Inspection on 23/07/08 for White Acres

This inspection was carried out on 23rd July 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

White Acres 12/11/09

White Acres 20/03/07

White Acres 28/09/05

White Acres 11/07/05

White Acres 28/10/04

White Acres 22/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/11/2008.

CARE HOME ADULTS 18-65 White Acres 15 Leicester Road Shepshed Loughborough Leicestershire LE12 9DF Lead Inspector Ruth Wood Unannounced Inspection 23rd July 2008 01:15 White Acres DS0000001681.V368941.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 White Acres DS0000001681.V368941.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. White Acres DS0000001681.V368941.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service White Acres Address 15 Leicester Road Shepshed Loughborough Leicestershire LE12 9DF 01509 502845 01509 502845 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) Prime Life Ltd Sandra Roberts Care Home 12 Category(ies) of Learning disability (12) registration, with number of places White Acres DS0000001681.V368941.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To be able to admit the named person of category LD/SI as identified in correspondence with the previous registration authority dated 11/05/00. To be able to admit the named person of category LD/ MD as identified in correspondence with the previous registration authority dated 10/08/01. 20th March 2007 Date of last inspection Brief Description of the Service: White Acres is part of the Prime Life Group and is situated in Shepshed, Leicestershire, in a residential area close to local amenities. White Acres is a care home providing personal care and accommodation for up to twelve people with a Learning Disability; on the day of the inspection the home was fully occupied. Accommodation is provided over two floors with access between the floors being via stairs. Communal areas are provided on the ground floor, with bedrooms located on the ground and first floor. The home has twelve single bedrooms, one of which has an en-suite facility. There is a rear garden, which is accessible to all the people who currently live at the home. The home is accessible by private or public transport. There is a limited parking area to the front of the building and on-street parking. Information about the home is available in the service users guide, which at the time of this inspection required updating. A copy of the most recent CSCI inspection report is available in the home’s entrance area. Current fees at the home range from £347.00 to £792.00 per week. The service provider should be consulted directly for details of any services provided, which are not included in these fees. White Acres DS0000001681.V368941.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The inspection visit took place on a weekday between 13:15pm and 19:15pm. Before the inspection the last inspection report, together with information received about the service since that inspection was reviewed. We spoke to two people who live in the home about their needs and how staff help to support them. We looked at their support plans and spoke to staff and the manager about how they delivered that support. We spoke to other people who live at White Acres about the kinds of activities they did and the relationship they have with staff and how they let them know if they aren’t happy. We spoke to the manager about the policies and procedures in the home that help to keep people safe and looked at records that show how people are supported to manage their finances and medication. One staff member was spoken to at length about their experiences of recruitment and training and we examined three people’s training and recruitment records. All communal areas and most people’s bedrooms were seen as part of the inspection. What the service does well: The people who live at White Acres appear to get on well with the staff. One person said, “I like the staff here” another person said, “The staff look after us well”. Relationships are friendly and open and people appeared comfortable with staff and able to speak to them freely. People said that they had regular meetings where they could tell staff things, say if they weren’t happy and could talk about the kinds of trips and activities they would like to do. People have good access to health care services and staff support them to access these. Doctors, dentists and opticians are all located close by in the village. One person said my doctor is “just up the road” and my dentist and optician “ are in town”. People’s support plans are clearly written and explain how staff can help to meet their needs. The plans are also regularly reviewed so that staff know when people’s needs have changed. One person who lives in the home has a paid and a voluntary job, some people go to college and other people go to a special day centre for people with White Acres DS0000001681.V368941.R01.S.doc Version 5.2 Page 6 learning disabilities. People go on holiday each year with staff support and also go out regularly on day trips. People like the food in the home, “We get good meals here”; the food is home cooked and people have a choice about what they would like to eat. What has improved since the last inspection? What they could do better: Information in the service users guide needs updating so that people who want to move into the home have accurate information. People should also have clear information about what is covered by the home’s fees. Information about the home should be presented in way that means it is easy to read and understand. Information about how people are supported to manage their medication should be kept in the medication records as well as in their support plans. There have been some changes in the Regulations about how certain drugs (called controlled medication) should be stored in care homes. This means that the people who own White Acres must make sure that the home has a special metal cabinet, fixed to a solid wall so that they can store these drugs if any of the people living in the home need to take them in the future. People such as relatives and commissioning social workers should be asked what they think about the quality of service provided in the home. Staff training on how to deal with people who sometimes have behaviour that challenges should be updated annually. The registered manager and staff would also benefit from an update in their knowledge of current multi-agency procedures in place, which safeguard and protect people and it is recommended that they access training in these areas, available from the local authority. The manager must also make sure that she tells the Commission about any incidents that adversely affect the wellbeing or safety of people who live in the home. Finally some improvements are needed to the home’s environment: • • The floor covering in the upstairs bathroom need changing to eliminate the strong smell of urine. The manager must assess the risks posed by the low guardrail at the top of the stairs and make sure that any risks she identifies are eliminated or minimised. White Acres DS0000001681.V368941.R01.S.doc Version 5.2 Page 7 • Suitable provision should be made for those people who live in the home who smoke. 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. White Acres DS0000001681.V368941.R01.S.doc Version 5.2 Page 8 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 White Acres DS0000001681.V368941.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is adequate Good assessment procedures ensure that people’s needs, can be met. Some information in the service user guide is inaccurate and in a format not readily accessible to some people who live or may choose to live in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager gave the inspector a copy of the service user guide. This still contains information about a previous registered manager and therefore needs updating. The guide is in a standard format, unsuitable for many of the people who live or who may wish to live in the home. The registered manager commented that the guide should really be available in a format with pictures to make it easier to understand. The manager was not aware of any further guides available for service users. When examining the systems in place for safeguarding people’s finances, it was noted that the bus fare for a staff member who had accompanied a person to a hospital appointment was paid for by the person themselves, out of their personal allowance. The senior staff member and manager confirmed that this was usual practice within the home if there was no staff member available who could drive the home’s transport. They also confirmed that people who live in the home pay for the cost of meals of staff members who accompany them if they have a meal outside the home. While reference is made to nominal charges being made for the use of transport in the Service User Guide, no reference is made to the people living at the home paying for staff meals if White Acres DS0000001681.V368941.R01.S.doc Version 5.2 Page 10 they are accompanied on an outing. This information should be made clear within the Statement of Purpose so that individuals and commissioners of the service are fully aware of what is included in the fees for the service. There have been no new admissions to the home for over three years so it was difficult to assess the admission process, however the registered manager stated that they would support people to make visits to the home before they moved in and assess their needs before offering a place in the home. Support plans for those people living in the home contain assessments of need covering all aspects of physical and emotional care. White Acres DS0000001681.V368941.R01.S.doc Version 5.2 Page 11 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, 9 Quality in this outcome area is good Support plans accurately reflect people’s needs, which helps staff meet people’s needs consistently. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two people spoke about their needs and how staff support them. This information is reflected accurately in their support plans, which show evidence of regular review. Discussion with one person’s key worker showed that they have a good understanding of the person’s needs and know how to access more information if required. Support plans contain risk assessments, relating to the kinds of activities that people take part in, such as going out unaccompanied and using public transport. People were observed being given choices in relation to activities, food and have also been involved in choosing the décor of their bedrooms. Support plans also contain a ‘Who am I’ booklet, which gives information about the person’s past and the kinds of things that they like doing. Plans also contain information about how the person prefers to communicate and the kind of strategies that staff may use to communicate with people effectively. White Acres DS0000001681.V368941.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, 17 Quality in this outcome area is good People have access to vocational and leisure activities are supported to maintain contact with family and friends and enjoy good food in pleasant surroundings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person who lives at White Acres has a personal timetable displayed on the notice board and staff are aware of what each person is doing each day. Most people go out during the day to specialist day centres or further education colleges; one person has both a paid and a voluntary job. People spoke positively about their daytime activities when they returned home. One person spoke about going to the local college to “do reading and writing” and said that they also liked doing jigsaws with the staff when they were not at college. All the people who live in the home are going on holiday to Caistor in September and several people spoke enthusiastically about this and showed the brochure to the inspector. One person said that they weren’t “that bothered about going” but the manager had persuaded them they would have White Acres DS0000001681.V368941.R01.S.doc Version 5.2 Page 13 a good time. Several people spoke about the kinds of trips they went on such as to Twycross Zoo and the Tram museum. People go on these trips using the company driver and minibus. Some people go out by themselves in the evenings using a taxi or bus. There are generally only two members of staff on duty at all times in the evening which could limit the opportunities for those people who require support to go out in the evenings. However it was noted that most people appeared tired after their daytime activities and several people got ready for bed after tea. The manager confirmed that most people were tired during the week but there was the opportunity to go out more at the weekend. A garden fete is held every year and the people who live in the home, help to run stalls and sell raffle tickets. Proceeds from the event go towards the ‘comfort fund’, which helps to pay for holidays and trips. A rota outlining people’s responsibilities for tasks in the home, such as feeding and cleaning the pet rabbit and helping with food preparation is displayed in the kitchen. People appeared generally positive about taking part in these tasks. People spoke about their relatives visiting and how they were supported to ring them on a regular basis. Dinner on the evening of the inspection was a choice of homemade ham, cheese and potato pie or homemade vegetable crumble. One person helping to set the table said, “We get good meals here”. People complete a choice sheet, saying which option they prefer. Menu records indicate that a balanced, nutritious diet is served. White Acres DS0000001681.V368941.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, 20 Quality in this outcome area is good People’s health and personal care needs are well met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People explained how staff help them with their personal care needs, “staff help me in the bath because I can slip over”. This information is recorded in support plans and staff are also able to explain how they support individuals. People’s access to health care is good, one person said that their doctor was “just up the road” and their dentist and optician “ were in town”. Support plans listed people’s visits to health care services, the outcome of the visit and the kind of support the person needs from staff members to access a particular health practitioner. ‘Grab sheets’ containing essential health information to take to accident and emergency are in place and one person explained how staff had accompanied them when they had been admitted to hospital. The medication trolley is stored appropriately. Staff who administer medication shadow an existing member of staff for approximately three weeks; the registered manager then assesses their competence. Some staff have also completed a course in the administration of medication. Only one person currently administers some of their own medication – the assessment for this could not be located within their support plan; it is recommended that White Acres DS0000001681.V368941.R01.S.doc Version 5.2 Page 15 copies of assessments relating to medication be included in the medication administration file. One person was able to explain how they looked after and used one of their inhalers but that staff kept and helped them to use the other inhalers that needed to be taken regularly. The manager explained that this was to ensure that the person took the regular medication correctly. Details of when people’s medication was last reviewed are contained within support plans. Amendments to Regulations relating to the Misuse of Drugs mean that the home must have separate storage for controlled medication. This should be a metal cupboard of specified gauge with a specified double locking mechanism. It should be fixed to a solid wall or a wall that has a steel plate mounted behind it with Rawl or Rag bolts. No controlled medication is currently stored or administered in the home. White Acres DS0000001681.V368941.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, 23 Quality in this outcome area is good The views of the people who live in the home are listened to and procedures and practice in relation to safeguarding are sufficient to ensure that people are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The relationship between the people who live and work in the home is open and friendly and people appear comfortable in staff’s presence. People said that they could tell staff if they had a problem, “I tell the staff if I’m not happy”. Formal, recorded ‘residents meetings’ are also held and people can raise any concerns that they have within this forum. Earlier in the year people raised a concern about the attitude of a staff member and this was dealt with promptly and appropriately. Consideration should be given to ensuring that people who live in the home have a personal copy of the complaints procedure in an easy-read format so that they know that they can also speak to someone outside of the home if they ever needed to. Some staff members have not received training in safeguarding vulnerable adults since June 2006 and it is recommended that this training be updated annually so that all staff are aware of their obligations and responsibilities under the safeguarding process. It is also recommended that the manager and staff access safeguarding training provided by the local authority so that they are aware of the current multi-agency procedures in place for alerting and responding to any incidents where people who live in the home may be at risk. Staff members are aware of certain triggers that may lead to certain people behaving in a way that challenges. Records show that some staff have received NAPPI training (a system of non-abusive psychological and physical White Acres DS0000001681.V368941.R01.S.doc Version 5.2 Page 17 intervention). Again consideration should be given to ensuring that all staff have access to this training on an annual basis. One resident said that another person who lived in the home sometimes hit them and other people or broke their glasses. This was confirmed during discussion with the registered manager, who said that these incidents had been referred to commissioning social workers and other professionals involved in their care and was recorded in the care file. Such incidents that affect the well-being or safety of people living in the home should also be notified to the Commission for Social Care Inspection as stated in Regulation 37. Clear records are kept for all transactions relating to people’s monies. Two people’s records were checked and there was a clear audit trail, which showed where money had come from. Receipts were in place for each transaction and staff sign after each transaction. Balances of monies held are checked regularly and the two balances and records checked during the inspection were accurate. Staff have Criminal Records Bureau checks and their names are checked against the vulnerable adults register before they come to work in the home. This helps to make sure that only suitable people work at White Acres. White Acres DS0000001681.V368941.R01.S.doc Version 5.2 Page 18 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, 30 Quality in this outcome area is adequate Some improvements are needed to ensure that the home’s environment is pleasant and fresh smelling throughout and meets the needs of all the people living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager said that the maintenance man visits twice per week and there is a book for recording any problems and the date that they are rectified. The manager said that she had audited the environment in January and some bedrooms were due to be re-decorated and new bed linen has already been purchased. This was seen. People’s bedrooms are individually decorated and contain personal items. The local environmental health department inspected the home on 17 June 2008 and awarded it two stars, judging the arrangements in relation to food hygiene as satisfactory. Recommendations made by the department have been met. Although the upstairs bathroom was clean and tidy there was a strong smell of urine in the room. The manager said that she believed that the smell had White Acres DS0000001681.V368941.R01.S.doc Version 5.2 Page 19 impregnated the floor covering and that this needed replacing. This should be done as a matter of urgency so that the room is pleasant and comfortable for people to use. A guardrail at the top of the stairs, immediately outside the bathroom is comparatively low and could pose a health and safety risk given the changing profile of the people living in the home. The manager agreed to conduct a risk assessment based on the people whose rooms are located on this floor and/or who used the bathroom and to consider whether the height of this rail needed to be changed. Since the introduction of new legislation, the home has been designated a nonsmoking environment. However there is no designated area within the home for those people living there who continue to smoke. This means that people have to smoke outside, even in poor weather; one person said that if it is raining, they go out with an umbrella. The registered manager agreed to consult appropriate guidance and ensure that suitable arrangements are made for the people living in the home who continue to smoke. White Acres DS0000001681.V368941.R01.S.doc Version 5.2 Page 20 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, 35 Quality in this outcome area is good Recruitment and training practice help to ensure that staff are competent and suitable to support people. Sufficient numbers of staff are not always available to meet the required staffing levels identified by the manager, as necessary to consistently meet people’s needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector discussed the recruitment process with a staff member on duty. They had completed an application form, come to the home for a formal interview and met with the people who live at the home. Two references were sought and they had a Criminal Records Bureau check and their name checked against the vulnerable adults register before starting work in the home. This information was confirmed by examining the staff member’s records. Two other staff members’ records demonstrated that recruitment information had been gathered before they started work in the home but one staff member had only one written reference on record. The staff member explained that they had undergone a formal induction period and had shadowed staff members when they first started work. They had now achieved a National Vocational Qualification (NVQ) in Social Care at level 2 and had undertaken NAPPI training and food hygiene and fire safety training. They White Acres DS0000001681.V368941.R01.S.doc Version 5.2 Page 21 had not received specific training in working with people with learning disabilities but staff records show that other staff members have competed an award under the Learning Disability Qualifications programme. (LDQ) A training matrix is in place, which shows when each staff member has completed certain types of training. Four staff members at the home have completed a NVQ in social care at level 2 and two staff members are currently undertaking a LDQ award. The registered manager discussed recent difficulties in ensuring that all shifts in the home were covered due to staff taking annual leave, sick leave and leaving the company. This had had a particular impact on night shifts where instead of two waking night staff there had been occasions where one person had slept in at the home, with one staff member doing the waking shift. The manager said that it as also difficult to ensure that there was always a senior member of staff on duty. She explained that she was currently recruiting extra ‘bank’ staff to rectify this issue. White Acres DS0000001681.V368941.R01.S.doc Version 5.2 Page 22 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, 42 Quality in this outcome area is good The views of people who live in the home inform the way the service is run. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has worked at the home for a number of years and is currently undertaking her Registered Manager’s Award and her National Vocational Qualification in Social care at level 4. The manager said that it was difficult at times for her to find time to manage as she was required ‘on the shop floor’ for large parts of the time that she was on duty. Not having access to a computer with an internet connection also made it difficult for her to keep up-to-date with latest guidance and good practice. The responsible individual for White Acres has stated that a request for the return of the AQAA (Annual Quality Assurance Assessment) for the service was not received and that the company therefore downloaded a copy of the White Acres DS0000001681.V368941.R01.S.doc Version 5.2 Page 23 document from the Commission’s website. This was not completed before the inspection but was completed and returned on 06/08/08. There was no evidence of a formal quality assurance assessment having taken place in the home since 1st December 2006 and the registered manager said that she had not been made aware of Prime Life’s arrangements for this. However the manager and staff do listen to and record the views of the people who live in the home and these inform the kinds of activities and events that take place. One person said, “We have ‘residents meetings’ and talk about different things with the staff.” Staff members confirmed that staff meetings are also held in the home. The views of other stakeholders and the representatives of people who live in the home (such as commissioning social workers and relatives) should also be sought as part of a process of ongoing assessment and improvement of the quality of the service. Labels on plugs indicate that portable electrical appliances were tested in November 2007. The training matrix demonstrates that staff receive training in fire safety, food hygiene, manual handling and first aid. This was confirmed through discussion with staff. Fire records demonstrate that equipment is tested weekly and that the people who live and work in the home are involved in fire drills. The registered manager is currently updating the home’s fire risk assessment. While risks are clearly identified, the way to reduce these risks is not always as clearly stated. It is recommended that the manager review the assessments to ensure that they always give sufficient and detailed information. White Acres DS0000001681.V368941.R01.S.doc Version 5.2 Page 24 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 2 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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X White Acres DS0000001681.V368941.R01.S.doc Version 5.2 Page 25 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&5 Requirement Timescale for action 15/09/08 2 YA20 13(2) 3 YA23 37 4 YA24 13 (4) The Statement of Purpose and Service Users’ Guide must accurately reflect the current management and staffing provision within the service. It should also state clearly which aspects of the service are included and not included in the fees charged. This is to ensure that people have accurate information to make an informed choice about the service. Secure storage must be put in 31/10/08 place for controlled drugs to meet the requirements of the Misuse of Drugs and Misuse of Drugs (Safe Custody) (Amendment) Regulations 2007 Incidents that adversely affect 24/07/08 the well being or safety of people living in the home should be notified to the Commission for Social Care Inspection A risk assessment must be 15/08/08 completed in relation to the potential dangers of the low rail on the stairs on the upstairs landing. Action must be taken DS0000001681.V368941.R01.S.doc Version 5.2 White Acres Page 26 5 YA30 16 (2) to eliminate or minimise any identified risks. The floor covering in the upstairs bathroom must be replaced to ensure that the persistent odour of urine in the room is eliminated. 31/08/08 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 YA1 Good Practice Recommendations The service user guide should be readily available in an easy read format so that it is accessible to the people who live in the home and to people who may wish to live in the home. Copies of assessments relating to medication should be kept in the medication administration file. Consideration should be given to ensuring that people who live in the home have a personal copy of the complaints procedure in an easy read format, so that they know that they can also speak to someone outside of the home if they want to. All staff should have access to NAPPI training on an annual basis. It is recommended that the manager and staff access training provided by the County Council in the local multidisciplinary protocols for safeguarding adults, to ensure that they are fully aware of current local practice. Suitable provision should be made for those people living in the home who smoke. The home’s quality assurance process should also seek the views of involved stakeholders such as relatives and commissioners of services. 2 3. YA20 YA22 4. 5. YA23 YA23 6. 7. YA24 YA39 White Acres DS0000001681.V368941.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 White Acres DS0000001681.V368941.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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