The provision of an office was a requirement at the last inspection and Mrs Christopher said she working on this. Staff facilities are in breach of regulation 23 and this was discussed with the registered provider, she intends to provide a suitable sleeping in facility, probably incorporated in the office. Secure storage for staff belongings is also required. The grounds are tidy with patios that are reasonably accessible. The garden at the back is on a slope. The home was clean and free from offensive odours on the day of the inspection. The laundry facilities are suitable with two washers and one drier (one washer was out of order). The home deals with all laundry and all staff undertake this. Residents said that on the whole the system works very well occasionally they get another residents clothing with their clean laundry. Suitable hand washing facilities are provided for staff along with protective clothing. Staff undertake infection control training as part of the NVQ syllabus and the registered provider gives some training. The White House DS0000065484.V299723.R01.S.doc Version 5.2 Page 17 The White House DS0000065484.V299723.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels meet the needs of residents and staff morale appears to be good. Residents are in safe hands and benefit from the 77.7 of care staff trained to at least NVQ level 2 in care. Recruitment procedures have been developed to offer protection to the residents but have not been fully implemented. The registered provider has been providing training for staff to help them be more competent in their roles. EVIDENCE: Evidence was provided in the form of documentation, records, observation and discussion with residents, relatives, staff and registered provider. The registered provider said there are staff vacancies but she hopes to have them filled very soon. Staff said there are two carers on duty all of the time. At night there is one awake and one sleeping. Rotas demonstrate satisfactory staffing levels are provided. There is a domestic on duty every morning although the care staff help with domestic duties and laundry, they also do all of the cooking. The registered provider’s husband undertakes maintenance tasks and the registered provider hopes to employ a new gardener very soon. Mrs Christopher has a new recruitment system in place and she has been sorting the staff files with an index in the front. The system will be tested when new staff are employed. Many of the existing staff have documents missing from their files; most have been working in the home for several years. Where The White House DS0000065484.V299723.R01.S.doc Version 5.2 Page 19 evidence of CRB and POVA information is lacking the registered provider has asked staff to provide this by showing her their disclosure documents. If these are not available the registered provider will undertake the checks again. The registered provider has developed a comprehensive induction programme for new staff. This has not yet been used but she will soon be recruiting new staff. The registered provider has improved the training provision for staff. 77.7 of care staff have an NVQ either at level 2 or 3. One carer has almost completed the level 2 and the registered provider said that all new care staff would be enrolled onto the NVQ level 2 course, if they have not already achieved the qualification. Three care staff are undertaking the level 3 qualification. Domestic staff have done part of an NVQ in cleaning. The registered provider said she is qualified to train staff in various skills and undertakes training elsewhere in the country. She stated that she is updating her moving and handling trainers certificate in November 2006. She must maintain evidence that her training skills are up to date. As necessary she must agree with other regulatory authorities the training she intends to provide and ensure it meets the legal requirements The registered provider said she has developed a training plan for staff, she will send a copy to the Commission. She has been providing staff training in fire prevention, manual handling, infection control, first aid and health and safety. She has not yet updated the staff training records so this could not be evidenced. The White House DS0000065484.V299723.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 Quality in this outcome area is adequate this judgement has been made using available evidence including a visit to this service. The Registered Manager is a person of good character and fit to run the home. The home is run in the best interest of the residents and they benefit from the Quality Assurance systems in place. The home does not deal with resident’s money; if the situation changes a suitable system must be put in place with safeguards to protect residents’ financial interests. The registered provider aims to ensure that the records required by legislation are maintained however they are not all available in the home and cannot be accessed for inspection when the owner is not at he own home. The management and staff promote the health and safety of residents, staff and visitors to the home; systems are being improved to heighten this. EVIDENCE: Evidence was provided in the form of documentation, records, observation and interviews with residents, relatives, staff and registered manager. The White House DS0000065484.V299723.R01.S.doc Version 5.2 Page 21 Mrs Christopher has owned the White House since December 2005 and is competent to run the home. She said she keeps up to date with current issues regarding her client group by networking and reading relevant care publications. She has made a great deal of improvements to the home and is very enthusiastic in her plans for the future. She has sought the views of staff, residents and relatives through meetings and surveys. Residents and staff spoke positively about the registered provider and residents said she talks to them and tries to make the home as they want it. Everyone spoke about the refurbishment that is taking place and the amount of money being spent on upgrading the home. Staff said that the way they work now is much better and that Mrs Christopher supports them well. There is a satisfactory quality assurance system in place. The registered provider has completed a survey to gain the views of staff, residents, relatives and other stakeholders regarding the service. The results of this are being used to guide improvements to the service. Further surveys will take place annually. The registered provider intends to undertake a variety of audits and has the paperwork ready to commence. These include medicines, accidents, inspection reports and meetings. At present the home does not handle any residents money, the resident or their representative does this. The registered provider is aware that if the situation changes she will require a suitable system and policy in place. Residents are not provided with lockable facilities at present, however when the new furniture is supplied a lockable drawer will be included. The registered provider endeavours to ensure that the records required by legislation are maintained. In order to comply with regulation 17 the records listed in schedule 4 must be maintained in the home; Mrs Christopher is aware of this and said that when suitable confidential facilities are available in the home she will move the records from her house. The registered provider endeavours to ensure that working systems are safe. All necessary service and equipment checks are undertaken as appropriate. Several vital pieces of equipment have broken down in the past few months and have been replaced, for example a washing machine, tumble drier and dishwasher. Accidents are few and are recorded and reported appropriately. COSHH data sheets are being obtained and the registered provider said they will be made available to staff. The registered provider has started to complete health and safety risk assessments to comply with legislation. This must include a risk assessment for the prevention of Legionella and all areas of the environment. The White House DS0000065484.V299723.R01.S.doc Version 5.2 Page 22 Statutory training has been taking place, for example moving and handling and first aid. Food hygiene training must be provided for all staff that handle food. The registered provider said she intends to do this; the content must be discussed with the Environmental Health Officer. The White House DS0000065484.V299723.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 The White House DS0000065484.V299723.R01.S.doc Version 5.2 Page 24 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 2 Standard OP19 OP38 Regulation 17, 23 13, 23 Requirement The registered provider must provide an office facility for staff. 2nd notification Environmental risk assessments must be completed, and must include: • external doors from residents bedrooms • windows that are not fitted with restrictors • the prevention of Legionella Timescale for action 26/03/07 26/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP12 OP18 Good Practice Recommendations Social and recreational activities should be more suited to individual residents, more organised and residents should know what is available and when. All staff should attend the local Adult Social Care “No secrets” training The White House DS0000065484.V299723.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 DS0000065484.V299723.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!