Inspection on 14/05/08 for White Waves

This inspection was carried out on 14th May 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

White Waves 12/11/08

White Waves 11/10/06

White Waves 26/10/05

White Waves 30/06/05

White Waves 14/12/04

White Waves 19/06/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE White Waves 17-19 Seal Road Selsey Chichester West Sussex PO20 0HW Lead Inspector Ian Craig Unannounced Inspection 14th May 2008 10:25 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address White Waves DS0000060930.V363175.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service White Waves Address 17-19 Seal Road Selsey Chichester West Sussex PO20 0HW 01243 602379 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) whitewaves@fsmail.net Platinex Limited Mrs J M Satchell Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Only Persons Over sixty five (65) Years of age to be admitted. Date of last inspection 11th October 2006 Brief Description of the Service: White Waves is a privately owned care home registered to provide accommodation and personal care for up to nineteen elderly (over 65 years) persons. The registered provider is Platinex Limited for whom Mr Satchell is the responsible individual. Mrs J M Satchell is the registered manager. White Waves is a detached two-story building situated in a residential road in the village of Selsey. It is a short distance from local shops and the seafront. Accommodation is arranged in thirteen single and three double rooms. A lounge and dining area provide communal space on the ground floor. There is a passenger lift, which serves all rooms with the exception of three, which are on a mezzanine level. The home’s weekly fees range from £335.00 to £650.00. White Waves DS0000060930.V363175.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 0 star. This means the people who use this service experience poor quality outcomes. The inspection was unannounced and lasted for 6 hours. Two inspectors were involved in the visit: Mr. Ian Craig and Mrs. Elizabeth Palmer. Evidence for the inspection came from the following: • Social services staff, including information regarding safeguarding procedures • Relatives of residents • Interviews with staff • Interviews with residents • Survey forms completed by residents and their relatives • Observations of residents and staff at the home • Discussions with the home’s manager • A tour of the premises • The home’s documents, records and policies and procedures • Information in the Commission records, including communications from people who wished to withhold their identity or did not give their identity. Registered service are required to complete an annual Quality Assurance Assessment (AQAA). Information in this document has also been used for the purposes of this report. What the service does well: The home carries out assessments of need of those referred for possible admission. This helps the home to assess if they can meet the person’s needs. Each person has a care plan with details of how needs are to be met by staff. These include assessments of risk for each person showing that measures are taken to promote residents’ health and safety. White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 6 Medication is securely stored and is administered according to pharmaceutical guidelines. There are a range of activities and stimulation for the residents. Residents stated how they like living at the home. Comments included the following: • ‘It’s very good here.’ • ‘It’s wonderful.’ • ‘The staff are marvellous.’ • ‘The food is excellent.’ • ‘I can choose from 2 main courses for the lunch time meal.’ Five survey forms were returned. These gave many positive remarks about the home, which is said to be ‘spotlessly clean,’ and that the staff are kind and helpful. One person said that staff respond promptly when the call point is used. The home is well maintained, clean and comfortable. What has improved since the last inspection? What they could do better: The home needs a period of stability in its management and staff team. The registered manager has had extended periods of leave in the 2 year period prior to January 2008. Six staff have left the home in the last few months. It was clear during this inspection that some staff, including the manager, are working excessively long hours to compensate for the absence of these care White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 7 staff. This has the potential to place residents at risk due to staff tiredness. It was also noted that there is a lack of cohesion in how the home runs, with disagreement and misunderstanding between some of the staff and the manager. For instance, some staff are of the understanding that they are not permitted to access residents’ records and care plans, and one staff who has recently started work has not seen any care plans and was unaware of a person’s lifting needs as set out in the care plan. Staff do not always sign a record when they complete a daily running records for residents, and much of the daily recording of significant events for residents is collectively recorded in a diary daybook. This does not promote the confidentiality of records or the effective monitoring of individual’s needs. It was not possible for the manager to tell which staff member had administered medication to residents from the initials given on the medication recording sheets. Staff have been recruited without the required checks, which places residents at risk. Not all staff have received training in moving and handling, including the manager. Additional staff need to be trained in first aid. The manager has not attended any training in either care, health and safety, medication or in managing a care home, although she states she intends to start the NVQ level 4 course in care and management in the near future. Keys are offered to residents so that they can lock their bedroom door if they are capable, but these locks are not of a suitable type as they do not allow staff access in an emergency. 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 Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments of needs of those referred to the home for possible admission are carried out. This ensures that the home can meet residents’ needs. EVIDENCE: Information about the service is available in the entrance hall. Records were looked at for those residents recently admitted to the home and those considering a move into the home in the near future. These include assessments of care needs being carried out before the person moves into the home. The assessments include details of care and social needs. White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 10 A resident described how she decided to move into the home and how she was assisted by the home in this. Survey forms referred to having opportunities to look around the home before moving in. White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a lack of understanding between the home’s management and some of the care staff regarding the agreed way to provide care. This has the potential to affect residents’ well being, treatment and safety. Each person has a care plan outlining how care is to be delivered by staff. EVIDENCE: Care plans were looked at for each of the residents living at the home. These include details of personal care, social needs, religious and cultural needs and risk assessments for specific needs where risk has been identified, such as for pressure sores and risks associated with a resident who administers his or her White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 12 own medication. Where a resident needs help with moving and handling there are guidelines for staff to follow. Staff completing the care plans record their signature and date on the plans. Records show that the home liaises with health professionals to arrange for checks and treatment. This includes general practitioners, opticians, dentists, chiropody services and the community nursing team for prevention of pressure sores. Daily running records are maintained for each person. These are collectively recorded in a daybook diary for all residents. It was noted that many of the entries were not signed by the staff member completing the entry. Some of this information was transferred to typed records in individual files. Many entries remain exclusively in the daybook for all the residents on the same page. It was unclear how this information is used and how confidentiality is ensured. Discussions took place with the manager about maintaining these records individually rather than collectively. Information was received by the Commission from social services prior to the visit, and from staff both before and during the visit, that care staff do not have access to care records. A staff member stated that she has not seen a residents’ care plan since starting work in the home 3 weeks previously. This person stated that as a result of this she was uncertain about the lifting arrangements for the person. It was noted that the staff member was not following the care plan. This person also stated she does not know that the person needs to have a cream administered. This was discussed with the manager and administrator, who maintain that care records are available to staff. A recently appointed staff member stated that she was confused by being given conflicting instructions from different staff. There were clear disparities between a senior carer and the manager about how to deal with one person’s needs. A staff member alleged that Mrs. Satchell deliberately failed to enter a record of an accident to a resident, whereas the manager stated that the event was not an accident. The manager also reported that the staff member had acted independently, and without consultation with the home’s manager, or the resident’s general practitioner, in administering another resident’s prescribed cream to the resident. Staff expressed the view that residents’ care needs are met. Residents state that they are treated with respect and that the staff are kind. Medication procedures were looked at. Signatures are recorded to show that prescribed medication is administered. Procedures for the storage and administration of controlled medication meet Royal Pharmaceutical Society guidelines. Staff receive training in medication procedures. White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 13 The Commission was informed that the manager administers medication to residents, but has not received training in this. Records show that Mrs. Satchell is only involved in witnessing, and recording, that controlled medication has been administered by another staff member who has received medication training. Staff record an initial each time they are responsible for administering medication. The manager could not tell which initial corresponded with the staff member, meaning that it was not possible to tell who had administered the medication. Mrs. Satchell agreed that it would be beneficial for the home to maintain a sample record of each staff member’s initial alongside their name. White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a range of activities and are able to exercise choice in how they spend their time. A nutritious diet is provided. EVIDENCE: There are numerous notices around the home displaying forthcoming activities. These include the following: • Exercises every 2 weeks • ‘Sing a longs’ every Monday afternoon • Reminiscence once a week • Seasonal parties • Accompanied walks White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 15 The manager stated that the provision of activities will be extended and that a ‘pat dog’ will be shortly provided for the residents. Information was received that since the manager’s return a resident was stopped from pursuing his previously agreed gardening activity. This was discussed with the manager and was denied. She added that a current resident is helping prepare window boxes with plants for the summer. Residents confirmed that activities are provided. One resident described how she likes to spend time in her room creating her own craft items for a local charity. Another resident prefers to spend time in the lounge, reading and observing daily comings and goings. Some residents have their own daily newspaper delivered. The two residents spoken to on the day of the visit described the food as ‘excellent’ and ‘very good.’ Both residents stated that there is a choice from two main courses at lunchtime. One staff member stated that one resident has liquidised food, but at the weekends every resident has liquidised food simply to make life easier for the staff. Comment was also made that all meal items are pureed together. Evidence from the following could not substantiate this: observation, discussions with the cook and the manager, and discussions with the residents. Pureed meals did not consist of all items being blended together but were liquidised separately. Evidence showed that the number of pureed meals provided varies according to the needs of the residents and that the cook acts on the instructions of the care staff. The care plan for one resident needs to be updated to show that pureed meals should be provided. Residents are able to have wine and beer if they wish. White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s recruitment procedures do not protect residents. The complaints procedure is available to residents and their relatives, although it is unclear how the home dealt with a recent complaint. EVIDENCE: The home’s complaints procedure is contained in the home’s literature. A revised complaints procedure was seen. Residents state that they would speak to the staff if they had a concern they wished to raise. A logbook is used to record complaints and any investigation and outcomes. A recent complaint was recorded and crossed out by the manager with an entry that social services are dealing with the matter under the safeguarding adults procedures. There was no further record of the outcome of any investigation by social services or any action the home may need to take. White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 17 Staff confirmed that they have attended training in abuse awareness. Records show that 4 staff attended this training in 2004, indicating that the training needs to be extended to all staff. Correspondece was received from the manager folowing the inspection stating that two staff atended adult protection training in 2008. Two of the three staff interviewed demonstrated an awareness of abuse and the agreed procedures. One staff member stated that she has not read any procedures or literature on the subject. The manager has not attended any training on abuse awareness or adult protection procedures, but from discussion is aware of the roles of the various agencies involved in any investigations. The home has a copy of the local authority adult protection procedures. Staff recruitment procedures were looked at as part of a Commission themed inspection of the safeguarding of people who live at the home. This showed that staff have commenced work in the home before the required checks have been carried out, such as, criminal record bureau checks. White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a comfortable, clean and well maintained environment. EVIDENCE: A tour of the premises was undertaken. Bedrooms are well maintained with the exception of a rucked carpet in one unoccupied bedroom, which is a trip hazard. Residents’ bedrooms have items of personal possession such as televisions, radios and items related to hobbies. Residents can have their own telephone line if they wish. One resident stated how useful it is to have her own telephone line. Another resident uses her mobile telephone. A resident White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 19 stated that she was able to bring some of her own furniture to the home. Residents are able to have a key to their bedroom if they wish, but it was noted that the locks are not suitable as they do not allow staff access in an emergency. At the time of the visit it was understood that none of the residents has a lock to his or her bedroom door. Should a resident decide to have a key to their bedroom door then a suitable lock should be installed. None of the bedrooms have a lockable drawer or cupboard so that residents can safely store valuables. Information provided to the Commission since the inspection demonstrated that the manager has conducted security risk assessments to determine if residents are able to use a secure container in order to keep their money and other valuables safely. Alternatively residents are encouraged to leave their possessions in the office for safekeeping. The lounge and dining areas have been redecorated since the last inspection. There is a ground floor shower room and a first floor bathroom with a bath hoist for those with mobility needs. All bedrooms, except one, have an en suite toilet. The Commission received information that a ground floor bedroom is used for toileting residents on a commode when the room’s occupants are sat in the lounge. This was discussed with the manager who denied such practice takes place. The home has a passenger lift. There is a mobile hoist for helping those with mobility needs. The home was found to be clean and there was an absence of any unpleasant odours. There is a laundry with specialist washers and driers as well as a macerator for dealing with waste. White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is a shortage of staff and staff working hours have the potential that residents’ needs may not be met. Staff do not work to care plans and receive conflicting advice on meeting residents’ needs Staff recruitment procedures do not protect residents. EVIDENCE: At the time of the inspection the home accommodated 10 residents. Staffing levels show that 2 care staff are on duty from 8am to 8pm each day often with additional staff and the manager. A cook is employed for seven days a week. In the two months preceding the inspection 4 care staff have left, as well as the deputy manager and a cook. The AQAA states that 3 full time and 7 part time care staff have left the home in the last 12 months. It was noted from the White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 21 rota that the home is short staffed and as a consequence of this some of the remaining staff, including the manager, are working 16-hour shifts. In February 2008 one staff member worked three 16 hour shifts and one 24-hour period awake in a single week. Mrs. Satchell stated that this was unusual and was necessary due to staff vacancies. Mrs. Satchell also stated that she works 16 hour shifts seven days a week and never leaves the home, but that this did not affect her performance through tiredness or that it would have any longer term effects on her abilities. These hours were reflected in the staff rota for the week commencing 10th May 2008 and in February 2008. The manager states that she will be recruiting additional staff. The home has an induction procedure based on nationally recognised standards. One person stated that she received an induction after starting work a few years ago. Someone who started more recently, states he has not had induction training as set out in the induction programme, but ‘shadowed’ another staff member. This person also stated she has not received moving and handling training and is involved in the transfer of residents. She also said she has not read any of the residents’ care plans and was observed providing care which did follow the care plan of one resident. Two of the eight care staff (25 ) have attained NVQ 2 or 3 in care according to the AQAA completed by the manager. A further 2 staff are studying NVQ level 2 or 3 which will take the total to the 50 as recommended by the national minimum standards. Not all staff have received training in moving and handling. Correspondence was sent by the manager to the Comission following the inspection stating that staff have attended training in food hygiene, dementia, health and safety, safe handling of medicines and Contamination by Substances Hazardous to Health (COSHH). Records of staff recruitment procedures show that five staff have commenced work in the home before the required checks were obtained. This includes three staff who started work in the home between April and November 2007 without Criminal Record Bureau (CRB) or Protection of Vulnerable Adults (POVA) ‘first’ being obtained until March and April 2008. For the most recent person appointed to work in the home a POVA ‘first’ check has been obtained as well as a reference from the person’s most recent employer. A second reference has not been obtained. It was noted that for one person there was no record or assessment of the person’s suitability to work with vulnerable persons when information had been received indicating this was needed. White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Management of the home is poor with a lack of coordination in how care is provided. The home’s management have not been monitoring the home’s procedures for staff training, induction or staff recruitment to a satisfactory standard. The manager and staff work excessively long hours potentially placing residents at risk. Lack of staff training places the health and safety of residents at risk. White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager has been registered with the Commission since April 2004. The manager does not have any training in medication, moving and handling, care or health and safety. At the time of the inspection the manager was taking steps to register for the National Vocational Qualification level 4 in care and management. The Health and Personal Care section of this report highlights the lack of coordination in delivering care and the disagreements between some of the staff and the management. Regulations require that a representative of the owner, Platinex Care, visits the home each month and completes a report on the home. The Commission received information that this person has not visited the home for 2 years. At the inspection one staff member repeated this but another staff member stated that the monthly visits take place and the person carrying out the visits is approachable. Reports were available for each month for the preceding 12 months with the exception of August 2007. The reports are signed and dated by the person completing them and include details of the visit to the home. The home has used comment cards to check the views of relatives, visitors and residents about the home. These have been compiled into an analysis form. The home has a business plan for the period 2004-2009, which includes a renovation plan for the period 2004-2005. One staff member stated that she does not have supervision but that she talks to one of the home’s senior carers about her work. Another staff member states she does not have supervision with the current manager but had supervision from a senior carer but this has now stopped. Records of supervision submitted to the Commission since the visit show that six care staff have received formal supervision during the period from January 2008 to May 2008. Some supervision sessions have been conducted by the manager and some sessions by a senior member of staff. The home handles residents’ finances and maintains accurate records of any transactions it is involved in. At the time of the inspection two staff have completed a first aid course. Not all staff involved in the transferring of residents is trained in moving and handling. The home’s passenger lift is working. Documentary evidence submitted since the visit has indicated that the company who undertake routine maintenance White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 24 has recommended that consideration is given to to upgrading some working parts. Documents provided since the inspection indicate this work has now been completed. Residents are protected from possible burns by radiator covers. Hot water outlets have temperature controls to prevent possible scalds from hot water when residents have a bath or shower. White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 3 3 2 X X STAFFING Standard No Score 27 1 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 3 2 1 White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/a STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 (2)(b) Requirement Individual care plans must be reviewed and updated to reflect nutritional needs and guidance for staff in meal provision. Care staff must work to the instructions and guidelines of the care plans. Care staff must be able to access residents’ records and care plans at all times. 2 OP9 13 (2) A sample record of the signature 14/07/08 used by each staff member when administering medication to residents must be maintained alongside their name so that the management can tell which staff member was responsible for medication procedures. Where the home has a complaint or matter for investigation by social services under the safeguarding vulnerable adults procedure a record of this must be maintained including details of the investigation and any outcomes. DS0000060930.V363175.R01.S.doc Timescale for action 14/07/08 3 OP18 13 (6) 14/06/08 White Waves Version 5.2 Page 27 Staff must receive training in the agreed safeguarding vulnerable adults procedures. 4 OP27 18 (1) (a) The home must deploy sufficient numbers of staff so that residents care needs can be met without staff having to resort to working excessively long hours. Staff must only start work in the home after the following checks have been completed: • A Criminal Record Bureau check is applied for and the home has received a Protection of Vulnerable Adults ‘first’ check. • 2 written references have been obtained. • Checks are made on the person’s suitability to work with vulnerable adults. Newly appointed staff must receive an induction which must be recorded. This must include instructions on caring for individual residents. The manager must review her training needs and complete appropriate training for the purposes of managing a care home. Daily running records for individual residents must be recorded individually for reasons of confidentiality, data protection and so that the daily occurrences can be monitored. Staff completing these records must complete a signature. A photograph of each resident White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 28 14/06/08 5 OP29 19 (1) (a) (b) 14/06/08 6 OP30 18 (1) © 14/07/08 7 OP31 9 (2) (b) (i) 14/08/08 8 OP37 17 Schedule 3 14/06/08 must be maintained with records. 9 OP38 13 (4) Staff must receive training in first aid so that the home has at least one staff member who has completed the 4 day qualified first aider course, and so that at any given time, including nights, there is a staff member on duty who has completed a basic first aid course. All staff must receive training in moving and handling. Bedroom carpets must be level and must not be a trip hazard. 14/08/08 10 11 OP38 OP38 13 (5) 13 (4) 14/08/08 14/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations White Waves DS0000060930.V363175.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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