Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 23/01/07 for Whitebriars Care Home

Also see our care home review for Whitebriars Care Home for more information

This inspection was carried out on 23rd January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Pre-admission assessments carried out by the care managers and registered manager form a good basis for the resident`s care planning and the health needs of the residents are well met. The staff respects the resident`s privacy and dignity, and this was supported by the residents spoken to by the inspector during the visit. There was evidence in the home of a good comprehensive activities programme. The residents in the home are given choices in regard to their daily routines, and again residents supported this evidence during the course of the inspection. Residents spoke highly of the food they received in the home this included one resident who was vegetarian. The home has a good complaints policy and procedure that is clearly displayed in the home. The registered provider ensures that there is a good maintenance, renewal and decoration programme in place and evidence was available on the day of the inspection that this programme is ongoing. Residents stated that the home is kept in good repair and is always bright and cheerful. Residents stated that staffing in the home is good and the staff rotas seen during the course of the inspection gave supporting evidence of this.

What has improved since the last inspection?

The registered manager has gained her NVQ level four since the last inspection and is awaiting her certificate of this qualification, and has been accepted at the registered manager by CSCI. The inspector viewed evidence that staff are now CRB checked prior to taking up employment in the home.

What the care home could do better:

Resident`s risk assessments must give staff clear guidance as to what steps they must take to keep risk to a minimum. Staff must complete the daily report on all residents to ensure that their assessed needs are being met, and to give sufficient evidence for care plan reviews. All medication must be recorded on MAR sheets when brought into the home, this includes the medication for those residents who are on respite care. Residents medication is their own property, and therefore written permission must be sort for the home to administer a resident`s medication. During the course of the inspection the inspector noted that one resident`s bedroom door was propped open with a doorstop, a requirement regarding this had been made at a previous inspection and had not been met. Staff recruitment needs to be reviewed to ensure that all prospective staff give a full employment history and two references are sought prior to employment. All staff should undertake mandatory training within the first six months of their employment and this training should be updated as and when required. Induction training for staff must meet the Skills for Care induction requirements. A good quality assurance system needs to be put in place, to include surveys of relatives and stakeholders, and recorded monitoring of systems already in place in the home. Any extra costs to the residents outside of the fee must be clearly stated within the service user guide and the statement of purpose. Any extra charges made to the residents` must be covered by a receipt.

CARE HOMES FOR OLDER PEOPLE Whitebriars Care Home 20 Bedford Avenue Bexhill on Sea East Sussex TN40 1NG Lead Inspector June Davies Key Unannounced Inspection 23rd January 2007 10:00 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 Whitebriars Care Home DS0000062356.V322854.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. Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitebriars Care Home Address 20 Bedford Avenue Bexhill on Sea East Sussex TN40 1NG 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) 01424 215335 01424 215335 info@whitebriars.co.uk Whitebriars Ltd Sally Ann Devlin Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users accommodated will be aged sixty-five (65) years or over on admission. The maximum number of service users to be accommodated is nineteen (19). One named service user under sixty-five (65) years on admission to be accommodated Date of last inspection Brief Description of the Service: Whitebriars is a care home providing personal care and accommodation for up to 19 older people. The home is located a short walk from Bexhill sea front and town centre with its shops, churches and other community services. There is good access to bus and rail routes. The house is a detached property set in its own grounds. Accommodation is provided on three floors, stair lifts are fitted to assist residents to access first and second floor accommodation, however those with bedrooms on these floors are still required to manage some stairs that are not covered by the stair lifts. The home has a large lounge and dining room area, whilst the outside of the building has a pleasant paved garden and fishpond. Fees are £340.00 to £450.00 Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a period of six hours. The inspector spoke with six residents, two members of staff, the registered manager and viewed documentation relating to the standards inspected. A tour of the home and grounds was undertaken, and it was noted that replacement of carpets and decorating was taking place during the inspection. What the service does well: What has improved since the last inspection? The registered manager has gained her NVQ level four since the last inspection and is awaiting her certificate of this qualification, and has been accepted at the registered manager by CSCI. The inspector viewed evidence that staff are now CRB checked prior to taking up employment in the home. Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 6 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. Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 7 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 Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 8 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): Standards 1and 3 Quality in this outcome area is good The homes statement of purpose and service user guide are regularly reviewed to ensure that prospective service users have sufficient information they need to make a decision about moving into the home. Service users moving into the home know that their needs can be met and that their independence will be maximised and promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service user guide and statement of purpose set out according to National Minimum Standards and is regularly reviewed to ensure that any changes in the home are updated. Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 9 The inspector viewed the care plans of four residents. These care plans contained the pre-admission assessments, where applicable from hospital, care manager and homes own pre-admission assessment. All pre-admission assessments gave comprehensive details on which to base a plan of care. Pre-admission assessments included social history, medical history, current physical health, mobility needs, mental and cognitive condition and medication. Evidence was available to show that the resident’s themselves and their relatives were consulted prior to admission into the home. The home does not offer intermediate care. Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 10 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): Standards 7 8 9 and 10 Quality in this outcome area is adequate The care planning system needs to be improved to provide staff with the information they need to meet the residents’ needs. The health needs of the residents are well met with evidence of good multi disciplinary working taking place on a regular basis. The records for medication in this home needs to be improved upon to ensure appropriate records are kept and residents’ choices are recognised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four care plans were viewed during this key inspection and the inspector found them to be detailed in the care that residents required. Care plans contained pre-admission assessments carried out by the registered manager of the home, and in some cases care managers and hospital assessments. There was documentation relating to personal care, weight charts, sight hearing and communication, foot care, skin care, mobility and dexterity, history of falls, continence, medication, mental state and cognition, social interests, personal Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 11 safety and relationships. The inspector noted that while risks were recognised, there was no clear steps for the staff to follow to reduce the element of risk for the resident’s. In three care plans there had been no daily report written for a number of days and therefore no evidence that these residents’ care needs had been met according to their plan of care. There was some evidence available in care plans to show that residents tissue viability was checked by care staff and any concerns were reported to the district nurse. During a tour of the building the inspector noted that some of the residents’ were using pressure relieving cushions in their armchairs. The inspector noted in two care plans reference had been made to the continence nurse visiting the home to assess the residents’ continence needs. Where the registered manager requires a psychiatric assessment, the referral will be made via the resident’s G.P. The home offers residents the opportunity to be involved in armchair exercises, which is included within the homes activities programme and carried out by a member of staff specifically employed to do activities with the residents. Care plans contained weight charts, and these showed that residents are weighed on a monthly basis, any concerns are reported to the G.P. Evidence was available in care plans to show that residents are able to see their own G.P. as and when required. Visits from and to chiropodists, dentists and opticians are also recorded in the care plans. The registered manager confirmed that if necessary residents are able to visit the audiologist at the local hospital regarding hearing problems and difficulties with their hearing aids. The home has up to date policies and procedures relating to the administration of medication, including the use of over the counter medications. There was a sheet available at the front of the MAR sheet folder, indicating those staff that had been trained to administer medication together with their initials. MAR sheets where properly completed for the administration of medication but the inspector noted that medications brought into the home mid month and the medication for a resident on respite care, had not been appropriately entered on to the MAR sheet, to include the date, quantity and initials of the member of staff receiving the medication into the home. There was no permissions within the care plans to state that residents wished to have their medications administered by the staff. Controlled drugs are kept for one resident, and the inspector witnessed that these were stored in a double locked cupboard, and that the controlled drugs registered was signed by two members of staff, when administered. The controlled drug corresponded with the quantity entered into the controlled drug register. All unused medication is returned to the pharmacy on a regular basis. The inspector spoke with six residents during the course of this inspection. All residents’ stated that staff respect their privacy, that personal care is carried out in their own en-suite, bedroom or communal bathroom and that doors are closed when these tasks are being performed. Staff address residents by their preferred name, which is also recorded on their plan of care. Residents Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 12 confirmed that they are able to have professional visits in the privacy of their own bedroom, and a G.P. who completed a general practitioners comment card also confirmed this. Most of the residents have their own private telephone in their bedrooms, and for those residents who do not wish to have their own telephone there is an office mobile phone they may use. The home does have one double bedroom but at the present time only one resident only occupies this. Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 13 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): Standards12,13,14and 15 Quality in this outcome area is good, Activities in the home and links with the local community are good and enrich the residents’ social opportunities. Residents are able to choose which visitors they wish to see. The manager enables the residents to maintain their independence. The meals in the home are good offering both choice and variety and catering for special diets. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs a member of staff to carry out activities with the residents, these activities can be delivered on a one to one basis or with a group of residents together. Activities include bingo, armchair exercises, quizzes, crafts, cooking, making greetings cards, board games, and painting. Residents have the choice as to whether they wish to join in with activities or not. Residents are also able to make decisions about when they get up or go to bed, and mealtimes are arranged around each resident’s choice. Meals can Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 14 also be served in the resident’s own bedroom if requested. Residents interests are recorded on their individual care plans. Some residents choose to go out into the community on their own, and when the weather permits staff will take residents to the local shops, supermarket and for walks along the sea front. The registered manager said that when visitors arrive in the home, she always informs the resident in the first place before taking the visitor to the resident, this enables the resident to have a choice as to which visitors they wish to see. The local Church of England visits the home once a month to give communion to those residents who wish to take part. Visitors from the church also visit the home to talk to residents. Some relatives take their resident’s out for a meal from time to time. The registered manager confirmed that there are no restrictions on visiting in the home. The inspector spoke with two service users who confirmed that they are able to manage their own financial affairs, and other residents receive help from their relatives or their solicitor. During a tour of the home, the inspector noted that all rooms were personalised with the resident’s own possessions, which included furniture, ornaments, photographs and pictures. The registered manager confirmed that residents’ are able to access their own care plans, and where a relative requests to view a resident’s care plan permission is sort from the resident prior to this happening. The inspector viewed the menus for the home, which run on a four-week rota. The menus showed that residents are offered a varied and nutritious menu, and that they are given a choice of meals at each mealtime. Residents are able to have input into menu planning via residents meetings. A record is kept of all the meals served to the residents. The home caters for special diets as and when necessary, one resident told the inspector that she is a vegetarian, and the home does an excellent job in catering for her vegetarian needs. At the present time none of the residents in the home require their meals to be liquidised. Residents are able to choose to eat in the dining room or in their own bedrooms as they wish Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 15 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): Standards 16 and 18 Quality in this outcome area is good, Residents know their complaints will be listened to and acted on. Arrangements for protecting residents are good and prevent them from being abused. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear complaints policy and procedure, which clearly gives the steps that will be taken, following a complaint to the home being made. This complaints policy is clearly displayed in the home, and copies are included with the statement of purpose and the service user guide. The registered manager was able to show written evidence of one complaint being made since the last inspection. This evidence showed that the complaint had been appropriately investigated and the outcome of the complaint reported back to the complainant within the twenty-eight day timescale set out in the policy and procedure. Staff are made aware of this complaints policy and procedure during the course of their induction. The inspector viewed policies and procedures relating to POVA and the whistle blowing policy and procedure. There has been one instance of financial abuse, which the registered manager reported to the appropriate authorities. An Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 16 adult protection investigation took place and this has since been closed. The majority of staff have completed abuse awareness training, which they found very helpful and enlightening. Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. The home has a good programme of maintenance, redecoration, and renewal providing residents with a comfortable ,homely place to live. The systems for preventing the spread of cross infection are good and protect the residents’ health. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector carried out a tour of the home and found it to be well maintained, decorated and furnished. The home has a programme of maintenance and renewal, and on the day of the inspection new carpets were being laid in a ground floor hallway, new carpets have also been laid in the communal lounge and dining room. The back garden is safe and secure for use by the residents. One resident has a built up area of garden in which he grows a few vegetables. A new external fire escape has been provided. On Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 18 the day of the inspection the home was clean and tidy. The building now complies with the requirements of the local fire safety officer and the environmental health officer. A recent independent fire risk assessment has also been carried out on the home, the inspector was shown a copy of the report, and the registered provider is in the process of making some changes suggested in the report. During a tour of the home the inspector did note that one bedroom door was propped open with a doorstop. The home does not use CCTV cameras. On the day of the inspection the homes was clean, tidy and free from offensive odours throughout. The home has a separate laundry room, hand-washing facilities are sited in the laundry room. The laundry room floor is tiled and waterproof. Two washing machines are available in the laundry room one is an industrial washing machine with a sluicing and disinfecting programme, the other machine is a domestic washing machine which is used for delicate fabrics. The registered manager however did tell the inspector that foul laundry is first soaked in a bucket prior to be put into the washing machine, this is not best practice for infection control. Staff are provided with protective clothing when dealing with clinical waste, and spillages. Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 19 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): Standards 27,28,29 and 30 Quality in this outcome area is adequate Staff are employment in sufficient numbers to meet the needs of the residents. Recruitment policies have not been consistently followed resulting in residents receiving care from staff that have not been appropriately vetted. Staff induction, qualifications and training in the home need to improve to ensure that residents are receiving care from staff who can meet their assessed needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels within the home are good with two staff on duty during the morning and afternoon shifts plus the registered manager or deputy manager; there is also one member of waking night staff on duty with a senior member of staff on call in the case of emergencies. The home also employs an activities co-ordinator to carry out the activities programme with the residents. The home also employs sufficient number of ancillary staff including cooks and domestic staff. The registered manager confirmed that at the present time 45 of care staff have achieved NVQ level 2 and above, with further care staff waiting to be booked onto a NVQ course. The inspector also noted NVQ certificates within the personnel files inspected. Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 20 The inspector looked at the personnel files of four members of staff chosen at random and found that recruitment practices need to be further improved upon to ensure that all staff provides a full employment history on their application form. The inspector also found that two personnel files did not contain two references and none of the files had two forms of staff identification within them. All files contained staff training certificates and induction records. A separate file showed that CRB checks are completed prior to a member of staff taking up employment within the home. Evidence is available to show that some staff do undertake mandatory training, but the registered manager needs to ensure that all staff have mandatory training within six months of their employment in the home and that staff have updates of this mandatory training on a yearly basis for moving and handling, fire safety and infection control, POVA and medication and three yearly for first aid and food hygiene. Evidence was available on personnel files to show that staff do have a period of induction at the beginning of the employment, but at the present time this does not meet Skills for Care induction standards. All staff receive the GSCC code of conduct, and the registered manager was able to show the inspector copies of this code. Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 21 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): Standards 31, 33, 35 and 38 Quality in this outcome area is adequate The management of the home is satisfactory, but further improvements need to be made to the quality assurance system and soe records to ensure tghat the residents are not placed at risk . This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has just completed her NVQ level 4 and is awaiting the certificate. She has yet to complete her RMA. Evidence was available via the registered manager to show that in the last year she has completed training in the Management of urinary incontinence, First Aid and Infection control. Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 22 The registered manager confirmed that residents have been sent a quality assurance questionnaire, and evidence is also available in the quality assurance folder of these completed questionnaires. Questionnaires have not been developed for relatives, stakeholders and staff. Written records are available to show that the fire system, health and safety risk assessments for the interior of the home are in place and an independent fire risk assessment has recently been carried out. No risk assessment has been carried out for exterior of the home. There is no recorded evidence that the registered manager regularly monitors care plans, care plan reviews, resident risk assessments, medication, food checks or the cleanliness of the building. The registered manager looks after some of the personal finances for the residents in the home and these monies are appropriately recorded for each individual resident. Each resident has their own finance sheet, with a record kept of all monies coming in and going out, receipts are kept of all purchases. During the course of the inspection evidence came to light that one resident was paying for personal shopping to be done, but there is no evidence within the service user guide or the statement of purpose to indicate that this charge would be made over and above the fees being charged to the residents’. The inspector requested a copy of the policy and procedure relating to staff accepting gifts, and this was very clear and comprehensive. The registered manager and personnel files showed that some staff have completed and updated their mandatory training in relation to moving and handling, fire safety, first aid, food hygiene, and infection control, this has been reported on under Standard 30. The inspector was shown current maintenance certificates for all appliances used in the home, but it was noted that wheelchairs currently in use by the home have not been regularly maintained. Risk assessments are available for the interior of the home and an independent fire risk assessment was carried out in October 2006. The registered manager confirmed that not all windows in the home have window restrictors fitted. The home has recently had new PVC windows fitted and the company still has some work to complete and this includes window restrictors on all windows. The inspector viewed the HSE accident book and found that all accidents had been accurately recorded. Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 17 x 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 2 x x 3 Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 Requirement Timescale for action 02/03/07 2. OP7 3 OP9 4 OP9 5 OP19 6 OP29 13(4)(b)(c Risk assessments must give ) Sched 3 clear guidelines to staff to ensure that risk to the resident is kept to a minimum 15(2)(b) The registered manager must ensure that a daily record is kept for each resident, to include the care they have received, to enable the care plan to be changed on review. 17(1)(a) MAR sheets must indicate the Sched. 3 date, quantity and signature of (3)(i) member of staff receiving the medication for those residents on respite care and for medication prescribed by the G.P. mid month. 12(2) The registered manager shall ensure that signed permissions are available in care plans to show that residents are willing for staff to administer their prescribed medication. 14(4)(c) The home must review the use of doorstops on fire doors. Requirement made at previous inspection on 08/11/05 and not met. 19 The registered provider must DS0000062356.V322854.R01.S.doc 23/02/07 02/03/07 02/03/07 02/03/07 02/03/07 Page 25 Whitebriars Care Home Version 5.2 Sched. 2 7 OP30 18(1)(a) 8 OP30 18(1)(c) (i) 24(1)(a) (b)(2)(3) 17 (2) Sched.4 9 OP33 10 OP35 ensure that all prospective staff provider a full employment history and that two references are obtained prior to the member of staff taking up employment in the home. The registered provider must ensure that all staff receive mandatory training within the first six months of their employment and that this training is updated in accordance of the recommended time limits. The registered provider must provide induction training for new staff to Skills for care requirements. The registered manager shall ensure that an appropriate system of quality assurance is developed. The registered provider must ensure that the service user guide and statement of purpose clearly describe what extra costs will be incurred over and above the fee charged and that an accurate record is kept of any financial transactions carried out on the residents’ behalf. 09/05/07 02/04/07 09/05/07 19/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP26 Good Practice Recommendations Foul laundry should not be soaked in a bucket as this will not contain the spread of infection. All foul laundry should be placed into the industrial washing machine on the sluicing and disinfecting programme. The registered manager to undertake RMA qualification. Wheelchairs currently used by the home are regularly DS0000062356.V322854.R01.S.doc Version 5.2 Page 26 2 3 OP31 OP38 Whitebriars Care Home 4. OP38 maintained. All windows in the home to be fitted with opening restrictors. Whitebriars Care Home DS0000062356.V322854.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Whitebriars Care Home DS0000062356.V322854.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!