Inspection on 19/06/07 for Welcome House - The Cedars

This inspection was carried out on 19th June 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Welcome House - The Cedars 23/05/06

Welcome House - The Cedars 07/02/06

Welcome House - The Cedars 15/02/05

Welcome House - The Cedars 19/05/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOME ADULTS 18-65 Welcome House - The Cedars The Cedars 2 Hartlip Hill Hartlip Sittingbourne Kent ME9 7PA Lead Inspector Joseph Harris Key Unannounced Inspection 19th June 2007 10:00 Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Welcome House - The Cedars Address Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Cedars 2 Hartlip Hill Hartlip Sittingbourne Kent ME9 7PA 01795 843837 01795 842209 Dr Toqeer Aslam Ms Heidi Baum Dr Toqeer Aslam Care Home 26 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (26) of places Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th November 2006 Brief Description of the Service: The Cedars is a large detached property with accommodation on three floors, offering twenty single and three double rooms, which are all currently used as single rooms. There are three sitting rooms on the ground floor, one of which is a smoking room. There is also a large dining room and a domestic sized kitchen. The home is located on a busy arterial road between Rainham and Sittingbourne, with the village of Newington some 15-20 minutes walk away, where shops and a mainline railway station are situated. There is a bus stop 200 yards from the property, which offers an hourly service to Rainham and Sittingbourne. The home does not have dedicated transport. There are reasonably well-tended gardens to the front and rear of the building, and ample parking for cars. The current scale of charges at The Cedars is £540 per week. Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection process culminated in a site visit to the service on the 19th June 2007. The visit commenced at 10am and concluded at 4pm lasting approximately 6 hours. During the course of the inspection process the home submitted an Annual Quality Assurance Assessment. Previous requirements and recommendations from past inspections and other regulatory activity were also considered. During the site visit the inspector held conversations with the Registered Manager, staff on duty, a number of service users in the home and the Operations manager. There were no opportunities to speak with visiting friends, relatives or professionals. A range of documents and records were examined including service user plans, staff files, training records, staff rotas, health and safety certificates and other information relating to the running of the home. A tour of the premises was also undertaken. What the service does well: What has improved since the last inspection? The registered manager and organisation have continued to make improvements to the service since the last inspection. The home has completed the process of updating service user plans and risk assessments moving towards a more person-centred approach to care planning. Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 6 The service users guide and statement of purpose have been updated satisfactorily. The quality assurance processes in the home have been further developed and improved. Work has been completed and is on-going to update the environment including a programme of redecoration within communal areas, some bedrooms and bathrooms and toilets. The registered manager is continuing to develop staff competency assessments as part of a planned induction programme. Medication storage facilities have been improved and processes with regard to medication administration strengthened. The organisation has continued to develop recruitment processes. Some attention has also been paid to the range of activities in the home, although this can continue to be developed. 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. The summary of this inspection report can be made available in other formats on request. Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4. Quality in this outcome area is good. Prospective service users have access to adequate information about the home and their needs are assessed prior to moving in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has reviewed and updated the service user guide and statement of purpose. These documents now provide more specific information about the service and the service user’s guide is written in a more accessible and easyto-read manner. Some photographs have also been included. It was reported that this document is made readily available throughout the home and the home needs to ensure that a copy of the guide is provided to all prospective service users at the point of referral along with a sample contract of residency. The statement of purpose has been developed in accordance with schedule 3 of the Care Home Regulations and covers the aims and facilities of the home. The majority of service users are referred through care management and Care Programme Approach (CPA) processes. Therefore the registered manager ensures that copies of the most recent care plans, risk assessments and background information is received at the point of referral. The Manager and/or senior staff then aim to visit the individual in their current Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 9 accommodation completing their own assessment form, which adequately addresses key areas of needs. If it is felt that the home will be able to meet the needs of the individual they are invited to visit the home for a short visit increasing to overnight stays as required. Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. Service users have an individual plan of care incorporating risk assessments and they are enabled to make decisions affecting their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A number of individual service user plans were examined during the course of the inspection, all of which have been fully updated and reviewed. The plans set out, in good detail, the needs and aspirations of each resident and provide clear guidance to enable staff to meet those needs. It was suggested that additional attention could be given to addressing future goals and activities of daily living for some service users with detail to enable staff to consistently assist residents in working towards these goals such as accessing public transport, cooking, budgeting and other skills working towards greater independence. Refer to recommendation 3. Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 11 Service users are supported in making decisions about their lives. The home has information available about advocacy services and self-help groups for the local area. Residents are supported to manage their own finances where appropriate; otherwise there are appointees in place who are independent of the service. Any limitations and restrictions required are discussed with the relevant service user and their care team, the home is advised to ensure that when restrictions are in place, these are clearly documented within the individual service user plan. Refer to recommendation 4. Suitable risk management processes are in place to ensure that service users are supported to take responsible risks. The home uses an initial risk assessment, which covers a range of potential risk factors. Specific risk management plans are then developed where a significant area of risk is identified providing adequate guidance to inform staff. All risk assessments and service user plans are reviewed at 6 monthly intervals or when needs change significantly. Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is adequate. The majority of service users are able to take part in a suitably active lifestyle with a range of activities, although low staffing levels inhibit this for some residents who require higher levels of support in the community. A healthy and balanced diet is offered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has improved the range of activities available in the home and the staff team have also researched information regarding available resources in the local area specifically for people with mental health problems. Residents needs and wishes have been considered and activity plans have been developed, although this is an area that the registered manager acknowledged can be further expanded with a wider variety of activities. The majority of service users are able to access the community independently and are happy to do so. The village of Newington is approximately 1 mile away and the home is on a main road with a bus route that connects Rainham and Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 13 Sittingbourne. It is reported that the home has an arrangement with the Swale Volunteer Bureau to provide transport for some residents and staff often use their own transport to take people to appointments, etc. Residents also stated that they often use taxi cabs to get into the local towns. The home does have low staffing levels at all times, which restricts the level of input service users can hope to receive when going out of the home. This is particularly the case at weekends when there is, according to recent and future staff rotas, only one member of staff on duty. This complete lack of flexibility does restrict some service users unnecessarily and can prevent people from achieving their short and long-term goals and wishes. This situation was discussed with the registered manager and the operations manager. Refer to requirement 1 and Standard 33. There is a welcoming atmosphere in the home and service users stated that their visitors are made welcome and can visit at reasonable times. There is adequate space in the home to enable people to meet in private should they wish to do so. There are fairly flexible routines in the home although a level of organisation and routine is required. Residents stated that staff are respectful and that they ‘get on well’ with all members of the staff team. This was also evident through observing interactions between staff and residents. Many of the residents take part in household chores and other tasks on a day-to-day basis. There are also rules regarding smoking and alcohol on the premises. Menu records were examined and a 4-week rolling menu is in operation, which is developed in part by service users with staff input. Residents are asked their choice of food before each mealtime and the menus demonstrate a balanced and healthy diet is offered. A good range of food was in stock including fresh fruit and vegetables and a range of non-perishables and frozen foods. A number of the service users stated that they quality of food is good and that choices are always available. The home does not have a dedicated cook and staff have to prepare all meals with some assistance from service users at times, which does have an impact on staff availability at these times of the day. The registered manager confirmed that where special diets such as diabetic, vegetarian and cultural diets are required these are catered for. There is a good-sized dining room and meals are taken in a relaxed and unhurried atmosphere. Service users can also choose when and where to eat within reasonable boundaries. Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. The health and personal care needs of service users are met and medication issues are appropriately managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Most service users require little support with meeting their personal care needs other than encouragement. However, a number of service users in the home are reaching older age and this is an area of support that does need regular review and consideration. Where residents do require greater levels of personal care the home has introduced suitably detailed plans of care and staff are aware of the needs of some individuals. Residents confirmed that staff treat them respectfully and respect their right to plan their time as they wish within therapeutic boundaries. For example residents can get up and go to bed when they wish, however, if this led to an altered sleep pattern that affects a person’s health then the home would put boundaries in place following consultation with the care manager and the service user. There are male and female staff in the home to allow individual needs to be catered for. The home Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 15 has established good links with community health services and each service user is registered with a local GP. Healthcare records are well maintained and there is evidence in a number of cases that the home has instituted appropriate action following concerns about an individual’s health. Records are kept of appointments with GPs, Psychiatrists, CPNs and complimentary health practitioners such as opticians, dentists and chiropodists with evidence that home liaises well and follows through any actions required. Medication processes are adequately managed and there were appropriate policies and procedures in place. The storage facilities have been improved and are kept locked at all times in a suitably temperature controlled environment. The storage facilities are not ideal, but suffice for the needs of the home. Controlled drugs are stored separately within two locked cupboards. All administration records were up to date and reasonably well maintained. The registered manager regularly assesses staff competency levels with regard to medication administration, however staff would benefit from progressing with formal medication courses in addition to the MDS training and in-house competency assessments. Refer to recommendation 1. Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. There is an adequate complaints process in place and service users are protected from forms of abuse. However staff training does need to be more comprehensive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear and accessible complaints procedure in place addressing all relevant topics. Service users stated that they would feel able to complain to the registered manager or staff on duty if they had an issue. Resident meetings are held regularly providing service users with the opportunity to raise issues of note. There are adequate policies and procedures in place addressing adult protection issues and abuse. There is a whistle blowing procedure in place. Staff demonstrated an awareness of these procedures and an understanding of adult protection protocols. Policies and procedures relating to financial matters are in place and records maintained. All staff have completed adult protection competency questionnaires and have watched induction videos on adult protection issues. One of the managers in the group of homes is currently working towards achieving a trained trainer qualification in abuse awareness and will provide structured training in this topic for staff. Refer to recommendation 2. Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28 and 30. Quality in this outcome area is good. The home is well maintained, safe and comfortable for service users meeting individual and collective needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises demonstrated that the home is in good decorative order and has been well maintained. There is a range of communal spaces including two lounges; a designated smoking room and a good sized dining area. The home has undergone some refurbishment and redecoration since the last inspection, which is now almost complete. This has included the redecoration of communal spaces, bathrooms and toilets. There is a domestic style kitchen with facilities that are in good working order. Residents spoken to said that they are happy with their bedrooms and a number of these were viewed and are adequate in size and suitable for purpose having been personalised to varying degrees. The home benefits from a large and well-maintained garden Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 18 with parking space to the front and a patio with garden furniture to the side and rear. On inspection the home was clean and hygienic and pleasant smelling. Laundry facilities are adequate, but would benefit from being included in the redecoration programme. It was reported that water fittings and supply meet relevant legislation and that the home complies with fire and environmental health requirements. Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. Quality in this outcome area is adequate. The home operates with minimal staff and training requirements need to be improved with regard to mandatory training. Staff are supported to achieve National Vocational Qualifications (NVQ) and service users are protected by the home’s recruitment practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a permanent staff team comprising of 2 carers and the registered manager. In addition to this the home employs two flexible workers who work between 25 and 40 hours per week. A further flexi-worker is in the process of being employed, although it was reported that they will not provide any extra staffing hours. 2 members of the care team have achieved NVQ level 2 or above and 1 staff member is currently working towards her NVQ4/RMA. The two flexi-workers are currently enrolled on their NVQ level 2 awards. The staffing levels are minimal in the home, but the registered manager stated that there a satisfactory numbers of staff on duty at all times. Duty rotas were examined for the current and following week, which demonstrated that there is Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 20 generally 2 staff on duty during the day from Monday to Friday. After 6.30pm this is generally reduced to one staff member and one person sleeps-in at night. This number of staff is not ideal, but rotas have been managed to ensure that there is some flexibility during the day to enable staff to support some residents who require it in the community. However, the inspector remains concerned at the shortage of staff at weekends. Both rotas examined showed that staff work alone throughout the weekend, which includes cooking and domestic duties, as the home does not employ a cook or cleaners. This allows no flexibility over the weekend and potentially puts an undue burden on staff. It is acknowledged that the majority of residents are content to access the community alone, but there are presently some residents who, it has been assessed, cannot go out without support and others who would like to be accompanied. Therefore there is a requirement, in order to meet these people’s needs, that additional staff are on duty during the weekend to enable this. Refer to requirement 1. Two staff files were examined for the newer employees of the home, which demonstrated that right and proper recruitment processes are followed. The files included at least two written references, proof of identity, CRB and POVA disclosure numbers and all other required information. The organisation is in the process of providing key staff with trained trainer qualifications in manual handling and adult protection. It was reported that these staff will be providing this training to carers in the near future. However, in respect of other mandatory training needs the home places an over-reliance on BVS training videos and in-house certification. This level of training, although adequate for induction purposes, should not replace formal training sessions and is not considered suitable for the level of work undertaken by care staff. Some staff have previously participated in external training with regard to food hygiene and fire safety and this level of training needs to be reintroduced into the organisation for all staff. Therefore mandatory training courses of suitable depth need to be arranged for staff in all mandatory training topics. Refer to requirement 2. The registered manager has instituted a number of competency based assessments covering topics such as adult protection, first aid, medication and fire safety. Additionally she is also developing a similar process for mental health awareness. This allied to specific induction processes for the home and TOPSS training videos does provide a good introduction to the home for new staff. It is advised that these induction processes are formalised, which should provide a good and in-depth competency based induction in line with the Common Induction Standards. It was reported that the organisation is currently working towards this goal. Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. The home is well run with attention paid to the views of service users, whilst promoting health and safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager provides a stable and positive influence on the home supported by some experienced and valued staff members. She has managed the home for approximately 10 years and has achieved the necessary qualifications for this role. Staff and service users stated that she is approachable and appreciate her leadership within the service. She has also Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 22 overseen a number of significant improvements in service provision over the past 12 months. The operations manager and registered manager have ensured that necessary improvements have been made to the quality assurance process, which include structured and action focused monthly monitoring visits and a series of questionnaires for service users, staff and relevant others. These responses have been formulated within an annual quality report and action points taken forward. These processes have helped and promoted the development of the service in a number of areas and should continue to drive this forward. All health and safety certificates and documentation was up to date and complete including service checks for utilities, environmental risk assessments, fire safety records, accident reports and safe working practices. The home does need to develop mandatory training for staff as referred to under standard 35. Refer to requirement 2. Welcome House - The Cedars DS0000024041.V337718.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA33 Regulation 18(1)(a) Requirement To ensure that sufficient numbers of staff are on duty, particularly at weekends, providing flexibility to meet the needs of all service users. To ensure that all staff receive suitably detailed and in-depth training covering all mandatory topics and that updates and refresher courses are provided as required. Timescale for action 01/08/07 2. YA35 18(1)(c) 01/09/07 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. 3. 4. Refer to Standard YA20 YA23 YA6 YA7 Good Practice Recommendations To provide staff with additional formal medication training over and above the Boots MDS and in-house competency assessments. To continue with plans to provide structured training for all staff regarding adult protection and abuse awareness. To develop consistent guidelines addressing service user’s future goals and activities of daily living. To clearly detail any restrictions in place for service users DS0000024041.V337718.R01.S.doc Version 5.2 Page 25 Welcome House - The Cedars within the care planning process. Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Welcome House - The Cedars DS0000024041.V337718.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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