Inspection on 15/11/05 for Whitefarm Lodge

This inspection was carried out on 15th November 2005.

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 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

Whitefarm Lodge 20/09/06

Whitefarm Lodge 20/06/05

Whitefarm Lodge 25/11/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Whitefarm Lodge Vicarage Road Whitton Twickenham Middlesex TW2 7BY Lead Inspector Sandy Patrick Unannounced Inspection 15th November 2005 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 Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 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. Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Whitefarm Lodge Address Vicarage Road Whitton Twickenham Middlesex TW2 7BY 020 8755 5740 01206 852 248 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) Care UK Community Partnerships Limited Mr Shane Michael Cosgrove Care Home 60 Category(ies) of Dementia - over 65 years of age (23), Old age, registration, with number not falling within any other category (37) of places Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Dementia Nursing Places To include no more than 23 service users requiring Dementia Nursing care at any one time. Dementia Places To include no more than 37 service users in the registration category of Older People with up to 25 requiring Dementia Care at any one time. Dementia Care Nursing Unit 2nd Floor Two qualified 1st level Registered Mental Health Nurses must be available on the nursing unit during the morning shift at all times. These nurses must not have any management responsibilities for the home or within the nursing unit. The Unit Manager for the nursing unit must be supernumerary at all times. The Home can admit one named service user under the age of 65 years. 20th June 2005 3. 4. Date of last inspection Brief Description of the Service: White Farm Lodge is a care home with nursing, providing accommodation and personal care for up to sixty service users. The home provides nursing care for up to twenty-three service users who have dementia. The building is owned by the London Borough of Richmond and is leased to Care UK Partnership who manages and run the home. The home is located in Whitton, close to the high street, local shops, churches, pubs and other amenities. The home is newly built and was registered in August 2004. The majority of service users and staff have transferred from two other local Care UK homes, which have now closed. All bedrooms are for single occupancy and have en suite facilities. There is a passenger lift between floors. There are attractive, well-kept grounds. The Registered Persons have produced a Service User Guide, which includes information on the aims and objectives of the service. Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 15th November 2005, and was unannounced. The Inspection Team included a Pharmacy Inspector. The report of his findings are recorded in Section 2 (Standard 9) of this report. The Inspection Team met with the Registered Manager, other staff on duty, service users and visitors to the home on the day of the inspection. They were made welcome by everybody. The atmosphere at the home was relaxed and happy and staff treated service users with respect and kindness. The nursing unit was lively and service users were encouraged to express themselves. Following the last inspection of the service in June 2005, the CSCI received comment cards from some service users who lived at the home. These were received too late for inclusion into the inspection report for June 2005. Thirtytwo cards were received. The majority of service users said that they liked living at the home. And all service users reported that they were well cared for and treated with respect. Most of the comment cards reported that they liked the food and activities, although some service users reported that they did not. ‘I am pleased with the care I receive. I feel safe living here and know that problems are dealt with’ The Lead Inspector was invited to join some service users for their midday meal. This was a pleasant social occasion as well as a tasty meal. Service users who spoke to the Inspection Team said that they liked living at the home and that they were well cared for by staff. What the service does well: The home is well laid out and service users have ample communal and private space. All bedrooms have en suite facilities and the home is attractive decorated. There is a pleasant garden. There are thorough procedures for the assessment of service users. Service users are able to visit the home prior to making a decision about living there. Service users’ needs are recorded within care plans, which are agreed by the service user and their representatives. These are subject to regular review and contain detailed social histories provided by the service user or their families. Service users reported that the home provides varied and interesting activities. Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 Page 6 Service users are able to access independent advocates. A service user committee has been organised and they have worked in partnership with the advocacy group to conduct quality surveys. There are excellent systems for quality monitoring and consultation with service users and their representatives. Staff who spoke with the Inspectors spoke positively about training and support from senior staff. There is a good range of information for staff on their roles and responsibilities. The Manager is well respected by service users, staff and visitors alike. Records are highly organised and up to date. What has improved since the last inspection? What they could do better: The Manager is aware of the needs of the service. Concerns identified by service users and staff are addressed and these are evidenced. There is regular consultation with all parties. This should continue. At this inspection, no serious deficits were identified and the home meets or exceeds the majority of National Minimum Standards. Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 Page 7 Some suggestions for improvements to the care planning system should be implemented and all service users must be offered a copy of their care plan. Some improvements for the environment have been suggested. Some improvements to medication recording are required. 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. Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 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 Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 There is a good range of information for service users and their representatives, which supports potential service users to make decisions about whether they wish to live at the home and existing service users information on their own care and key procedures. There are appropriate procedures for the assessment and admission of service users including trail stays. Service users and their representatives are issued with contracts of care which outline the terms and conditions of residency. The home does not provide intermediate care. EVIDENCE: The Registered Person has produced a Welcome Pack, which incorporates the Service User Guide and Statement of Purpose. This includes the required areas and gives a range of information, including the philosophy of care, aims Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 Page 10 and objectives, information on services and facilities and staffing. All service users are issued with a personalised welcome pack, which includes details of their keyworker. Copies of these documents and the home’s complaints procedure are available in bedrooms and communal noticeboards. Leaflets and information about the home, activities, advocacy groups and the Charter of Rights were also available throughout communal areas. There have been no changes to the Welcome Pack since the last inspection, apart from where information has been updated. Fifty-six places are contracted to people who are funded by the local authority. Care UK has recently created four places for privately funded service users. Twenty-three places are for service users with dementia and nursing needs. The nursing unit is appropriately staffed and procedures have been designed to meet the needs of the unit. Assessments of need are appropriately reflected within service user plans. Daily care notes are made and there is evidence of regular reviews. The home works closely with health care professionals who offer support, advice and training. Staff are offered a wide range of training appropriate to their roles. All service users are assigned a keyworker who is responsible for overseeing care provision and is a contact for the service user and families. All service users and their representatives have been issued with tenancy agreements outlining the terms and conditions of residency. Signed copies of these agreements are held at the home. These contracts include information on fees, termination of contract, quality assurance, insurance, trail periods and facilities and services. The document is available in large print if required. Senior staff and the Nursing Manager conduct full assessments of need on all potential service users. Copies of assessments were seen. Potential service users are invited to visit the home and meet with other service users. All service users are admitted on a six week trial stay. At the end of this period a review meeting is held, where the service user, their representatives, the placing authority and representatives of the home make a decision about whether the service can continue to meet that person’s needs. Evidence of these six week review meetings was seen within service user files examined. Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 Individual service user plans are in place and include detailed information on meeting needs. Service users do not have access to the new care planning system and must e given copies of their care plan. Personal and health care needs are recorded within service user plans and are monitored. Service users are able to access external health care services and the staff work in partnership with health care professionals. The nursing unit offers specialist support to service users who have nursing needs and dementia. Specialist training and information for staff helps them to understand and meet these needs. The home has good arrangements for the ordering, storage, recording and auditing of medication and has access to a pharmacist for advice. Minor omissions in recording and labelling were found although there was no risk to the health or welfare of any residents. EVIDENCE: A new computerised care planning system has been introduced at the home since the last inspection. All staff have been trained in the use of this. Staff Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 Page 12 who spoke with the Inspector demonstrated a good knowledge of how to use the system. The staff have worked hard to transfer information from written care plans to the computer and this work was completed in a short time scale. The Inspector looked at care planning, risk assessment and monitoring information stored in the new computerised care planning system. Care plans for individuals were detailed and focused on individual needs and wishes. There was an emphasis on maintaining independence and choice. Individual care plans were in place regarding health and social needs. Information was up to date and care plans were subject to regular recorded review. Senior staff told the Inspector that there had been some problems with the system not meeting the exact needs of the home. However, they said that the IT support had been very good and suggested changes had been implemented. The computerised care planning system does not include photographs of service users. The organisation should consider arranging for the system to include photographs so that staff can easily identify the service user for each care plan. At the time of the inspection there was only one printer in use at the home. This situation is problematic for staff working with service users who may need to print out care plan information. Senior staff reported that the Manager has organised for each unit to be equipped with printers. Copies of care plan information must be printed off and shared with service users. A record of their agreement to individual care plans must be maintained. Service users must be consulted regarding any changes to their care plans. All service users are registered with local GPs. One GP holds a weekly surgery at the home. The staff on duty reported that they work closely health care professionals. Service users told the Inspectors that a dentist, optician and chiropodist visited the home. Health care needs are recorded within service user plans and there are systems for monitoring these. Staff on duty demonstrated a good awareness of individual needs. The Inspectors saw detailed care plans in place around the areas of continence and nutritional needs. Wound assessments and care plans in relations to these were seen to be in place. The written medication policies and procedures were found to be adequate on the last inspection and were not reviewed on this visit. All medications administered by staff along with the records relating to receipt, storage, administration and disposal of medication were examined. The Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 Page 13 person in charge of each unit was interviewed, the administration of medication on one unit observed, all medication not supplied in the monitored dosage system was counted and compared to the amount the should be in stock according to the records of receipt and administration and the audit records on all units reviewed. From these observations and discussions medication twelve items were labelled “to be used as directed”. Directions for administration are written on the administration record. This issue has been raised with the GP and according to the person in charge was picked up by the advisory pharmacist on the last visit. Two residents did not have the quantity of medication recorded for medication prescribed with a variable dose. The medication was supplied in the monitored dosage system indicating how many is given at each time. All medications not supplied in the monitored dosage system were dated when opened. This enables a good audit trail for the use of all medication. All other records had been completed accurately and provided evidence that all other medication had been administered correctly, changes to medication clearly identified, medication was stored and administered safely by appropriately trained staff, regular audits had been performed and any necessary action taken. Service user plans include information on personal needs. Personal preferences and choices are recorded. Service users confirmed that staff treated them with respect and offered choices. Service users are offered same gender carers. All bedrooms have en suite facilities. Bathrooms at the home are large and appropriately equipped with specialist baths and showers. A hairdresser visits the home once a week. Service user plans indicate preferred times to rise and retire, and preferences for baths or showers. Staff were observed to knock on doors before entering and used preferred forms of address. Throughout the day staff were seen treating service users with respect, dignity and kindness. Names of keyworkers are detailed within each service user’s room. There are appropriate procedure in place regarding dying and death. The home has a bereavement pack offering information and advice for service users and their families. There is a multi-faith room which service users, visitors and staff can use for private worship or for quiet reflection. Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 & 15 Service users are able to choose from a range of organised activities and staff ensure that individual support is offered to meet social needs. Service users are involved in the development and review of their own care plan. Service users are consulted about the running of the home and are able to make choices about how their care is delivered. Service users are listened to and their opinions are acted upon. There is a varied menu offering choice and nutritional balance. EVIDENCE: The home employs two Activity Officers. There is a planned programme of activities open to all service users. The Activity Officers were planning Christmas activities with service users at the time of the inspection. These included entertainers, a Christmas Party and some trips out. Regular organised activities at the home include visiting libraries, nature watch, art, quizzes, music, sing-a-longs, film afternoons and craft activities. These are well advertised throughout the home and service users are able to participate as they wish. The home is visited by a hairdresser and service users can make appointments to see her. Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 Page 15 There are a number of communal lounges and rooms throughout the home. Service users were seen to spend time in these enjoying listening to music, socialising, watching television and talking to staff. The staff on duty spent time reading, knitting and chatting to service users as well as helping them with practical tasks. The Activity Officers have recorded activity participation and enjoyment within individual care plans. A room on the second floor was due to be refurbished and equipped so that it could be used a sensory room. Staff spoke enthusiastically about this and felt that it would be an invaluable resource for some of the service users. A local advocacy group visit the home to facilitate service user meetings every six weeks. Relative and service user meetings are held twice a year. The Nursing Manager spoke to the Inspector about ways in which the staff support non-English speaking service users. This included liaison withy family members and the use of pictures and words in both English and service users’ first language. There is an appropriate menu, offering a choice of wholesome, freshly prepared food. Trained catering staff are employed throughout the day and prepare all main meals. Food is delivered to the units in heated trolleys. Smaller kitchenettes on each floor are well stocked with snacks, drinks and fresh fruit. Service users reported that they were able to eat their meals in their room or at different times if they wished. They also told Inspectors that they were able to have snacks and drinks whenever they wanted them. The Lead Inspector joined the service users on one floor for their midday meal. This was well prepared and tasty. Meals, including soft diet meals, were presented attractively. Service users were offered choices. The service users who sat with the Inspector told her that food was well prepared and that they were able to make choices. Service users were offered second helpings, coffee and fruit at mealtimes. Staff serving the food were wearing disposable gloves. The Manager should assess whether this is necessary as it creates an institutionalised feel and staff should not be handling food directly. The menu for the home was not displayed in an accessible format for all service users. Some service users had forgotten what the meal choices were and did not know what they would be having to eat. The Manager should consider how best the menu can be displayed so that service users are aware of what their meal will be prior to it being served. Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 There is an appropriate complaints procedure, which is accessible to service users. Procedures are in place to protect service users from abuse. EVIDENCE: There is an appropriate complaints procedure which is available to service users within the Service User Guide and on display throughout the home. There is a record of complaints. This indicates that concerns and complaints are fully investigated and that the complainant is given appropriate information following the investigation. The home has adopted the London Borough of Richmond Protection of Vulnerable Adults procedure. Care UK has its own procedures on abuse and whistle blowing. All staff have attended training in recognising and reporting abuse or have applied to attend this. The Inspector saw evidence of this in the staff training files which were examined. Care UK has sound recruitment and selection procedures and pre employment checks, including criminal record checks, are made on all staff prior to employment. Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26 The environment is safe, well maintained and comfortable. Service users have unrestricted access to communal areas and report that they are happy with the environment. EVIDENCE: The home was purpose built and registered in August 2004. Accommodation is provided on three floors. All bedrooms are for single occupancy and have en suite facilities. There are nine additional WCs, six bathrooms and two shower rooms, all with WCs. Bathrooms and shower rooms are equipped with specialist equipment. Rooms are large and appropriately designed. The building is well lit, ventilated and heated throughout. The building is attractively decorated and furnished throughout. Additional staff facilities include shower rooms, changing facilities and a rest room. There is an attractive garden. There are a small number of parking spaces available. There are lounges, quiet rooms and dining areas on each floor. There is additionally a garden room on the ground floor. These are attractively Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 Page 18 decorated and furnished. The hairdresser has an allocated room. Kitchenettes are available on each floor. All bedrooms are appropriately equipped and furnished. Service users are able to personalise their rooms. Bedrooms are equipped with call alarm systems, television aerial points and thermostats. There is a call alarm system available in all rooms. The home is equipped with a passenger lift and hand rails in corridors. All service users are individually assessed for equipment needs and referrals to health care professionals are made as necessary. There are a number of hoists available at the home. Specialist nursing beds are available. All staff receive training in manual handling. Moving and handling risk assessments are in place for all service users. Examples of these were seen in all the service user plans examined. The home was clean and odour free throughout. There are appropriate procedures for infection control, disposal of clinical waste and Control of Substances Hazardous to Health. There are appropriate laundry facilities. Hand towels and liquid soap were available in all bathrooms and WCs. Service users stated that they were very happy with the facilities at the home and enjoyed the garden and lounges. The home employs a full time maintenance man who undertakes regular checks on the building and health and safety. These are appropriately recorded and action has been taken to address any concerns. All bedrooms have en suite WCs. The home was built so that these rooms could also include a shower. Consideration should be given to equipping these rooms with shower facilities. Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 Staff are employed in sufficient numbers to meet the needs of service users. The staff team is well organised and there are appropriate procedures for supervision and support. Staff are offered a range of training and feel that this is well organised and gives them the knowledge and skills to meet the needs of service users. Staff recruitment procedures include thorough pre employment checks. EVIDENCE: There is a good range of information for staff on their roles and responsibilities. All staff have comprehensive job descriptions and additional guidance and information were seen to be available. The home was well staffed at the time of the inspection. reported that the home does not use agency staff. The Manager There is a clearly defined staffing structure. The Nursing Manager and Team Leaders manage teams of nursing and care staff. A Team Leader is on duty at all times and sleeps at the home over night. Care UK have developed a training programme for local homes and staff at White Farm Lodge access this training. Training that staff were undertaking around the time of the inspection included manual handling, appraisal, supervision, protection of vulnerable adults and diabetes. The Manager Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 Page 20 reported that local health care professionals offer training and support to staff. Staff training profiles are maintained and indicate that all staff receive a range of training relevant to their role. Some of the nursing staff have undertaken additional qualifications in working with people who have dementia. Some of the senior staff at the home have trained to be manual handling instructors and are able to train, assess and support staff. One senior member of staff spoke about this. They said that they were required to undertake regular training and assessment. All staff have been trained in the use of the new computerised care planning system. There is an appropriate procedure for the recruitment of staff including a formal interview with the Manager. Four staff recruitment files were examined. These were complete and evidenced thorough pre-employment checks. There is evidence of regular staff meetings and individual supervision. Staff opinions and views are recorded and information on practice issues, policies and procedures and inspections are shared with them. Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 36, 37 & 38 The Manager is appropriately experienced and qualified and has demonstrated a commitment to the development of the service. The management style is open, positive and inclusive. Procedures are in place to promote good health and safety. Records are appropriately maintained and information is accessible, organised and up to date. EVIDENCE: The Manager is experienced and previously managed another of Care UK’s homes. He is currently undertaking an NVQ Level 4. The Manager has consistently demonstrated an excellent understanding of the needs of the home, of individual service users and of staff. He has shown a Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 Page 22 commitment to the training and support of staff to improve the skills and knowledge of the staff team. The staff who spoke with the Inspector reported that they were well supported and received regular supervision and training. They told the Inspector that the Manager listened to their opinions and was very supportive. All staff receive regular recorded supervision from their line manager. There is an appropriate induction training package for staff, which includes shadowing experiences staff, training events, and workbook and practical assessment. The Manager reported that there had been some changes to the senior management structure in the local Care UK. He said that this had been positive and that there was improved access to support networks. Records are well organised, up to date and accessible. There is evidence of thorough checks on health and safety and fire safety. Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 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 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 3 4 3 Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 Page 24 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 OP7 Regulation 12 15 Requirement Timescale for action The Registered Person must 31/01/06 obtain signed agreement for all service user plans from the service user or their representative. Service users must be offered a copy of their care plan. The Registered Person must 15/12/05 ensure that the quantity of medication administered is recorded for all items of medication prescribed with a variable dose. 2. OP9 13(2) 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 Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 Page 25 1. OP7 The Registered Person should consider including a photograph of each service user within the computerised care planning system. Staff working on each floor should have access to a printer linked to the care planning system. 2. OP9 It is recommended that all medication be labelled with directions for administration. The Registered Person should consider ways in which the menu can be displayed more clearly for service users. The Registered Person should reassess the whether it is necessary for staff serving food to wear disposable gloves. 3. OP15 4. OP23 The Registered Person should consider installing showers within en suite facilities for service users. Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Whitefarm Lodge DS0000061209.V260136.R01.S.doc Version 5.0 Page 27 - 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. 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