Inspection on 07/02/06 for Welcome House - The Cedars

This inspection was carried out on 7th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 33 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Welcome House - The Cedars 19/06/07

Welcome House - The Cedars 23/05/06

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 Sarah Montgomery Unannounced Inspection 7th February 2006 04:00 Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 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 Care Home 26 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (26) of places Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd August 2005 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 currently used as singles. The home is located in a semi-rural area, with the village of Newington a 15 minutes walk away, where shops and a mainline railway station are situated. There is a bus stop 200 yards from the property. There are gardens to the front and rear of the building, and ample parking for cars. Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Sarah Montgomery (Regulation Inspector) and John Walker (Regulation Manager) conducted this unannounced inspection on February 7th 2006, between 4pm and 8.30pm. Evidence was gathered from a variety of sources, and these included speaking with service users, the home manager, and care staff. A partial tour of the building was undertaken. Care plans, assessments and risk assessments were inspected, as was the statement of purpose and the service user guide. What the service does well: What has improved since the last inspection? What they could do better: The inspectors are concerned that the home is insufficiently staffed to meet the needs of service users. Risk assessments read indicated serious health and safety concerns, yet the home has no waking night staff and minimal staff on duty during the day. The home has conducted their own assessments regarding hours of care needed by service users. The inspectors question the validity of these assessments. Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 Page 6 The inspectors did not witness any positive interactions between staff and service users. The manager has been asked to address this issue. 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 House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 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.V282890.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Service users cannot be confident they have sufficient information to make an informed choice about where to live. Prospective service users cannot be sure that the home they choose will meet their needs and aspirations. EVIDENCE: The home’s statement of purpose and service user guide is not specific to the home. Services described within the document are general, and do not reflect the current services offered at the home. As with all Welcome House care homes, the statement of purpose describes the Cedars as multi-functional; offering short-term, long-term and respite. When questioned, the manager agreed that placements at the home are longterm, although said that on occasions (approximately 4 per year), service users are admitted for respite. No documents could be found describing a respite service, nor does the home provide any consultation with existing longterm service users regarding admitting service users into their home for short periods. It is recognised as good practice that homes offering a long-term placement do not also offer a respite service. Welcome House is required to review its statement of purpose and service user guide. Detailed examination of the statement of purpose suggested that Welcome House may be using inappropriate language within it. An example of this is ‘service users deemed suitable are also offered a key to their own room if they so wish’. Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 Page 9 The statement of purpose asserts that ‘our service users require a minimal level of support to maintain their independence, and are encouraged to do this’. Care plans read during the inspection, and conversations with service users and the manager, raises questions concerning the overall validity of this statement. The manager informed the inspectors that just one or two current service users are currently assessed as fitting the profile of moving towards independence. The evidence obtained raised concerns about the home’s staffing hours. The statement of purpose and service user guide both state that the home is staffed 24 hours a day. While this is true, the staffing is regarded as minimal and the inspectors could not see how the needs of services users could be met with such limited staffing resources. The home conducts their own ‘assessment of staffing requirements for service users’, in which most service users are assessed by the home as requiring 3 or 4 hours care per day. Observations made during the inspection, coupled with reading of care plans and risk assessments, evidence a failure to meet service users needs and aspirations. A service user assessed as being ‘at risk of harm to himself and others’ has been ‘assessed’ by the home as requiring 3 hours care per day. Questions regarding the safety of the individual, other service users in the home, and the safety of members of the public, could not be answered by the manager. Assessments are poor and totally unsatisfactory. Service users are not protected from harm, and the inspectors could only conclude that needs and aspirations are not addressed adequately or met at all. Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9. Service users cannot be confident that their assessed and changing needs and personal goals are reflected in their individual plan. Service users cannot be sure that risk assessments keep them safe. EVIDENCE: Inspectors requested to talk to service users about their care plans and risk assessments but were informed this would not be practicable. Information gathered regarding care plans and risk assessments was taken from the written documents and conversations with the manager. Care plans were inspected and the following observations were made; information included in care plans is insufficient to be considered effective documents. Care plans read more as ‘pen portraits’ and do not include information as to how support can be given. An example of this is ‘staff to monitor and help support (service user) with moods’. No description of the ‘moods’ are given, nor are any monitoring tools available, or any indication of guidelines regarding what support or help is required. Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 Page 11 Monthly keyworker reports were brief and did not offer an insight into recognition of changing needs or whether goals and aspirations had been met within current care plans. The statement of purpose profiles service users at the home as needing minimal levels of support to maintain independence. No evidence could be found on care plans that service users are supported to gain or to maintain independent living skills. There are no formal assessments or teaching programmes linked to care plans. When asked of the current mental health diagnosis of service users in the home, the manager listed the following; schizophrenia, institutional depression, self-neglect, challenging behaviour, and mood swings – (manic depression). While inspecting the care plans, the inspectors asked the manager how staff are guided to support service users with regard to their mental health, and also asked her to give some examples of the type of support within a care planning framework. In considering this question, the manager recognised that staff training in this area and current support given to service users was insufficient. Risk assessments do not protect service users. The evidence suggested that service users are at risk from harm, and current practice in the home indicates that service users are neglected. An example of this is a risk assessment on a service user who knowingly self-harms. The risk assessment gives a brief outline of staff responses to the self-harming behaviour. When questioned, the manager could not point to any documents that monitor staff response, nor could any indicators that staff are aware of the service user’s behaviours or whereabouts during the day be evidenced. Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 14 and 17. Service users have limited opportunities for personal development and cannot be confident that they will be supported to take part in appropriate leisure activities. Service users cannot be sure they are offered a healthy diet. EVIDENCE: The statement of purpose indicates that independent living training will be given. The home’s care philosophy states ‘our care philosophy is to support and encourage all of our residents to lead as normal a life as possible and to reach their full potential. This is achieved by offering guidance and assistance with every day living skills and by encouraging residents to participate in the planning of their own care…’ Service users living at the home are not given any training regarding independent living. No evidence was found to indicate that assessments regarding independent living have been undertaken, or that teaching programmes to assist service users in line with the home’s philosophy and statement of purpose exist. One file inspected had a letter from the service user to another service user agreeing to pay back £380. When questioned, the manager stated this was for Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 Page 13 a holiday taken last year. The manager was reminded of standard 14 which states; ‘service users in long term placements have as part of the basic contract price the option of a minimum seven-day annual holiday outside the home, which they help choose and plan’. The manager agreed to refund any service user who had paid for his or her own holiday, and further agreed that the practice of loans between service users will cease. Service users spoken with all expressed satisfaction with meals at the home. However, no evidence was available to inspectors regarding the diet offered to service users, with the manager informing inspectors that the menus kept at the home are not a true reflection of food offered, and are not used at all. There was no fresh fruit or fresh vegetables available for the inspectors to see. The manager said all the fruit had been eaten, and that she freezes fresh vegetables. The inspectors questioned the practice of freezing fresh vegetables, pointing out that by virtue of freezing them they were no longer fresh. The inspectors asked how menus were compiled. They were informed that the first two service users out of bed each morning made the two choices for the main meal of the day. This is not recorded anywhere, and the home cannot demonstrate that service users are provided with healthy, nutritious and balanced meals. Given that the home has a number of service users over the age of 65, particular attention must be made to diet. The home is required to evidence regular recorded consultation with service users regarding menu choices, and these choices must be recorded on a menu which can be inspected. Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19. Service users cannot be confident that their emotional health needs are met. EVIDENCE: Service users at the Cedars have a diverse range of mental health difficulties. Conversations with service users and the manager, and inspection of risk assessments and care plans indicated that emotional health needs are not met. The evidence indicated that the health, welfare and safety of service users is compromised, and service users live in an environment where staff are unable to fully support them in ensuring their emotional needs are met. Service users spoke openly to inspectors about their emotional needs. These included suicidal feelings, self-harm, alcohol abuse, and self neglect. Given that the Cedars is a home for people with mental health difficulties, and Welcome House states that it is ‘promoting excellence in mental health’, no evidence could be found to enable the inspectors to conclude that individuals emotional support needs are either addressed or, in some cases, recognised. The home has no records in which it can demonstrate how an individual is being supported. Care plans and risk assessments do not contain sufficient information to enable staff to gain an understanding of support needs. Risk assessments which contain some detail, fail to adequately address methods in which the risk would be addressed and/or reduced. Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 Page 15 Staffing at the home is inadequate, and does not allow for individuals to be supported appropriately or effectively. Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): THESE STANDARDS WERE NOT INSPECTED. EVIDENCE: Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26, 27, 28 and 30 Service users would benefit if communal areas, including bathrooms and toilets, and some bedrooms were redecorated, and in some cases, refurbished. They would further benefit if the home were clean and hygienic. EVIDENCE: The Cedars is a large home, and a tour of the building evidenced many areas to be unclean and dirty. Several service users bedrooms had sticky floors, stained sinks, and dirty bed linen. Communal areas, in particular bathrooms, were not adequately cleaned, had communal towels presenting a high risk of cross infection, and floors that were very stained. No radiators had covers on and present a serious hazard to service users. The television lounge has seating for nine people. The furniture is shabby and old looking, particularly the patterned sofa and chair. The curtains are too short for the window. The smoking room has garden furniture. (plastic table and 4 chairs). It is not a welcoming room, and the paint on the walls is chipped in many places. The walls outside this room are damaged. Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 Page 18 The ‘green room’ described by a member of staff as ‘the staff room’, but described by the manager as the service users lounge, is decorated to a high standard and has comfortable furniture. When questioned, service users indicated that they do not use this room. Bathrooms in the extension were inspected. The following was noted; in one bathroom the panel was coming off the bath, the radiator did not have a cover, the toilet is very stained, the curtain is too long for the window, the sealant around the bath is uneven and dirty, and the communal towel in the bathroom poses a serious risk to cross infection. In the other bathroom the floor is very stained. An area where a bath hoist used to be the flooring is uneven and presents as a risk. The door to the boiler was not locked. The hot water was tested and was tepid. All bedrooms inspected were of concern to the inspectors. The following was noted; in bedroom 13 the bed was broken. An unpleasant and overwhelming odour was present in the room. Bedroom 16 also contained an unpleasant odour. In bedroom 17 the bed linen was inspected. This was found to be dirty and stained. A thin sheet covered the mattress. This sheet, apart from being dirty had food items over it. Springs were coming through the mattress. The sink was stained and the floor dirty and sticky. The radiator was not on and the room was cold. The service user had two jumpers on. There were no drawers in the room. Room 20 was similar to Room 17 in that it had dirty and stained bed linen and a dirty floor. In room 21 the service user smokes. There is no risk assessment regarding this. In Room 23 the wardrobe is broken. The fridge in the kitchen has a door handle missing and a bare bulb exposed inside. The bin did not have a lid. Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 33. Service users cannot be confident they are supported by staff that are competent and effective. EVIDENCE: The home is registered for 26 adults with mental health issues. At present 19 service users live at the Cedars. A small staff team supports them. During the hours of 8am and 10pm, two members of staff are on duty. The manager is available between 9am – 5pm Monday to Friday, but has a dual role as Head of Home for two other registered homes, and cannot always be guaranteed to be in the home. Part of Welcome House’s philosophy is not to employ cleaners or cooks, stating that service users participate in these duties. However, conversations with service users and the manager evidenced that in reality service users do not participate in cleaning or cooking. Indeed, during the inspection the two staff on duty were cleaning the home, and no interaction with service users, or attempts to include service users in cleaning, were noted. The inspectors questioned the manager as to how the staff can clean the home, cook and prepare all meals, and undertake to provide support to service users. The manager accepted that at least one staff member was ‘busy’ with cooking and/or cleaning most of the time. This leaves one member of staff to support 19 service users. The inspectors concluded that goals and aspirations in individual care plans are not realised. The statement of purpose and Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 Page 20 philosophy of care is not adhered to, and service users receive at best basic care given the availability and resources of the staff. Service users spoke positively about the staff, describing them as ‘nice’ and ‘kind’. When inspectors asked service users about how they are supported by staff, particularly regarding their mental health, service users indicated that support was not given. One service user spoke about finding comfort in reading a bible, however, this was not possible, as he needed stronger reading glasses. He indicated that this has been a problem for at least a year. The inspectors were not given a satisfactory answer as to why the service user had not received support in this area. The home does not employ waking night staff and the inspectors would question this lack of support at night. The inspectors were made aware during the inspection of a number of service users who require support during the night. The home has, in the past employed waking night staff, and is required to ensure that waking night staff are again employed at the home to ensure the health, safety and welfare of service users. Information gathered from care plans, discussions with service users and the manager, and the observations made during the inspection, evidenced that staffing is not adequate to meet the present needs of the service users in the home. Based on figures from the residential forum, this home should have 531 support hours per week. The present support hours are significantly less, with 236 support hours, which include the manager hours. Welcome House must address these staffing shortfalls as a matter of urgency, and ensure that The Cedars is appropriately staffed to enable the service user to receive the support required, including waking night staff. Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 43. Service users cannot be sure they live in a well run home, or that they benefit from competent and accountable management. EVIDENCE: The manager presented as very committed to the home and the service users. The inspectors were impressed by her determination to provide a good service. However, the inspection process revealed significant shortfalls and indicated that overall, outcomes for service users are very poor. National Minimum Standards are not met or adhered to, and the home is failing to comply with Regulation. Underpinning these failures is the inadequate staffing levels at the home. The inspectors recognise that the manager and staff can only work with the tools they have, and these tools are unsatisfactory in providing quality care to service users. Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 Page 22 The evidence obtained evidence that Senior management at Welcome House are failing service users, and possibly misleading prospective service users and their representatives. Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 1 2 X 3 1 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 1 27 1 28 1 29 X 30 1 STAFFING Standard No Score 31 X 32 1 33 1 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 X X 1 X LIFESTYLES Standard No Score 11 1 12 X 13 X 14 1 15 X 16 X 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 1 X X 1 X X X X X 1 Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 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 YA1 Regulation 4(1)(a)(b)(c) Requirement Timescale for action 21/04/06 2 YA1 4(2) 3 YA1 4(3)(a) 4(3)(b) The registered person shall compile in relation to the care home a written statement (in these Regulations referred to as “the statement of purpose”) which shall consist of – (a) a statement of the aims and objectives of the care home; (b) a statement as to the facilities and services which are to be provided by the registered person for service users; and a statement as to the matters listed in Schedule 1. 21/04/06 The registered person shall supply a copy of the statement of purpose to the Commission and shall make a copy of it available on request for inspection by every service user and any representative of a service user. Nothing in regulation 16(1) or 21/04/06 23(1) shall require or authorise the registered person to contravene, or not DS0000024041.V282890.R01.S.doc Version 5.1 Page 25 Welcome House - The Cedars 4 YA1 5 YA1 6 YA1 to comply with – (a) any other provision of these Regulations; or the conditions for the time being in force in relation to the registration of the registered person under Part 2 of the Act. 5(1)a,b,c,d,e,f The registered person shall 21/04/06 produce a written guide to the care home (in these Regulations referred to as “the service user’s guide”) which shall include – (a) a summary of the statement of purpose. (b) The terms and conditions in respect of accommodation to be provided for service users, including as to the amount and method of payment of fees; (c) A standard form of contract for the provision of services and facilities by the registered provider to service users; (d) The most recent inspection report; (e) A summary of the complaints procedure established under regulation 22; The address and telephone number of the Commission. 5(2) The registered person shall 21/04/06 supply a copy of the service user’s guide to the Commission and each service user. 5(3) Where a local authority has 21/04/06 made arrangements for the provision of accommodation, DS0000024041.V282890.R01.S.doc Version 5.1 Page 26 Welcome House - The Cedars 7 YA1 6(a) 6(b) 8 YA3 14(1)(d) nursing or personal care to the service user at the care home, the registered person shall supply to the service user a copy of the agreement specifying the arrangements made. The registered person shall – 21/04/06 (a) keep under review and, where appropriate, revise the statement of purpose and the service user’s guide; and notify the Commission and service users of any such revision within 28 days. The registered person shall 31/03/06 not provided accommodation to a service user at the care home unless, so far as it shall have been practicable to do so – (d) the registered person has confirmed in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service user’s needs in respect of his health and welfare. The registered person shall 31/03/06 not provided accommodation to a service user at the care home unless, so far as it shall have been practicable to do so – (a) needs of the service user have been assessed by a suitably qualified or suitably trained person; (b) the registered person has obtained a copy of the assessment; DS0000024041.V282890.R01.S.doc Version 5.1 Page 27 9 YA3 14(1)(a) (b)(c) Welcome House - The Cedars 10 YA6 15(1) 11 YA6 15(2)(a) (b)(c)(d) 12 YA6 12(1)(a) 12(1)(b) there has been appropriate consultation regarding the assessment with the service user or a representative of the service user; Unless it is impracticable to 31/03/06 carry out such consultation, the registered person shall, after consultation with the service user, or a representative of his, prepare a written plan (“the service user’s plan”) as to how the service user’s needs in respect of his health and welfare are to be met. The registered person shall – 31/03/06 (a) make the service user’s plan available to the service user; (b) keep the service user’s plan under review; (c) where appropriate and, unless it is impracticable to carry out such consultation, after consultation with the service user or a representative of his, revise the service user’s plan; and notify the service user of any such revision. The registered person shall 31/03/06 ensure that the care home is conducted so as – (a) to promote and make proper provision for the health and welfare of service users; to make proper provision for the care, and where appropriate, treatment, education and supervision of service users. DS0000024041.V282890.R01.S.doc Version 5.1 Page 28 Welcome House - The Cedars 13 YA9 13(4)(b) 13(4)(c) 14 YA11 12(1)(b) 15 YA17 16(2)(i) 16 YA19 12(1)(a) 12(1)(b) 17 YA19 12(2) The registered person shall ensure that – (b)any activities in which service users participate are so far as reasonably practicable free from avoidable risks; and unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. The registered person shall ensure that the care home is conducted so as – (b) to make proper provision for the care and, where appropriate, treatment, education and supervision of service users. The registered person shall having regard to the size of the care home and the number and needs of service users – (i) provide, in adequate quantities, suitable, wholesome and nutritious food which is varied and properly prepared and available at such time as may be reasonably required by service users. The registered person shall ensure that the care home is conducted so as – (a) to promote and make proper provision for the health and welfare of service users; (b) to make proper provision for the care and, where appropriate, treatment, education and supervision of service users. The registered person shall so DS0000024041.V282890.R01.S.doc 17/03/06 31/03/06 17/03/06 17/03/06 17/03/06 Page 29 Welcome House - The Cedars Version 5.1 18 YA19 12(3) 19 YA26 16(2)(c) 20 YA26 16(2)(e) 21 YA27 23(2)(j) 22 YA27 23(2)(n) far as is practicable enable service users to make decisions with respect to the care they are to receive and their health and welfare. The registered person shall, for the purpose of providing care to service users, and making proper provision for their health and welfare, so far as practicable ascertain and take into account their wishes and feeling. The registered person shall having regard to size of the care home and the number and needs of service users – (c) provide in rooms occupied by service users adequate furniture, bedding and other furnishings, including curtains and floor coverings, and equipment suitable to the needs of service users. The registered person shall having regard to size of the care home and the number and needs of service users – (e) arrange for the regular laundering of linen and clothing. The registered person shall having regard to the number and needs of the service users ensure that – (j) there are provided at appropriate places in the premises sufficient numbers of lavatories, and of wash basins, baths and showers fitted with a hot and cold water supply. The registered person shall having regard to the number and needs of the service users ensure that – (n) suitable adaptations are made, and such support, DS0000024041.V282890.R01.S.doc 17/03/06 17/03/06 01/03/06 17/03/06 31/03/06 Welcome House - The Cedars Version 5.1 Page 30 23 YA28 23(2)(h) 24 YA30 16(2)(j) 25 YA30 16(2)(k) 26 YA30 13(3) 27 YA30 23(2)(d) equipment and facilities, including passenger lifts, as may be required are provided, for service users who are old, infirm or physically disabled. The registered person shall having regard to the number and needs of the service users ensure that – (h) the communal space provided for service users is suitable for the provision of social, cultural and religious activities appropriate to the circumstances of service users; The registered person shall having regard to the size of the care home and the number and needs of service users – (j) after consultation with the environmental health authority, make suitable arrangements for maintaining satisfactory standards of hygiene in the care home; The registered person shall having regard to the number and needs of the service users ensure that – (k) keep the care home free from offensive odours and make suitable arrangements for the disposal of general and clinical waste. The registered person shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. The registered person shall having regard to the number and needs of the service users ensure that – (d) All parts of the care home are kept clean and reasonably decorated. DS0000024041.V282890.R01.S.doc 31/03/06 17/03/06 17/03/06 01/03/06 17/03/06 Welcome House - The Cedars Version 5.1 Page 31 28 YA32 12(5)(b) 29 YA33 18(1)(a) 30 YA37 10(1) 31 YA43 24(1)(a) 24(1)(b) The registered provider and registered manager shall, in relation to the conduct of the care home – (b) encourage and assist staff to maintain good personal and professional relationships with service users. The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users – (a) ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. The registered provider and the registered manager shall, having regard to the size of the care home, the statement of purpose, and the number and needs of the service users, carry on or manage the care home (as the case may be) with sufficient care, competence and skill. The registered person shall establish and maintain a system for – (a) reviewing at appropriate intervals; and (b) improving, the quality of care provided at the home. 17/03/06 17/03/06 17/03/06 31/03/06 32 YA43 24(2) The registered person shall supply to the Commission a report in respect of any review conducted by him for the purposes of paragraph (1), and make a copy of the report available to service DS0000024041.V282890.R01.S.doc 31/03/06 Welcome House - The Cedars Version 5.1 Page 32 users. 33 YA43 24(3) The system referred to in paragraph (1) shall provide for consultation with service users and their representatives. 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA14 Good Practice Recommendations Service users have as part of the basic contract price the option of a minimum seven-day annual holiday outside the home, which they help choose and plan. Welcome House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 Page 33 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 House - The Cedars DS0000024041.V282890.R01.S.doc Version 5.1 Page 34 - 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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