Inspection on 16/05/06 for Whitehaven

This inspection was carried out on 16th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Whitehaven 21/08/07

Whitehaven 15/12/06

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 16th May 2006 09:30 Whitehaven DS0000048443.V292243.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.V292243.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.V292243.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 Mrs Janice South Care Home 14 Category(ies) of Learning disability (14), Learning disability over registration, with number 65 years of age (1) of places Whitehaven DS0000048443.V292243.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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. Date of last inspection 5th November 2005 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 Registered Manager is now Mrs Janice South, who is responsible for the day-to-day running of the home. Whitehaven DS0000048443.V292243.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 at 9.30am and lasted for 7.5 hours. During the visit the inspectors spent time speaking to service users and staff and observed interactions and activities being undertaken. A tour of the building was carried out, which covered communal areas and service user’s bedrooms and the inspectors brought to the attention of the manager some areas of concern, which included water temperatures and the safety and cleanliness of the environment. Ms South said they would be dealt with immediately. The pre-admission assessments for two new service users were seen and six care plans were tracked with any issues arising being discussed with Ms. South and other staff members. The inspectors observed lunch being served and saw menus and food records. Records for the management of the service were also seen including, staff recruitment, health and safety, maintenance and fire records. Prior to the visit the inspectors met to discuss the service and plan the visit using an inspection plan record. The manager of the home completed a preinspection questionnaire, which was used to give further information regarding the home. A parent was spoken to about their views about the care provided in the home via a telephone conversation. Evidence received during a monitoring visit following the last inspection and complaints received by the Commission were also used to inform the assessment of the service provided. Feedback given by the inspectors to Ms South and the Deputy Manager at the end of the visit highlighted that standards regarding assessments, care plans, safety of service users and staff and the environment had fallen since the last visit. A letter was sent from a Regulation Manager to the Registered Provider following the visit, detailing concerns regarding standards at the home. The overall outcome for service users is considered to be poor. Whitehaven DS0000048443.V292243.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: There needs to be improvements to pre admission assessments to ensure that the resident group are compatible and that the staff team are not working from out of date information leading to service user needs not being met. Care plans need to be in place for all service users and these documents need to be regularly reviewed and updated with risk assessments included. Care plans should also contain details of how healthcare, social and emotional needs will be met. The home needs to improve community access and opportunities for personal development for service users and ensure that residents are supported to be aware of their rights and responsibilities in the local community and within the home. The home also needs to ensure that service users are motivated and involved in stimulating activities. Medication recording needs to be further improved to specify what PRN medication has been administered to service users. There is an urgent need for the home to ensure that both service users and the staff team are protected from the risk of physical attacks or risk of abuse. Risk assessment need to be in place regarding all challenging behaviour management and where restraint strategies have been agreed they should be followed and recorded correctly. There is an urgent need for the manager of the home to ensure that all service users are living in a clean, hygienic and safe environment. The home is in need of modernisation and refurbishment and furniture that has been broken in service user’s bedrooms should be replaced. Risk assessments should be Whitehaven DS0000048443.V292243.R01.S.doc Version 5.2 Page 7 carried out to ensure that service users are receiving the support they need to keep their rooms clean and free from risk of infection. Systems should be put in place to ensure that the staff team receive appropriate training and support. At present there are no staff meetings other than senior team meetings, which are designed to cascade information to other staff. Records in the home and observation of interactions show that staff team do not have an understanding of their roles and responsibilities and regular supervision is not yet in place. As many of the service users being supported have poor verbal communication skills, the manager of the home needs to ensure that their needs are understood. This is particularly important as English is a second language for most of the staff team Systems and the recording of expenditure should be further improved to ensure that service users are protected from the risk of financial abuse. Incidents and accidents in the home should be recorded in the correct files and where necessary reported to the Commission under the regulation 37 requirements. Working practices, staff support, communication and records should be improved to ensure that the home is run in the best interests of service users. and a quality assurance process should be put in place to gain feedback on the service provided. To ensure that both service users and staff are protected, fire training for both day and night staff should be updated and water temperatures kept at a safe level at all times. 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. Whitehaven DS0000048443.V292243.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.V292243.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 4 Quality in this outcome is poor. This judgement has been made using available evidence including a visit to the service. To ensure that service users and staff are protected from risk, further improvements need to be made to the preadmission procedure. EVIDENCE: The pre-admission assessments for two recent service users were seen and both had basic information regarding the care needs of each person. There is still no information available about the compatibility of residents or evidence that current service users are involved in the process of choosing who they live with. To ensure the safety of both residents and staff members the assessment process must be reviewed and improved. The environment is still volatile with a large number of incidents of challenging behaviour occurring, which results in assessed needs not being met. Whitehaven DS0000048443.V292243.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality in this outcome is poor. This judgement has been made using available evidence including a visit to the service. Care plans do not reflect the current health and social status of the residents in some cases they still need to be written. The majority are in urgent need of review and should include risk assessments EVIDENCE: Care plans for six residents including the two most recent were tracked. Despite some improvements to the care planning process having been made at the last visit when a new care planning system was being put in place, very few further improvements have been made. For the two latest residents admitted to the home there have been no current care plans written and the staff team are working from outdated information provided from former placements. Risk assessments have not been completed for many residents and those that are in place have not been recently updated and reviewed. Whitehaven DS0000048443.V292243.R01.S.doc Version 5.2 Page 11 The deputy manager of the home showed the inspectors care plans that are being worked on which are still on the computer but there is very little current information available to assist staff in their roles. Whitehaven DS0000048443.V292243.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 16 & 17 Quality in this outcome is poor. This judgement has been made using available evidence including a visit to the service. Despite improvements having been made to the food provided, there has been a failure to identify the residents’ preferences regarding their leisure pursuits and other aspects of their social needs. EVIDENCE: Three of the residents were out attending College and another was on holiday with one parent and a member of staff. This would indicate that some consideration has been given to the mental and social welfare of some residents The care plans scrutinised for the purpose of case tracking were poor and had not been recently reviewed and updated. Even though some specific difficulties had been identified for individuals, there were no plans in place to deal with any aspects of relationships or sexuality. There was no evidence in the care plans examined that any resident had an activity plan agreed for them. There were also specific areas of need such as Whitehaven DS0000048443.V292243.R01.S.doc Version 5.2 Page 13 regular counselling support identified and agreed for one resident but there was no evidence that this having happened. Another example of the lack of stimulation was found in the fact that one resident, who was recorded as having disturbed nights with extremely disturbed behaviour associated with them was asleep throughout the whole period of inspection. Staff said they would not wake the person because they were afraid of the behaviours the person might display might display if they did. Other people were just wondering around in an aimless fashion and although there were staff members ensuring their safety there appeared to be no understanding of the need for resident’s involvement or stimulation. There is evidence from the number of complaints made by local residents concerning noise and disruption, that service users are not well accepted or integrated into their local community. One person spends a great deal of time isolated in their self contained flat. This person’s plan records that they have an agreed one to one staffing ratio at all times but this was not happening. The food provided for the day was noted to contain fresh vegetables and at lunchtime individuals were seen to be eating a varied selection of meals of their choice. When asked M said, “it’s good food”. Whitehaven DS0000048443.V292243.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome is poor. This judgement has been made using available evidence including a visit to the service. Although the home works with a variety of healthcare professionals, observation, recording and staff’s skills need to improve to ensure that service user’s healthcare and emotional needs are met. EVIDENCE: As previously mentioned the care plans examined for the purpose of tracking were found to be incomplete and heavily reliant on previous and outdated assessments and care plans undertaken by the previous placement or care manager. There is evidence in records to show that the home works with a variety of healthcare professionals including community teams, psychiatrists and district nurses and appointments are recorded. From the number of outbursts recorded and witnessed on the day of the visit, it would appear that residents’ emotional needs are not being met to any great degree. A medical review had taken place for one person and the changes to his medication had been appropriately recorded. Medication was stored Whitehaven DS0000048443.V292243.R01.S.doc Version 5.2 Page 15 administered and disposed of properly and medication-recording sheets were found to be up to date and signed appropriately. In one person’s daily log “given as needed”, known as PRN medication, was written on several occasions although there was no indication of what medication had been given. This could be a dangerous practice should more than one medication be prescribed PRN as an overdose could be administered. The in-house policy regarding staff’s responsibilities and responses in the event of a “sudden death” occurring has been reviewed. Whitehaven DS0000048443.V292243.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome is poor. This judgement has been made using available evidence including a visit to the service. Complaints are recorded and acted upon but service users are at risk because correct procedures are not followed when staff members deal with challenging behaviour. EVIDENCE: The home has a complaints procedure in place and one formal complaint from neighbours has been recorded plus two informal complaints from service users. There is evidence from written outcomes to show that complaints are acted upon in an appropriate manner. Although most of the staff team have attended training in the protection of vulnerable adults from abuse there is evidence from daily recording, observation and incidents and accident reporting that service users, staff members and visitors to the home are at risk. Risk assessments and behaviour management plans have either not been put in place or have not been reviewed and updated. An example of this was that the staff team had been trained in physical interventions for two specific service users. Records showed that the plan had not been followed correctly when dealing with incidents, therefore putting both the resident and staff at risk. There was not a copy of the agreed plan on the service user’s files, therefore leading to staff having no guidelines to follow. Incidents are not always recorded and filed in the correct location, therefore highlighting a lack of understanding in the staff team of the correct procedures to follow. Whitehaven DS0000048443.V292243.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26 & 30 Quality in this outcome is poor. This judgement has been made using available evidence including a visit to the service. The décor and fabric of the home is in a poor condition and in need of urgent refurbishment. EVIDENCE: Although there has been some decorating and upgrading carried out in recent months the environment is currently in need of updating and refurbishment. In communal areas the furniture is basic and in need of improvement. The sofa in the lounge is ripped and an armchair is covered in dried paint. There was a strong smell of urine in one of the toilets and in some service user’s bedrooms. The upstairs bathroom has been refurbished but there are jagged edges to the plastic wall covering, the door edging is not completed and a tile is missing from the wall. There was flood damage in the hall and stairs and a large damp patch on one service user’s ceiling. These areas were pointed out at the last visit. Whitehaven DS0000048443.V292243.R01.S.doc Version 5.2 Page 18 The service needs to review and update care plans with regard to the needs of service users in keeping their rooms clean and hygienic. In one room there was a large build up of toothpaste and lime scale on a sink, which could constitute a health and infection hazard. One specific bedroom, which was found to be in an unacceptable hygienic and environmental state, was pointed out to the manager at 10am as needing cleaning and making safe. This still had not been suitably carried out by 4pm in the afternoon, when it was again highlighted Ms South. Some bedrooms are dark and unwelcoming and would benefit from brighter decoration. In a self contained flat within the home most of the furniture has recently been destroyed by the person occupying the flat. In order to ensure that people are living in a clean and safe environment, the needs of service users should be reassessed and recorded. Whitehaven DS0000048443.V292243.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 36 & 36 Quality in this outcome is poor. This judgement has been made using available evidence including a visit to the service. Although there are sufficient numbers of staff on duty, the lack of communication and staff skills leads to risks for both service users and the staff team. EVIDENCE: There has been two new staff members recruited since the last visit. The records of both were seen to contain all of the required documentation, including CRB checks and two references. As many of the service users being supported have poor verbal communication skills, the manager of the home needs to ensure that their needs are understood. This is particularly important as English is a second language for most of the staff team. Through observation and talking to both service users and staff it was clear that communication was a difficulty within the service and this has been discussed with Ms South at the last two visits. The home used to provide English lessons for the staff team but these have been discontinued. There were seven care staff plus the Deputy, the Registered Manager and a maintenance person working at the home. During the course of the visit, the Whitehaven DS0000048443.V292243.R01.S.doc Version 5.2 Page 20 inspectors witnessed the staff members relating to the residents with kindness and humour. In particular the Deputy Manager was seen to be deferential and respectful when speaking with the residents. There is a new training matrix in place and each staff member has a training record on file. Training includes adult protection, medication, infection control and behaviour management and control. However some staff members still have not yet accessed all mandatory training. Only the two senior staff at the home have completed the NVQ award. The manager said that many of the overseas staff had completed relevant training in their home countries, which equates to the award. It is recommended that Mrs. South contact the Skills for Care consortium to check on the relevance of the qualifications and place the outcomes on each person’s personal file A programme of supervision is displayed in the home but from discussions with staff and looking at records it is clear that all staff have not yet received supervision. Senior staff meeting take place on a regular basis with a plan then in place for each senior staff member delegated to cascade information to a number of other staff. There is little or no evidence to show that this is happening in practice. Through observation and reading reports and other documentation in the home, it is clear that the staff team need increased support to ensure that they fully understand their roles and responsibilities. Whitehaven DS0000048443.V292243.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41 & 42 Quality in this outcome is poor. This judgement has been made using available evidence including a visit to the service. To ensure that the home is safely managed, communication between the manager and staff team, staff support, systems and records need to be improved. EVIDENCE: Records were found to be inconsistent, with care plans varying in the detail and there has been failure to report significant incidents under Regulation 37 requirements including recording of incidents and accidents. Few risk assessments were in place and daily records were negative and sketchy in detail. The home needs to improve its policies and practices to ensure that service user’s monies and financial interests are protected at all times. Service users rights and best interests were not safeguarded as care plans and other records do not reflect the package of care that had been agreed by the Whitehaven DS0000048443.V292243.R01.S.doc Version 5.2 Page 22 care manager on the individual’s behalf. Examples of this were where individuals had been agreed for one to one staffing or counselling sessions, which were not being carried out. Health and safety records were seen, which included fire records, gas certificates, and electrical appliance testing and maintenance records. Staff fire training was out of date for both day and night staff. Despite records showing that water outlets are tested and recorded weekly, several taps in service user bedrooms were found to be too hot. The maintenance man was informed and adjusted the outlets during the visit. There had been no quality assurance initiatives undertaken since the last key inspection. Whitehaven DS0000048443.V292243.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 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 CONCERNS AND COMPLAINTS CHOICE OF HOME Standard No Score 1 X 2 1 3 1 4 1 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score Standard No 22 23 Score 3 1 1 1 1 1 X ENVIRONMENT Standard No Score 24 1 25 1 26 1 27 X 28 X 29 1 30 1 STAFFING Standard No Score 31 1 32 2 33 1 34 3 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000048443.V292243.R01.S.doc LIFESTYLES Standard No Score 11 2 12 2 13 1 14 2 15 X 16 1 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Whitehaven Score 1 1 3 X 1 X 1 1 1 X X 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. 2. Standard YA2 YA3 Regulation 14 14 Requirement Service users are only admitted to the home following a full assessments of needs The registered manager should demonstrate that the home can meet the assessed needs of individual service users Each service user should have a comprehensive plan of care in place, which is regularly reviewed and updated to reflect changing needs. The registered manager should ensure that service users are offered opportunities to participate in the day to day running of the home Risk assessments should be completed to ensure that service users can be supported take risks in an assessed and managed way Service users should be enabled to develop and maintain social, emotional, communication and independent living skills Service users should be supported to become part of and participate in the local community and have access to a range of appropriate leisure DS0000048443.V292243.R01.S.doc Timescale for action 25/06/06 25/06/06 3. YA6 15 25/06/06 4. YA8 15 25/06/06 5. YA9 16 (j) 25/06/06 6. YA11 12 25/06/06 7. YA13 12 25/06/06 Whitehaven Version 5.2 Page 25 activities. 8. YA19 12 The registered manager should ensure that the changing healthcare and emotional needs of service users are reviewed and met. The registered manager should ensure that fire training in regularly updated. The registered manager should ensure that service users are safeguarded from Physical, financial, psychological, sexual and neglectful abuse at all times. The registered manager should ensure that each service user is provided with a bedroom that has suitable furniture and fittings. The registered manager should ensure that the home is kept clean, hygienic and free from offensive odours and risk assessments should be compiled with regards to individual service users support needs. The registered manager should ensure that communication in the home is improved to ensure that the staff team benefit from clarity of roles and responsibilities. The registered manager should ensure that regular staff meeting are held and that these meetings are recorded and actioned. The registered manager should ensure that all staff receive regular supervision and support. The registered manager should ensure that an effective quality assurance system, which is collated and published is in place The registered manager should ensure that all records in the service are kept up to date and are accurate. DS0000048443.V292243.R01.S.doc 25/06/06 9. 10. YA42 YA23 23.4 13 (6) and (7) 25/06/06 25/06/06 11. YA26 23 25/06/06 12. YA30 13.2 (k) 15/06/06 13. YA31 18.5 (b) 25/06/06 14. YA33 18 25/06/06 15. 16. YA36 YA39 18 24 15/07/06 15/08/06 17. YA41 24 15/06/06 Whitehaven Version 5.2 Page 26 18. YA42 24 The registered manager should ensure so far as is reasonably practical the health, safety and welfare of service users and the staff team. 15/06/06 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 YA20 Good Practice Recommendations Records of PRN medication administered should identify which medication has been given. 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