Inspection on 22/11/06 for West Haven

This inspection was carried out on 22nd November 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

West Haven 25/01/07

West Haven 23/11/05

West Haven 22/04/05

West Haven 08/09/04

West Haven 15/04/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 West Haven 146 Huddersfield Road Dewsbury West Yorkshire WF13 2RW Lead Inspector Bronwynn Bennett Unannounced Inspection 22 November 2006 09:10 nd West Haven DS0000026332.V315544.R02.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 West Haven DS0000026332.V315544.R02.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. West Haven DS0000026332.V315544.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service West Haven Address 146 Huddersfield Road Dewsbury West Yorkshire WF13 2RW 01924 461720 01924 461720 westhaven146@tiscali.co.uk 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) Catholic Care (Diocese of Leeds) Mr Peter Simmons Care Home 7 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1) of places West Haven DS0000026332.V315544.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. When the person with LD(E) is no longer living at the home, the Category of Registration reverts to LD for 7 persons of either sex. 23rd November 2005 Date of last inspection Brief Description of the Service: Westhaven is a home for up to 7 adults who have learning disabilities. The home is owned by Catholic Care. It is located within close proximity to public transport links and local shops and is a short walk from the centre of Dewsbury with all its amenities. The home has ample communal space where people who receive services are able to spend time, including three lounges and a dining room. The home has a large, private garden, providing a safe environment for people living at Westhaven The provider informed the Commission for Social Care Inspection on 21.10.06 that the fees are £597.93 per week. West Haven DS0000026332.V315544.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit carried out by the inspector. The inspector arrived at the home at 9.10am and left at 4.10pm. During this visit the inspector spoke to some service users, some of the staff and the deputy manager Ms Julie Wade. The inspector read care records, audited a sample of medications, reviewed staff recruitment and training records, and carried out a tour of the home. In addition to this visit the Commission for Social Care Inspection sent six questionnaires to service users living at West Haven. Six completed questionnaires were returned. There were six service users living at the home on the day of this visit. Surveys were sent to six service users relatives two GPs and two health care professionals. The inspector received responses from two relatives surveys. Other information used as part of this inspection process includes notifications from the home to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, copies of the monthly management visit reports produced by the care provider, and a pre inspection questionnaire completed by the deputy manager. The inspector would like to thank everyone for their assistance during this inspection process. What the service does well: The potential needs of the service users are assessed prior to admission into the care home. The service users and the staff interact well. During this visit the service users appeared relaxed and happy with the staff working at the home. The service users are supported to plan and enjoy a choice of meals. The staff has worked well to enable the service users to be part of the local community and take part in activity. West Haven DS0000026332.V315544.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. West Haven DS0000026332.V315544.R02.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 West Haven DS0000026332.V315544.R02.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): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users’ individual needs and aspirations are assessed prior to admission. EVIDENCE: Five of the service user surveys received by the Commission for Social Care Inspection said that they received sufficient information about the home prior to moving in. Two Service users commented that they were invited to visit the home and stay for tea prior to their admission. The home is currently towards a planned admission for a service user to the home. The process of admission to the home was discussed with the deputy manager of the home. And the social services community care assessment was seen. No service user is admitted to the home without a full assessment and regular visits where they are introduced to existing service users living at the home. West Haven DS0000026332.V315544.R02.S.doc Version 5.2 Page 9 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 poor This judgement has been made using available evidence including a visit to this service. The service users assessed and personal needs and goals are not recorded in their care plan. The support required by service users to make decisions and the risks taken as part of an independent lifestyle are not appropriately recorded in the care records kept. EVIDENCE: The Commission for Social Care Inspection received surveys from all the service users living at the home. All the service users said that the staff treat them well and they are able to make decisions about what they do each day. Two service users’ records were audited during this visit. None of the records looked at held an up to date plan of care. There was no evidence available that a care plan had been drawn up with the involvement of a service user or made West Haven DS0000026332.V315544.R02.S.doc Version 5.2 Page 10 available in suitable formats that service users can understand. The overall standard of the care records is poor. There was evidence of regular reviews held for service users. A review was being held involving the service user and other relevant professionals during this visit. In the absence of care plans it was not clear what evidence was used in order to complete the review? There were no individualised procedures for helping the service users manage their behaviour, specialist interventions or individual personal care needs recorded in the care records looked at. However, through discussion with some of the staff it was clear that some service users have specific needs that require a detailed plan of care. The staff were observed during this visit interacting well with the service users respecting their right to make decisions. The staff advised that service users are supported to handle their own finances and lockable facilities are provided for this purpose. There was no information recorded in the individual records audited of the level of support required by and individual or decisions made by service users. This information must be made available in the care plan. There were some risk assessments seen in the care records looked at. But the information recorded was vague and lacked sufficient detail. In addition it was difficult to ascertain the accuracy of these documents as some were not dated, named, signed or reviewed. There was no regular monitoring of service users weight in the records looked at. These issues were discussed during this visit. Where such a risk exists the individual must have an assessment for nutrition and their weight monitored. Where an individual is over the age of sixty five then there must be a risk assessment in place for tissue viability (to measure the risk of developing a pressure sore). A falls risk assessment and manual handling assessment must be in place when required. The care records must contain up to date risk assessments relating to any identified risks as part of an individual’s preferred lifestyle. The information recorded must be clear, easy to follow and outline the level of risk and the measures in place to minimise the risk and any associated hazards. West Haven DS0000026332.V315544.R02.S.doc Version 5.2 Page 11 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): 12,13,15,16 and 17. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service users are supported to be part of the local community and take part in appropriate activities. Service users are supported to maintain relationships with family and friends. Generally, the service users’ rights are respected and individuals’ choice and independence is promoted. EVIDENCE: Some service users have paid jobs or are attending the local technical college. Here service users are supported to pursue interests and hobbies and develop skills. The service users have chosen to go out on a group trip to see the Christmas lights and for a Christmas dinner. West Haven DS0000026332.V315544.R02.S.doc Version 5.2 Page 12 The service users were seen being supported by the staff in their chosen activity throughout the day. Activities were recorded in the daily records kept. The service users are supported to be part of the local community and go out independently if they wish. The service users currently take part in a wide range of activity such as, the church, gym, social education centre and shopping. The staff has worked well in helping service users find out about appropriate activities they can take part in. The staff spoken with said that they have improved the service users’ activity within the local community. This is good practice. There was little information recorded in the individual records seen regarding the service users’ links with the local community. The service users hold monthly meetings were they are supported to share their views about how the home is run. The service users are supported to maintain relationships with family and friends. And individuals spoken with said they are able to see their family and friends when they wish. One of the staff discussed how she supports a service user in writing letters to relatives. Some service users have chosen to use mobile phones in order to keep regular contact with their friends and relatives. There was good interaction and relationships noted between the service users and the staff. The staff were observed treating individual’s in a respectful and dignified manner throughout this visit. Some of the service users spoken with said they clean there own rooms with the support of staff. However, the support required to undertake this activity was not recorded in the care records looked at. Each service user is supported to plan the home’s main menu and choose a day to plan a meal. In addition to choosing food, the service users are active in shopping for food and in the preparation of meals. During this visit the service users went out shopping for the home and enjoyed assisting the staff making the evening meal. As meals are generally planned from cookery books there tends to be little use of processed foods and ready meals. This is good practice and generally supports individuals to choose a healthy diet. Alternatives meals are provided and specialist diets are catered for by the home. West Haven DS0000026332.V315544.R02.S.doc Version 5.2 Page 13 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 poor This judgement has been made using available evidence including a visit to this service. The service users may not receive personal support in their preferred way. The institutionalised practice of mouth care must stop. Although generally the service users health care needs are met. It would be of benefit to review the individual care records and include a health care plan. The home’s medication policy and procedure does not sufficiently protect the service users. EVIDENCE: There was no information in the care records that showed the service users receive the care and support they need in their preferred way. Nor was there information to show that service users do have some choice of the staff that works with them, such as same gender. A named key worker was identified in the individual records looked at and the service users spoken with said they knew their key worker. West Haven DS0000026332.V315544.R02.S.doc Version 5.2 Page 14 During this key visit the inspector saw individual tooth brushers and toothpaste kept in the home’s laundry facilities. A member of staff was asked the reason for this and said this is where many service users brush their teeth. It would seem that this practice has long been established in the home and has gone unchallenged. This practice must stop. It is institutionalised and unacceptable and poses a potential health and safety risk to the service users. There was no information available to show that service users have a health care plan. However, there was evidence in the records that the service users are supported to access NHS healthcare facilities and access visits to their GP. Some service users have their weight monitored at facilities outside the home. This is not an ideal situation for the service users. Suitable scales should be purchased in order that service users weights can be monitored in the home. A recommendation is made in this report about the matter. The home’s medication system was audited and the medication for two service users was checked. One medication was accurate. One medication could not be fully reconciled with the records kept by the home. This was due to a medication not being carried forward onto the current MAR (Medication Administration Record) sheet. This was discussed with the staff at the home who agreed to take immediate action to rectify the matter. The home had a stock of “homely remedies” such as Paracetamol. The current policy and procedure for this practice is that service users can take such remedies for two days prior to contact with a GP. Homely remedies should only be given with prior consent from the individual’s GP and this consent documented. All instructions relating to the dispensing of service users medication must be clearly recorded. West Haven DS0000026332.V315544.R02.S.doc Version 5.2 Page 15 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 good This judgement has been made using available evidence including a visit to this service. The service users feel that their views are listened to and acted upon, and they are protected from abuse. EVIDENCE: All service users who responded to the surveys said that they knew who to speak to if they were not happy. And five of the surveys said that service users knew how to make a complaint. The relatives who responded to the survey said they were aware of the homes complaints policy and procedure. A service user spoken to said they knew who to speak with if they had any concerns or wished to complain. The home displays a complaints policy and procedure in a suitable format for the service user. This requires updating to include the information for how to contact the Commission for Social Care Inspection. There was no complaints policy and procedure displayed for visitors to the home. This was discussed with the deputy manager. The staff records looked at showed that they had received protection of vulnerable adults training. And a one of the staff spoken with had a good understanding of the necessary actions that must be taken should there be any allegations of abuse. West Haven DS0000026332.V315544.R02.S.doc Version 5.2 Page 16 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 and 30 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The home is generally clean but action must be taken to ensure the home provides a safe and well-maintained environment. EVIDENCE: Five of the surveys received by the commission for Social Care Inspection said that the home is always fresh and clean. As part of this visit a tour of the home was carried out and the home was generally clean and odour free. The lounge areas are comfortable and homely and a service user’s room had been personalised by the individual. The West Yorkshire Fire Service informed the organisation of the necessary works that need to be carried out. No work has yet been completed and the timescales given to carry out such work and has now past. During this visit the inspector was advised that quotes have been obtained for the fire safety work. West Haven DS0000026332.V315544.R02.S.doc Version 5.2 Page 17 However, the organisation must give outstanding fire safety work priority in order to ensure the health and safety of the service users and the staff. The external back door was sticking and not opening and closing freely. All fire doors must kept in a good state of repair in order to meet fire regulations. The interior doors were seen held open by door wedges. This is not good practice. The current practices in relation to fire safety are not acceptable and do not ensure the health and safety of the service users and the staff working in the home. The home must complete an up to date fire risk assessment and send a copy of this to the CSCI. A letter of concern has been issued to Catholic Care and requirement made in this report relating Health and safety in the home. A tour of the home was carried out. The bathrooms are in particular need of repair to ensure they are fit to be used by the service users. These areas should provide a homely environment for service bathing and personal care needs. Two windows did not have the required window restrictors and a removed cupboard has left a wire exposed in the wall. These areas must be made safe as a matter of urgency. Communal soap and towels were seen in the toilets and bathrooms. This poses a potential cross infection risk to the service users. Suitable paper towel dispenses must be fitted to communal areas. The laundry facilities were seen and were well organised. However, a bottle of bleach was left on the laundry room sink. All potentially harmful substances must be kept in a locked (COSHH) cupboard. The organisation must undertake a survey of the premises. The necessary repairs must be carried out to ensure the home is in a good state of repair externally and internally. West Haven DS0000026332.V315544.R02.S.doc Version 5.2 Page 18 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. This judgement has been made using available evidence including a visit to this service. The staff work hard to support the service users. The lack of specific training and sufficient numbers of staff does not ensure the service users are fully supported. The home’s recruitment policy and procedure requires some improvement to ensure it is sufficiently robust to protect the service users. EVIDENCE: The service user surveys said that the staff always listen and act on what they say. The relative surveys said that they are satisfied with the overall care provided at the home. The service users were seen being treated well by the staff. A service user spoken with said they were very happy living at the home and liked the staff who cared for them. The inspector did see the service users interacting well with the staff and there is relaxed and homely atmosphere in the home. West Haven DS0000026332.V315544.R02.S.doc Version 5.2 Page 19 The records for three staff working in the home were audited. Two of the records held the required information. The other record examined did not have a full employment history. All staff should have a full employment history and any gaps should be explored. A discussion took place with a representative of the organisation regarding the safe keeping of satisfactory police checks, Criminal Record Bureau (CRB) checks. The information received by the CSCI shows there is currently a shortage of staff cover in the home. It appears that there has been no staff cover provided for sickness. This has caused further concern regarding staffing levels where staff has taken their holiday entitlement. The organisation must take action to ensure sufficient numbers of staff are employed at the home. The deputy manager said that four staff has achieved NVQ (National Vocational Qualification) level 2 or equivalent in care. Three of the staff spoken with said they had received induction training at the home. One of care staff said they had completed LDAF (Learning Disability Award Framework) accredited training. Two training records were audited. Both showed the staff had undertaken training in adult protection, infection control, health and safety, food hygiene, oral hygiene and movement and handling. The deputy manager said that staff had not received training this year. This should be addressed. The organisation should ensure there is a training and development plan. Staff should have five paid training and development days (pro rata) per year. There was no record of fire training being undertaken by the staff (see standard 42). One of the staff has completed training in dementia care. However, similar training should be extended to all staff. This will assist the staff in providing the care that may be required by an older person. West Haven DS0000026332.V315544.R02.S.doc Version 5.2 Page 20 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): 37,39,41 and 42 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The current management arrangements do not sufficiently ensure service users benefit from a home a well run home. Generally, the home is run in the best interests of the service users. The health, safety and welfare of the service users, and the staff, is not sufficiently promoted and protected. EVIDENCE: The registered manager is currently taking extended leave from the home. The deputy manager advised that there is currently no responsible person for the management and running of the home. This is not acceptable. The organisation must appoint persons suitable for the management of the home West Haven DS0000026332.V315544.R02.S.doc Version 5.2 Page 21 during the registered persons absence. The CSCI must be notified in writing when the appropriate arrangements have been made. There is some quality monitoring carried out at the home. There are monthly staff and service user meetings. In addition, there are quality visits made by a representative of the organisation. Service users are supported during meetings to air their views and make decisions about what happens in the home. A service users spoken to said they are able to discuss and plan trips out in their meetings. The fire records were checked. There were some gaps in the weekly recording of the fire alarm system. There was no record of emergency lighting checks being carried out. However, staff advised that the appropriate professional checks the emergency lighting every six months. There should be visual checks carried out on the emergency lighting on a daily basis. And weekly checks of emergency lights carried out as part of the fire alarm testing. There are fire drills carried out at the home that service users are involved in. But there was no evidence available that staff has undertaken fire safety training. This is not acceptable. All staff must complete fire safety training and have six monthly updates in this training. A requirement is made in this report regarding this matter. West Haven DS0000026332.V315544.R02.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 1 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 3 2 X 1 X 2 X 2 1 X West Haven DS0000026332.V315544.R02.S.doc Version 5.2 Page 23 YES 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 YA6 Regulation 15.1 & 15.2(a) Requirement The registered person must ensure all service users have a care plan. And the service users know that their assessed and changing needs are reflected in their individual plan. The registered person shall so far as is practicable enable service users to make decisions with respect to the care they receive. The decisions made by service users must be recorded in their individual plan of care. The registered person must ensure that risk assessments are kept up to date to ensure they reflect the current level of risk identified for the individual service user. The registered person must ensure that the service users preferred and required personal support is recorded in their plan of care. The registered person must take action to ensure the service users privacy and dignity is respected. Service users brushing their teeth in the home’s laundry DS0000026332.V315544.R02.S.doc Timescale for action 22/01/07 2. YA7 12.2 22/01/07 3. YA9 13.4(c) 22/01/07 4. YA18 12.2 22/01/07 5. YA18 12.4 (a) &13.3 22/11/06 West Haven Version 5.2 Page 24 room must stop. 6. YA20 13.2 The policy and procedure for medication must be followed to protect the service users. The medication records must be kept up to date. All medication carried forward from the previous month must be transferred onto the current MAR sheet. 7. YA24 23.4 The registered person must complete the required fire safety works as requested by West Yorkshire Fire Service. Previous timescale of 31/12/05 not met. The home’s fire risk assessment must be reviewed and take into account the current staffing levels in the home and the present fire risks to service users and care staff. A plan and timescales for such works must be sent the CSCI by the date stated opposite. The organisation must undertake 22/01/07 a survey of the premises. The necessary repairs must be carried out to ensure the home is in a good state of repair externally and internally. The external back door must be repaired to ensure it opens and closes properly and allows unrestricted access in and out of the home. Window restrictors must be fitted to the identified windows. The bathrooms must be repaired and redecorated to ensure they West Haven DS0000026332.V315544.R02.S.doc Version 5.2 Page 25 22/11/06 22/12/06 8. YA24 23.1 & 23.2 9. YA30 13.3 10. YA33 18.1(A) 11. YA37 38.2 (e) 12. YA6 YA41YA42 17 provided suitable facilities for service users personal care needs. The registered person must make suitable arrangements to prevent infection and the spread in infection at the care home. The use of communal soap and hand towels must stop. Liquid soap and paper towels should be fitted to communal areas accessed by the service users and the staff. The registered person must ensure there are sufficient numbers of staff on duty to meet the health and welfare needs of the service users. Adequate levels of staff must be working in the care home at all times. In the case of the registered manager being absent. Arrangements must be made for another person to manage the care home during this absence and the proposed date this appointment will be made. The registered provider must ensure accurate and up to date records are kept relating to service users, and any other records required for the effective and efficient running of the home. The registered person must make arrangements for people working in the care home to receive suitable training in fire prevention. Such training must be updated at six monthly intervals. The home’s fire alarm systems must be tested on a weekly basis. In addition the emergency lighting must also be checked on a weekly basis with the DS0000026332.V315544.R02.S.doc 22/12/06 22/11/06 22/12/06 22/01/07 13. YA42 23 (d) 22/01/07 14. YA42 23.4 (v) 22/11/06 West Haven Version 5.2 Page 26 appropriate records kept. 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. 5. 4. Refer to Standard YA19 YA22 YA32 YA35 YA34 YA39 Good Practice Recommendations All service users should have a health care plan. The complaints policy and procedure should be displayed and accessible for all visitors to the home. All staff should receive training that meets the specific needs of the service users. The organisation should develop and staff training and development plan. The employment history of all staff working at the care home should be recorded in the staff files kept. The organisation should develop quality assurance and quality monitoring systems. The results of surveys should be published and made available to service users, family and friends, and any other interested parties. West Haven DS0000026332.V315544.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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. 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