Inspection on 15/12/06 for Whitehaven

This inspection was carried out on 15th December 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Whitehaven 21/08/07

Whitehaven 16/05/06

Whitehaven 05/11/05

Whitehaven 17/05/05

Whitehaven 18/10/04

Whitehaven 27/04/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Whitehaven 43 Summerley Lane Felpham Bognor Regis West Sussex PO22 7HY Lead Inspector Mrs A Taggart Unannounced Inspection 15th December 2006 09:30 Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitehaven Address 43 Summerley Lane Felpham Bognor Regis West Sussex PO22 7HY 01243 587222 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) Allied Care (Mental Health) Ltd Post Vacant Care Home 14 Category(ies) of Learning disability (14), Learning disability over registration, with number 65 years of age (1) of places Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Learning Disability aged 18-65 years (LD) One service user in the category Learning Disability LD(E), over 65 years of age may be accommodated. Only service users aged 18-65 years may be admitted. That there be no further service users admitted to the home until such time as the registered persons can demonstrate that the requirements set out by the Commission for Social Care Inspection in the Inspection Report dated 16 May 2006 have been met or are being met satisfactorily. Date of last inspection Brief Description of the Service: Whitehaven is registered to provide care for fourteen people who have a learning disability. The additional conditions of registration are that one named person in the service user category Mental Disorder (MD) under the age of sixty-five may be accommodated and one service user in the category Learning Disability (LD), over the age of sixty-five years may be accommodated. Only service users aged eighteen to sixty-five may be admitted. Whitehaven is a detached, two storey building in a residential road in the village of Felpham. There are thirteen rooms with hand-basins, one bathroom and one shower room. Two of these rooms have been joined to make a self-contained flat within the home. There are two adjoining communal rooms, one of which is used as a dining room. There is a separate room that is accessed via the patio area and is used for an office. Whitehaven is a non-smoking house. There is a car park at the front of the building and a garden for the use of service users at the back of the building. Allied Care (Mental Health) Ltd own Whitehaven. The responsible individual for the company is Mr Aslam Dahya. The home is currently without a Registered Manager and is being managed by an acting manager Ms. Zoë Rutter Current fees are £1,020.00 to £1, 833.00 per week. Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced visit was carried out by two inspectors, Mrs. Allen and Mrs. Taggart at 9.30am and lasted for six hours. Prior to the visit a pre-inspection questionnaire was sent to the acting manager, survey forms were sent to service users and comment cards to families and professionals involved with the home. The contents of the last two key visit reports and a random visit report were read and taken into consideration in planning the visit, as was any other documentation and correspondence relating to the service. During the visit the inspectors spoke to service users and the staff members on duty and spent time observing staff practice and interactions with service users. Four care plans were tracked with any relevant information or concerns discussed with the staff on duty and the acting manager. The inspectors looked at food records and saw lunch being prepared and served. The medication system was seen and errors were found in recording and administration. A tour of the building was undertaken, during which time, all communal areas and bedrooms were seen and it was noted that significant improvements to the environment had been carried out. Records such as the complaints book, fire records and staff fire training, maintenance records, staff files and incident and accident reporting were also seen and although most were in good order, there were concerns regarding the lack of reporting of accidents by staff to the acting manager. The acting manager Ms. Rutter had completed and returned the pre-inspection questionnaire with supporting evidence and feedback from families and from a visiting chiropodist was positive saying that the service had improved since the acting manager had been in post. Ms. Rutter assisted with the visit and received feedback from the inspectors. Following the last key inspection on 16th May 06 two random visits have also been carried out at the service, the last being on 22nd August 2006. There is at present a voluntary agreement in place with the Registered Providers, Allied Care Ltd, that no new service users will be admitted until a Registered Manager is in post and a period of stability and improvement within the home has been proven. Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: To ensure that service users are protected at all times the medication system needs to be reviewed to ensure that errors do not occur, the reporting of accidents to service users needs to be improved and a Registered Manager recruited. To ensure that the staff team understand the needs of the people they are supporting, training should be carried out as soon as possible in mental health Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 7 awareness and the staff team should receive further training in report writing and the need for completing daily records. In order to strengthen the staff team and support the acting manager it is recommended that an experienced deputy manager should be recruited to the home. 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. Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 and 3 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. All service users have recently undergone a re-assessment with funding authorities in order to ensure that the home can met their needs. EVIDENCE: The Statement of Purpose and Service User Guide have recently been updated to reflect the change in address of the Commission. There is a voluntary agreement in place from the Registered Providers that no new service users will be admitted until a Registered Manager has been recruited and the home has proven a period of improvement and stability. All of the current service users have undergone a recent re-assessment of their needs with care managers but the acting manager said that one person was to be assessed again as it was felt that their specific needs were impacting on the other people in the home and it was thought that the person needed a more specialised service Evidence gained by observing interactions between service users showed that there is still some conflict in the service and all of the people living in the home are not yet compatible. Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 10 Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 8 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service Although care plans are detailed and comprehensive, the present format could be simplified to provide better understanding and guidance for the staff team. EVIDENCE: The acting manager has worked very hard to improve the quality of care plans in the home and there is now comprehensive information to inform the staff team of the individual needs of each service user. The plans contain personal care guidelines, risk assessments and behaviour plans and have been recently reviewed and updated. Staff members said that they were introduced to the care plans during induction but not all of the staff team had signed to say they had read them. Specific issues contained in care plans were recorded as being discussed at team meetings. Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 12 Although the care plans are detailed and comprehensive they also form very large documents, many of which need to be signed and dated or filled in on a daily basis. While tracking four care plans the inspectors found that may of the documents had not been signed or dated and in many of them recording was sporadic or had not been completed. The possibility of using simpler care plans that could easily be understood and acted upon by the staff team was discussed with the acting manager Ms. Rutter. There were also concerns that in filling in records staff had written phrases such as “attention seeker” and “very naughty”, to describe the behaviour of service users, which demonstrates a lack of respect and understanding of the needs of people with learning disabilities and mental health needs, who display challenging behaviour. Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11 12 13 14 15 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although some service users have opportunities to take part in appropriate activities and are part of the community, for others there is little evidence of community access or opportunities for development. EVIDENCE: There is now a range of activities available for service users examples include attending college, horse riding, visits to a church group, visits to the pub and a pantomime and one person attends indoor rock climbing. On the day of the visit two people were at college supported by two members of staff. In the home, when the inspectors arrived, some people were still in bed or just wandering about and there was no activity plan for the day in place. Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 14 When the acting manager came on duty two staff members began to play bingo and board games with service users and in the afternoon a karaoke session was held and one person went shopping. One person was asleep in bed until lunchtime, the staff on duty said that this person had been up much of the night. Another service user was asleep on the sofa until lunchtime, also having been up for much of the night. One service user said, “ I like to clean my room myself and I go out to the local post office and shop”. I am on healthy eating plan so I have lost weight and have been out to buy new clothes”. Although activities have improved for some people, observation during the visit and records show that for some of the people living in the home there is very little stimulation or interest besides watching television or videos. The home’s daily records sheets for two service users were tracked over a thirty-six day period. For one person under the activities heading, there was “none” recorded for twenty-six days and on other occasions the plans recorded “watched favourite video or on three occasions “went for short walk” or “short drive”. For another service user, who lives in a self contained flat within the home there was also no evidence of regular stimulating or community activity and records show that the person seems to be isolated in their room for most of the time. For twenty out of thirty-six days tracked, activity records said “none” and other activities were often just going on a drive to take people to college. A staff member commented that this person was, “ happy, contented keeps himself to himself but gets lonely”. The acting manager Ms. Rutter said that the staff on duty, do spend time in the flat with the service user, but there are no records to evidence this. A new, very well equipped sensory room has just been added to the home and is still being completed in order to be fully operational. Service users said they liked the equipment and were looking forward to using the room. Food records and menus were seen and the inspectors saw lunch being prepared and served. The meal was a fresh, healthy prawn salad and people said they enjoyed it. The menu showed that a cooked meal would be offered at suppertime. Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 and 20 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Although the outcomes for the healthcare needs have improved, there are potential risks to service users in that accidents are not reported and there are errors in administration and recording in medication system. EVIDENCE: In order to meet the healthcare needs of service users, there is evidence from care plans and daily reports that the home is working with a variety of healthcare professionals, including psychologists, psychiatrists, care managers and also a speech and language therapist. There is also the availability of a counsellor and aromatherapist who visit the home on a regular basis. Records show that service users also access the dentist and some people have recently undergone basic health checks. The staff team have received training in managing challenging behaviour and restraint and where restraint has been used, detailed records are in place. It is advised that the records are kept in a more accessible place in order for them to be more easily inspected and monitored. Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 16 For one person there was a plan in place from a speech and language therapist which required monitoring forms to be completed daily. The records were in place, but recording was sporadic and often was not filled in for several days. Food records for other service users also were regularly not completed. For another service user who is prone to bruising, accident records had been completed but the incidents of bruising were not reported to the acting manager in order to be investigated and monitored. Medication was kept in a locked cabinet in a locked room and only the senior staff member on duty has access to the key. Staff members who administer the medication have received training from the local pharmacist. Despite a monthly internal audit being carried out, during the visit errors were noted in records in that medication had been signed for and not given and there was a gap in the Medication Administration Recording sheets. One person’s PRN, “taken when needed” medication was recorded in the controlled medication book but had not been entered on the medication sheets. A requirement has been made regarding the administration and recording of medication. Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints from service users are dealt with, but there are still complaints from neighbours that have not yet been resolved. Although the staff team have an awareness of adult protection issues, incident and accidents are not all reported to the manager for investigation. EVIDENCE: There are complaints from neighbours regarding the home that are still unresolved and a public meeting was held to discuss the issues of concern. Although the Registered Provider indicated that closer relationships with neighbours would be further sought, there is no evidence of this at the service. The acting manager said that no new complaints had been received from neighbours, since three people, who had very disruptive and very noisy behaviour patterns had been moved to other homes. Following the recent theft of service user’s monies at the home, new procedures and recording systems have now been put in place to and a new safe has been purchased and fitted in the office. There was evidence in the complaints book that complaints and concerns from service users are now recorded and acted upon in a timely manner. There have been three Adult Protection referrals in the home since the last visit, two of which were upheld with two staff members being dismissed and one placed on the Protection of Vulnerable Adults Register. Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 18 The staff working at the time of the visit confirmed that they were aware of the home’s “whistle blowing” policy and had attended training in the protection of vulnerable adults from abuse. Although all of the staff team interviewed said that they would report any suspicion of abuse straight away to the acting manager, as previously stated, there are potential risks to service users by all accidents and injuries to service users not being reported to the acting manager for investigation. Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 26 28 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There have been significant improvements to the environment and the home provides a warm and comfortable environment for the people who live there. EVIDENCE: There has been a great improvement in the physical environment by communal areas having been updated and refurnished and the dining room had just had a new carpet fitted and new tables and chairs purchased. The lounge area has new furniture and most areas have been redecorated. Service users and staff were decorating the lounge for Christmas and there was a selection of service user’s artwork on the walls in the hall and dining room. The rugs in the hallway would benefit from being steam cleaned. Service user’s private bedrooms are mostly comfortable and homely and have been personalised with personal belongings, TV’s and music centres. Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 20 One person lives in a self-contained flat within the home and said they had chosen their own furniture and decoration. Another service user showed the inspector new furniture he had chosen himself and indicated that he was very pleased with the changes to his room. One person has only a bed in their room and the reasons for this are detailed in their care plan. Water temperatures in bedrooms were checked and found to be at a safe level. Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the staff team are kind and caring, outcomes for service users would benefit by shifts being more structured and training given in the care of specific conditions such as autism and mental health awareness. EVIDENCE: There were six care staff and the acting manager on duty. Two people had accompanied service users to college, which left four staff members and the acting manager in the house. It was observed that there was no real plan for the morning other than who would be carrying out personal care support, the people on duty were unfocussed and until the acting manager arrived, no real leadership or organisation of the shift was in place. The person the inspectors were told was a senior carer and one of the shift leaders was in the kitchen cooking for much of the day and the other person was quite new and did not seem to have an awareness of their responsibilities regarding shift management. Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 22 It would benefit both the staff team and outcomes for service users, if a daily plan were put in place, which guided each staff member on their tasks for the day The staff members on duty were however kind and caring in their dealings with service users and were seen to be responsive, friendly and patient. One staff member commented that the service was “challenging, but good to work in”. The service users living in the home have very complex needs and in order for the staff team to better understand how to support them, there was to have been training carried out in mental health and autism awareness. The acting manager said that this had been postponed by the trainer and was booked for early in the New Year. The staff files for three new staff members were seen and all contained the required documentation, including current Criminal Bureau Checks and two references. The acting manager is to be commended on the work she has carried out to update staff files. Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 38 39 40 and 42 Quality in this outcome area is adequate. Although the home is being well managed on a temporary basis, to ensure long-term stability, a registered manager should be recruited without delay. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Whitehaven is currently being run by a very experienced and committed acting manager, who has worked hard to improve the care standards and living conditions within the home. The deputy manager, who was also very experienced, has been seconded to another Allied Care home. The acting manager said that she is delegating some responsibilities to two current staff members, but records show that neither people yet have received training in the skills required for management. Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 24 Feedback in comment cards showed that families are aware of, and very pleased with the positive changes brought about by Mr. Rutter’s management style and approach. Ms. Rutter said that she had interviewed several people for the post of Registered Manager, but none to date have had demonstrated the skills and experience to run such a complex service. It remains a Requirement that the home recruits a Registered Manager without delay and no new service users will be admitted until the person has been registered and a period of stability has been proven. Ms Rutter has worked very hard to update the policies and procedures in the home and is to be commended on the changes and improvements she has made. Records for the running of the business were seen and most were in good order. As previously stated in this report, to ensure that service user’s needs are fully met, improvements need to be made to recording in daily records, care plans and health care recording. Allied Care Ltd acts as financial appointee for many of the service users living at Whitehaven and it was discussed with Ms. Rutter that perhaps as good practice, independent appointees or legal representatives could be explored as being more appropriate to represent these individuals. Where monies are held on the service for individual service users, they are securely locked in a safe, records are in good order and receipts kept on file. Three service users monies were checked and found to be correct. Fire records and fire staff training were seen to be up to date, maintenance records were in place and hot water tests were recorded on a regular basis. As a result of this visit, Requirements have been made regarding the administration and recording of medication and the reporting of injuries to service users and there is still an outstanding Requirement for a manager to be employed and registered without delay. Whitehaven DS0000048443.V318839.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 2 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 3 27 x 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 2 x LIFESTYLES Standard No Score 11 2 12 2 13 2 14 2 15 2 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 x 3 3 x x 2 2 x Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 26 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 YA20 Regulation 13 (2) Requirement To ensure that service users are protected at all times the Registered Provider should ensure that systems for administration and recording of medication are improved. To ensure the safety of service users at all times, the Registered Provider should ensure that accidents or injuries to service users are reported and investigated. To ensure the future safe management of the service, the Registered Provider should ensure that a manager is recruited and registered as a matter of urgency. Ongoing Requirement Timescale for action 30/01/07 2. YA19 13.4 (b) 30/01/07 3. YA37 10 (1) 30/01/07 Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 27 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 YA41 Good Practice Recommendations In order to ensure that the staff team completes records and paperwork in a more effective manner, it is recommended that the acting manager consider simplifying the systems of recording care plans and daily records in the home. In order to the acting manager and ensure consistency in the service in their absence, it is recommended that an experienced deputy manager is employed. 2. YA33 Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Whitehaven DS0000048443.V318839.R01.S.doc Version 5.2 Page 29 - 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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