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Inspection on 04/11/05 for Welcome Care Home Ltd

Also see our care home review for Welcome Care Home Ltd for more information

This inspection was carried out on 4th November 2005.

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 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

The home has now got good information for service users explaining the services the home provides, and offers new service users the opportunity to visit and stay over before moving in. Relatives and friends are welcomed and can visit at any time. One relative said that the home is "good, clean and safe; my dad likes it and I can visit when he wants me to. Staff are very caring and respectful". These comments were supported by similar comments from service users. Health care support is very good, and there is high level of involvement from a range of health professionals such as GP who visits the home every two weeks, mental health team, Nutritionist, Chiropodist and a weekly visits from a woman who does dancing and singing with service users. Service users comments included "the staff look after me very well and are very caring" Religious needs are catered for and the manager often takes people to church and attends the coffee gathering afterwards. Other activities are offered such as bingo, social centre visits (St Lawrence Hall, and the Davenport Club). Service users are supported to be independent in going out in the local area and many do so. Food is good and the home is clean and well maintained. Staff receive good levels of training.

What has improved since the last inspection?

The information for service users has improved in the home`s Statement of Purpose and Service User Guide. The system for consulting service users on menu setting is better and service users now say they are very happy with the food offered. Issues of concern about loud music being played in communal areas previously raised by service users have now been resolved and communal areas are peaceful, allowing conversation and relaxation.

What the care home could do better:

The home needs to include more social and leisure activities in individual plans based on individual service users` interests and review plans at least every month. Some practices regarding the giving of medication need to be reviewed to ensure that all service users are made aware of medication being given to them. Any variation to this must be formally agreed with service users representatives, the GP and social services, to make sure that peoples rights are protected. There needs to be a formal statement of who the home shares service users information with and how confidentiality will be protected, and the homes complaints policy needs more emphasis on confidentiality and advocacy support. The Adult Protection policy needs to be updated to ensure that service users are better protected and staff will need more training in this area. The home also needs to collect better information on staff when they are being recruited, especially focusing on making sure that references are provided by previous employers, and involve at least one other member of staff in interviewing staff. Staff need more regular formal supervision, at least every two months, and the home needs to produce better information for service users based on annual audits of the home, showing how well it is doing and what needs to improve.

CARE HOMES FOR OLDER PEOPLE Welcome Care Home Ltd 26-28 Fordel Road Catford London SE6 1XP Lead Inspector Sean Healy Unannounced Inspection 4th November 2005 10:00 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 Welcome Care Home Ltd DS0000025650.V258065.R01.S.doc Version 5.0 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. Welcome Care Home Ltd DS0000025650.V258065.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Welcome Care Home Ltd Address 26-28 Fordel Road Catford London SE6 1XP 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) 020 8697 5024 Mrs Margaret Newland Mrs Margaret Newland Care Home 15 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Old age, not falling within any other of places category (0) Welcome Care Home Ltd DS0000025650.V258065.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. the home is registered for a maximum of 15 persons whose primary needs are old age and dementia 15th November 2004 Date of last inspection Brief Description of the Service: The Welcome Care Home provides personal care and accommodation for a maximum of 15 older people. The overall aim is that of offering care and support, in a homely environment, trying to create a happy and relaxed family atmosphere. The underlying philosophy, stated in the home’s brochure, is that of a holistic approach to care. The registered provider is a company belonging to its representative: Mrs Margaret Newland, who is in day-to-day control of the home. A deputy manager assists her and a team of fifteen care staff, a mixture of men and women. The home was opened in 1993 and consists of two semi-detached Victorian houses, which have been joined into one. There is a rear garden with a patio, a fishpond and a lawned area, which is well maintained. Thirteen of the home’s bedrooms are single with en-suite toilet facilities. There is one shared room, which has a wash hand basin only, but exclusive use of a nearby toilet. There is a passenger lift and a short stair lift to ensure access to all parts of the house. The home is situated in a quiet side road in the Catford area, with some local shops nearby. The centre of Catford, where there are public transport (buses and trains), other civic amenities and shops, is about one mile away. Welcome Care Home Ltd DS0000025650.V258065.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced, and took place over one day. It was facilitated by the registered manager and assistant manager. Two staff were interviewed, one of whom was a long-term member of staff and one more recently appointed. A group of service users gave their views of the home and two separate service users also contributed individually. A visiting relative also said what she thought of the home and the care provided. There were no service user vacancies. What the service does well: What has improved since the last inspection? The information for service users has improved in the home’s Statement of Purpose and Service User Guide. The system for consulting service users on menu setting is better and service users now say they are very happy with the food offered. Issues of concern about loud music being played in communal areas previously raised by service users have now been resolved and communal areas are peaceful, allowing conversation and relaxation. Welcome Care Home Ltd DS0000025650.V258065.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Welcome Care Home Ltd DS0000025650.V258065.R01.S.doc Version 5.0 Page 7 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 Welcome Care Home Ltd DS0000025650.V258065.R01.S.doc Version 5.0 Page 8 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): 1 and 5. Prospective service users have complete information they need to make an informed choice about where they live, and prospective service users and their relatives have the opportunity to visit the home to assess the quality of care prior to admission. EVIDENCE: The homes Statement of Purpose and Service User Guide are now updated and provide adequate information about the service the home provides. Regarding trial visits to the home prior to moving in, there is evidence, from discussion with service users and the provider, that the policy and practices of the home had not changed, and allow good opportunity for service users to “test drive” the home before deciding to move in. Wherever possible service users were encouraged to visit before moving in. Staff also go to see service users in their own homes, particularly when users were not able to visit. One relative confirmed that her dad had ample opportunity to visit the home before moving in and said that this was very important for her dad, and helped to build his confidence and trust in the staff. Welcome Care Home Ltd DS0000025650.V258065.R01.S.doc Version 5.0 Page 9 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): 7,8,9,10 and 11 Service users’ health and personal care needs are set out in a personal care plan, and are being met; however, social care needs are not properly planned, which may result in low activity and boredom. Service users are not properly assessed or supported regarding their ability to manage their own medication, and don’t always feel that they are properly informed about their medication. Service users are treated with respect and their rights to privacy upheld, and are assured that staff will treat them and their family with respect, in instances of serious illness or death. EVIDENCE: There were individual assessments that provided the basis for the care to be delivered. This included a risk assessment. The provider said that all care plans had been drawn with the involvement of the service user or their representative and they were reviewed regularly. Inspection of service users’ files continued to demonstrate that service users’ health, and personal needs had been addressed in the care plan. Much more emphasis had been given to the health and physical care needs than to the social, cultural and emotional side. The managers had acted on the previous recommendations, striving to make the care plans holistic and she and the assistant manager have now attended a three-day training course on holistic care planning. All plans are Welcome Care Home Ltd DS0000025650.V258065.R01.S.doc Version 5.0 Page 10 not currently being reviewed monthly, but the manager agreed to start doing this. (Refer to Requirement OP7) (Refer to Recommendation OP7) There was evidence, from records and discussion with service users, managers and staff, of the attention paid to maintaining and promoting service users’ health. Attention was given to personal and oral hygiene. Community nurses and psychiatric nurses visited when required. The home had support from other specialist nurses, including tissue viability nurses if necessary. All the service users were registered with one general practitioner who attended the home at least fortnightly and at other times when necessary. One relative commented on the good commitment the staff had to helping her relative to address some previously difficult areas of personal care support and complimented the staff on their approach. The provider said that none of the service users administered their own medications, as none was able to manage this safely. However not all service users assessments are clear on this issue and there is not an agreement on this in all care plans. (Refer to Requirements OP9) At least one service users is being given medication which is being disguised in order to achieve compliance, and the manager said that this was in order to ensure that the service user consistently takes her medication which is in her interests, and had been verbally agreed. However this is not reflected in this service users care plans. Every effort must be made to ensure that service users are aware of the medication they take and formal written agreement is noted in care plans in cases where this is not possible. Any such agreement must have full written approval of the GP, social worker and an advocate or family member. (Refer to Requirements OP9) It is the case that staff signing for medication sometimes give the medication to other staff to administer. This is not acceptable practice and must be addressed by the home. (Refer to Requirements OP9) The routines and the conduct of the home promoted service users’ fundamental rights to privacy and dignity. This was supported by comments received from service users and relatives and from observing the way in which staff addressed and interacted with service users. The home does establish service users’ wishes regarding arrangements after death in consultation with the service users and families. Welcome Care Home Ltd DS0000025650.V258065.R01.S.doc Version 5.0 Page 11 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 Service users feel that the lifestyles experienced in the home match their preferences, and cultural, and recreational interests and needs. Service users maintain contact with their families, friends and community contacts, and are helped to exercise control in their lives. Service users receive wholesome and appealing balanced diets, in pleasing surroundings and at suitable times. EVIDENCE: Welcome Care Home Ltd DS0000025650.V258065.R01.S.doc Version 5.0 Page 12 Service users’ files continued to show that activities were planned and recorded, and provided a useful insight into activities that the staff undertook with individuals. (Refer also to OP standard 7 requirement) At last inspection service users had said that they would like some day trips, especially to the seaside, paid for by the home. The manager has now discussed this with the commissioning authority and tried to have this funding secured, but has been unsuccessful. The manager committed to continue to provide as much of these activities as possible within current funding available to the home. All service users look after their own money and are given the opportunity for the home to safeguard their money if requested. Each service user has been assessed regarding their money management abilities and support needs on admission and this is recorded on their files. Financial management support offered in the home is adequate. Information was available to enable service users to access advocacy services, should they wish to do so. There was a four weekly menu. The provider said that all service users knew that they could ask for alternatives and many did that. Two service users said that: “The food is excellent and staff tell us what is going to be on tomorrows menu and ask if we’d like anything different”. They also confirmed that they can have meals at times that suit them. Welcome Care Home Ltd DS0000025650.V258065.R01.S.doc Version 5.0 Page 13 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 Service users can be confident that their complaints will be acted on and taken seriously. Service users may not always feel that they are protected from abuse by the home’s policy. EVIDENCE: The home has a complaints policy, which is adequate, but would benefit from placing more emphasis on confidentiality when reporting recording and investigating complaints, and in including a description of how complaints will be reviewed. There were copies of older policies available, which should be disposed of to avoid confusion. (Refer to two Recommendations OP16) The last recorded complaint was in July 2003, but it was felt that it would be beneficial to raise awareness amongst staff and service users/relatives regarding the current complaints policy, emphasising it’s use as a tool for improving services. (Refer to Recommendations OP16) The home had an adult protection and a whistle blowing policy. Discussion with staff demonstrated that they were aware of the procedure, but there was also some suggestion that complaints may be an area, which needs more discussion and awareness raising. The provider said that prevention of abuse was discussed regularly with staff at supervision and at team meetings. (Refer to Recommendations OP 16) The home had an adult protection and a whistle blowing policy and staff receive training on these policies. The provider said that prevention of abuse was discussed regularly with staff at supervision and at team meetings. Welcome Care Home Ltd DS0000025650.V258065.R01.S.doc Version 5.0 Page 14 However the Lewisham local authorities policy was reviewed in mid-2005, but the home does not have a copy of this revised policy and needs to amend it’s policy to reflect current best practice. The home will then need to provide staff with update training. (Refer to two Requirements OP18) Welcome Care Home Ltd DS0000025650.V258065.R01.S.doc Version 5.0 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): 20,24 and 26 Service users have access to safe and comfortable indoor and outdoor communal facilities, and live in safe comfortable bedrooms with their own possessions around them. The home is clean, pleasant and maintained to a high level of cleanliness and hygiene. EVIDENCE: Service users said that the home was welcoming and clean. Overall it provided a range of comfortable and accessible shared spaces for its users. There was a well-kept garden that was regularly used, a lounge at the front of the house and another sitting area in the conservatory at the rear. All spaces are adequate in size, and regular health and safety checks are done to ensure safety. It had been the case that loud music was being played in communal areas which some service users found uncomfortable, but the manager has now sensitively addressed this issue. Two service users said that they found the home and their rooms comfortable and that staff respected the privacy of their rooms. All bedrooms meet the minimum space standards and the single rooms have en-suite toilet and wash hand basin facilities. There is one double room, but Welcome Care Home Ltd DS0000025650.V258065.R01.S.doc Version 5.0 Page 16 care is taken to maintain privacy for both service users in this room. The home has conducted a questionnaire survey with service users regarding how they would like the home and their rooms decorated and has since decorated some rooms in response to service users wishes. The home was clean and tidy. Service users said that the home was always well kept. Hand washing facilities were available in all areas where staff might handle infected materials. The laundry was small, but the facilities provided were satisfactory. There was a policy to control the spread of infection. Welcome Care Home Ltd DS0000025650.V258065.R01.S.doc Version 5.0 Page 17 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 Service users needs are met by the numbers and skill mix of staff, and are in safe hands at all times. Service users are not yet fully protected by the homes recruitment practices, but staff are trained and competent to do their jobs. EVIDENCE: The home employs fifteen care staff employed on contracts of 20 hours on average, and there were no staff vacancies. There is a mix of male and female staff to reflect the gender make up of service users. The staff team has sufficient numbers and complementary skills, backed by a programme of training, to support the assessed needs of the current service users’ group. This maintains a minimum of: - Three staff for the morning /early afternoon shift (two care assistants and often a manager) - Two for the afternoon/evening shift - Two at night, of which one asleep and one awake. The home employs a cleaner. Staff NVQ qualifications and training show that there are currently enough staff qualified and almost qualified to meet requirements. On examination of five staff files it was evident that some work still needs to be done regarding ensuring that proper and complete screening of staff credentials takes place prior to appointment. The following issues need to be addressed: Welcome Care Home Ltd DS0000025650.V258065.R01.S.doc Version 5.0 Page 18 1. The home does not complete it’s pre-employment checklist for all staff and this makes checking the order and timing of when checks were done difficult to check. 2. References do not show the capacity in which the referee knew the applicant, and are not accompanied by a company stamp. 3. One employees file, employed since 30/09/05 only contains one reference, as the other does not have the referees name on it. 4. The interview panel sometimes only consists of the registered manager, and sometimes formal interviews do not take place, but some staff are appointed on the basis of having worked at the home as a volunteer or student. This process does not ensure that new employees will be appointed on the basis of meeting the full requirements of the role, and may be contrary to equal and fair employment practices. (Refer to Repeated Requirement OP29) (Refer to new Requirement OP29) CRB checks and POVA checks were found to be in order. All staff receive structured induction training, completed within the first six weeks of employment. There is an ongoing training plan in place for all staff. Welcome Care Home Ltd DS0000025650.V258065.R01.S.doc Version 5.0 Page 19 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): 33 and 36 The home makes efforts to include service users views in making decisions, but cannot yet demonstrate fully that the home is run in the best interests of service users. Staff are supervised but formal supervision is not as frequent as is required. EVIDENCE: There was evidence, at this inspection, that thought has been given to instituting an effective quality assurance system, based on seeking the views of service users. Some service users surveys have been carried out, in relation to food provided and décor, but there is not a means of making service users aware of findings, or a system for using information to formulate a development/improvement plan. There are currently no annual quality audits taking place. These issues were previously raised and must be addressed by the home. (Refer to Repeated Requirement OP33) Welcome Care Home Ltd DS0000025650.V258065.R01.S.doc Version 5.0 Page 20 Policies and procedures are generally reviewed regularly but the home does not have a systematic approach to reviewing policies and procedures. As a result some may need updating such as the Adult Protection policy. (Refer to Requirements OP33) Staff have regular contact with the homes manager, but formal staff supervision does not consistently happen for all staff every two months. (Refer to Requirements OP36) Welcome Care Home Ltd DS0000025650.V258065.R01.S.doc Version 5.0 Page 21 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 3 X X X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 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 2 X 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X 2 X X Welcome Care Home Ltd DS0000025650.V258065.R01.S.doc Version 5.0 Page 22 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 OP7 Regulation 15.1 Requirement The registered manager must ensure that all service users care plans are reviewed at least monthly and that records are kept of dates of these reviews The registered manager must ensure that all service users abilities and wishes regarding self medication are recorded on their individual care plans and that action is taken to support any individuals who may wish to self medicate The registered manager must ensure that every effort is made to ensure that service users are fully made aware of the medication they take, and that formal written agreement is noted in care plans in cases where this is not possible. The registered manager must ensure that medication is only administered by staff trained to do so, and that it is administered only by the person signing for it’s administration The registered manager and provider must ensure that the DS0000025650.V258065.R01.S.doc Timescale for action 31/12/05 2 OP9 12.1,2,3 31/01/06 3 OP9 12.1,2,3 31/12/05 4 OP9 13.2 30/11/05 5 OP18 13.6 31/12/05 Welcome Care Home Ltd Version 5.0 Page 23 6 OP18 13.6 & 18.1 c i homes Adult Protection and Whistle Blowing policies are reviewed to be consistent with the requirements of the local authorities current policy, in order to best protect service users from abuse The registered manager must ensure that all staff training is updated in relation to current requirements of the local authorities Adult Protection policy The registered provider must ensure that all statutory checks, to ensure suitability of staff, are conducted and inform the decision to appoint. To this end, existing files must be reviewed and appropriate steps taken, if necessary. In particular, all previous work and education history must be obtained for all staff and any gaps must be explored. This is a repeat of a previous requirement Timescale 01/03/05 Unmet. Continued failure to meet this requirement may result in enforcement action. 31/01/06 7 OP29 19 31/01/06 8 OP29 19 The registered provider and manager must ensure that all staff recruitment is based on equal opportunities and ensures the protection of service users. In doing so they must ensure that all staff are appointed on the basis of an interview process, conducted by more than one individual, who is experienced and qualified to do so. This must be reflected in the home’s recruitment policy. The registered provider must put in place and maintain a system DS0000025650.V258065.R01.S.doc 31/01/06 9 OP33 24 28/02/06 Welcome Care Home Ltd Version 5.0 Page 24 for reviewing and improving the quality of care provided at the home. The system must be based on seeking the views of service users. This is a repeat of a previous requirement, Timescale 01/07/05 Unmet. Continued failure to meet this requirement may result in enforcement action. 10 OP36 18.1 a The registered manager must ensure that staff receive formal supervision at least six times a year. 31/12/05 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 OP7 Good Practice Recommendations The registered manager and staff should continue to development and improvement of information on all service users individual social care needs and leisure interests and put in place an individual weekly planning system for each service user as an aid to success Review the homes complaints policy to place more emphasis on confidentiality and the process for reviewing complaints The registered manager should ensure that all old versions of the homes complaints policy are removed from the home The registered manager should explore ways of raising awareness amongst staff and service users about the benefits of using the complaints system as an aid to improving the quality of service The registered manager should develop a policy review schedule to ensure all policies and procedures comply with current legislation and that service users are fully protected DS0000025650.V258065.R01.S.doc Version 5.0 Page 25 2 3 4 OP16 OP16 OP16 5 OP33 Welcome Care Home Ltd Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Welcome Care Home Ltd DS0000025650.V258065.R01.S.doc Version 5.0 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!