Inspection on 21/08/07 for Whitehaven

This inspection was carried out on 21st August 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Whitehaven 15/12/06

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 Mr E McLeod Unannounced Inspection 21st August 2007 11:30 Whitehaven DS0000048443.V342813.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.V342813.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.V342813.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.V342813.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. 15th December 2006 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 selfcontained 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. At the time of the visit, there was a specific condition imposed that the service does not admit any more service users until there is a manager in place who is in full control of the home. This is now a voluntary agreement. Current fees are £950 to £1, 897.15 per week. Whitehaven DS0000048443.V342813.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was arranged to follow up requirements made at the previous inspection and to undertake a further assessment of how the home is meeting the key national minimum standards. The visit was undertaken by one inspector and lasted for six hours. Planning for the visit took into account information received on the service since the previous visit, including a CSCI annual quality assessment self-audit (AQAA) from the home which updated us on service provided in the home, four survey forms returned to us by people living in the home or their relative giving their view of the service provided, and a letter of complaint passed on to us. During the visit we talked to people living in the home, to the manager, and to three members of staff. We also looked at three sets of care plans and other records relating to the care provided and health and safety in the home. We sampled two sets of staff recruitment and training records. We observed interactions between staff and people living in the home, and visited areas of the home including three bedrooms and the main communal areas. What the service does well: What has improved since the last inspection? The system for the administration of medicines has been improved and made more safe for people. Whitehaven DS0000048443.V342813.R01.S.doc Version 5.2 Page 6 In the last 12 months all rooms and bedrooms have been refurbished and decorated, and some rooms have had new carpets and flooring, Suggestions made by people living at Whitehaven have resulted in changes such as the purchase of a bird table, and changes to the menu, and in response to a suggestion made by relatives and staff, an equipped sensory room has been set up. The temporary provision of a sensory room and an activities co-ordinator have helped increase the number of activities available to people living in the home. Closer monitoring of accident records is now in place to ensure that the subsequent action plan has been carried out. What they could do better: There is a need for care plans to better reflect the changing needs and personal goals of people living at Whitehaven, and to provide more accessible guidance for staff. Managers need to identify what staff are in need of what training or updating training and ensure all staff are trained in core topics, health and safety topics, and specialist training relevant to caring for the people who are living in the home. . There was a lack of evidence that the provider is properly monitoring the service provided in the home. Surveys the home has carried out on the service provided have not been published and made available to interested parties, and have not been summarised and contributed to a plan for the development of the service. There has been a history of inconsistent management of the service, and previous inspection reports reflect this in inappropriate admissions to the home and poor staff practice. A manager who is appropriately qualified and experienced needs to be registered for the service to help ensure that these past concerns are not repeated. Whitehaven DS0000048443.V342813.R01.S.doc Version 5.2 Page 7 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.V342813.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.V342813.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are arrangements in place for people’s needs to be assessed before they are admitted to Whitehaven, during which the home will consider if they are able to meet the person’s needs. A written and costed contract or statement of terms and conditions between the home and the person living in the home are being provided. EVIDENCE: The statement of purpose for the home was updated in July 2007. This advises people living at Whitehaven, their relatives and prospective residents of the service that will be provided in the home. The service has voluntarily agreed with CSCI not to admit any new people to the service pending the outcome of improvements being undertaken. There have therefore been no admissions to the service since the previous inspection. Whitehaven DS0000048443.V342813.R01.S.doc Version 5.2 Page 10 The manager has advised us that the procedure for admissions has been revised and updated within the past 12 months. During the inspection visit, the manager said that it was important that a stricter admission procedure be followed to ensure that the resident group at Whitehaven is compatible and that their needs can be met. We are advised in the annual CSCI quality self-assessment audit (AQAA) by the manager that people referred for admission to Whitehaven are visited and assessments are carried out, and that social worker care plan information is requested. Compatibility with the current service user group is taken into consideration, and this is part of the reviewed admission procedure. There is provision for transitional visits and a probationary stay is said to take place after preparation for this is completed. While blank copies of a standard contract between the home and people living there were available at inspection, contracts for some individual residents were not available. These were however provided subsequent to the inspection visit. Whitehaven DS0000048443.V342813.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a need for care plans to better reflect the changing needs and personal goals of people living at Whitehaven. People are being assisted and encouraged to make their own decisions. Areas of possible risk for each person are being assessed, and judgements are being made where people can be supported to take responsible risks which will enhance their independence skills. EVIDENCE: Whitehaven DS0000048443.V342813.R01.S.doc Version 5.2 Page 12 At the previous inspection we advised that the care plans provided for each person living in the home needed to provide more concise and clearer guidance to staff on how the person’s needs were to be met. Previous to the inspection visit the manager advised us that care plans and risk assessments have been further developed in the past year, and that care plans and risk assessments are in place and are being regularly reviewed. Three sets of care plans were sampled. It was evident that different care plan formats are now existing side by side in the one care plan, leading to a large file full of information of varying relevance to the care that is planned to take place for the person being cared for. We looked at three sets of care plan reviews. We found that while the care plan review for one person said simply “no change” the key worker report for the same person indicated a number of new activities being undertaken with him to support his independence skills. This is working information that needed to be included in the care plan, and indicates the need for the care plan to be more flexible, more easily accessed and revised. One to one support is provided through a key worker system to allow people to express their wishes, thoughts and feelings. We interviewed staff, and they gave examples of how they are supporting the person to make choices and decisions. People living in Whitehaven talked to us about their choice of holiday and plans for holidays during our visit. Risk assessments which had been recently updated were found on all the care plans sampled. The manager and staff interviewed described responsible risks taken which can assist the person towards greater independence and quality of life. An example given was of one person who previously has been afraid of water who after having been taken to a hydrotherapy pool is keen to continue going there. Whitehaven DS0000048443.V342813.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are helping people to practise their social and communication skills, and independent living skills are being encouraged. People are being assisted to continue their education and training and to do things they enjoy. People are being supported to make use of facilities in the local community. Staff are seeking to ensure that daily routines promote independence and individual choice. Arrangements are in place for people to choose food they like and to have healthier menu choices. EVIDENCE: Whitehaven DS0000048443.V342813.R01.S.doc Version 5.2 Page 14 The manager told us that an activities co-ordinator has been employed, and that more daily structure and activities have been introduced, and that this had a positive effect on people living in the home. The manager has told us that four people presently attend further education, and several others are currently being assessed for suitable courses which will begin in September 2007. On the day of the inspection visit, outings and activities were taking place and activities records seen indicated that a consistent level of opportunities for people to practice life skills and remain active are being provided. The manager has advised us that each person is offered opportunities to attend the church of their choice. The manager has told us that a speech and language therapist visits three people in the home to assist in the development of their communication skills. One member of staff interviewed said that makaton signing skills were helpful in communicating with one particular person. Independence and daily living skills are being encouraged – for example one person does his own laundry, some of his own cooking, has an individual shopping budget and buys his own food. Activities where staff are providing support in the community include shopping trips, meals out, and visits to the library and pubs, swimming and horse riding. One person showed us the art and craft work she had been doing, and we visited the crafts room and a bedroom which has been temporarily changed into a sensory room. The manager told us that during the day this is well used by people for the chance to relax and use the equipment in the room. People living at Whitehaven are going on holidays of their choice, and being supported to do this by staff. The manager tells us that the company contributes £520 per person towards the cost of their holidays each year. Whitehaven DS0000048443.V342813.R01.S.doc Version 5.2 Page 15 On the day of the visit, routines were found to be flexible – particularly where one to one support is being provided for the person. We are advised that staff agree the menus with people before shopping for food, and that people can choose to assist on the weekly shopping trip. Mealtimes are said be relaxed, unrushed and flexible to suit individual needs. The manager told us that fried food is avoided, and staff interviewed provided examples of how they are helping people to choose a healthier diet. Whitehaven DS0000048443.V342813.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are providing sensitive and flexible personal support. People are being assisted to access the healthcare services they need. The system for the administration of medicines has been improved and made more safe for people. EVIDENCE: The manager told us that staff will ask if the resident is happy with the person who has been allocated to do their personal care. People living in the home require high levels of support, and we observed that staffing levels provided are at present able to ensure flexible personal support Whitehaven DS0000048443.V342813.R01.S.doc Version 5.2 Page 17 is being provided. Staff interviewed said that people choose what they wear and how they look, so for example one person had done her own make up that morning. Healthcare records seen indicated that people are receiving the medical support they are in need of. We also tracked the healthcare of one person who had been suffering weight loss and dental problems which a relative told us in a survey form had taken a number of months for staff to arrange. While we found that records for this did not evidence all the contact staff said they had had with the healthcare services concerning these matters, the outcome for each matter was clearly recorded and services had been accessed accordingly. Certificates for staff training in the administration of medication were seen on staff files. Health care action plans and medical services were sampled on care plans. The manager has told us that guidelines for occasional medicines have been developed, and that homely remedies information is now in place for each person. Risk assessments for self-medication are provided for each person. Staff told us that no people living in the home are responsible for their own medicines. Records seen indicated that the system for administering medicines has been improved to ensure more rigorous checks are carried out and medicines are administered more safely. The previous requirement made in respect of this is now assessed as met. Whitehaven DS0000048443.V342813.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home and others can expect to have their concerns or complaints investigated and the conclusions communicated to them. People are being protected against abuse and self harm. EVIDENCE: The complaints procedure is posted on ground and first floor notice boards and in the service user’s guide. The complaints record was sampled, and it was noted that no new complaints have been recorded since the previous inspection. CSCI has received through a local member of parliament a complaint referring to unruly behaviour outside the care home and a local shop. This was discussed with the manager, who said that as people living in the home are generally supervised when they leave the building, it was unlikely to have been them involved in the incidents. Whitehaven DS0000048443.V342813.R01.S.doc Version 5.2 Page 19 The manager told us that training in the protection of vulnerable adults has been completed by all staff, and whistle blowing procedures are in place for both staff and people living at Whitehaven. The manager also advised that all people living at Whitehaven have risk assessments regarding harm or abuse from others. A member of staff interviewed advised us of the support provided at night to protect a person who self-harms. Senior staff advised us that they had hoped to attend a briefing update on local adult protection procedures, but there had been no places available on the most recent briefing. Staff interviewed confirmed that they are receiving training in restraint techniques. The manager said that restraint is used as a last resort and has been employed twice in the past year. We looked at the record for the most recent restraint incident, and advised that the recording for this would be improved by detailing the restraint used and for how long, and its’ effectiveness. A restraint plan was sampled on the care plan of the person concerned, which provides clear guidelines for staff on techniques to be used. A monthly provider visit record from April 2007 seen indicated that the company checked the records of pocket money held for three residents. Whitehaven DS0000048443.V342813.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a safe, comfortable and homely environment. People’s bedrooms are decorated and furnished to meet their needs. Communal areas which meet people’s needs are provided. The home is kept clean and fresh. EVIDENCE: The manager has told us that the in the last 12 months all rooms and bedrooms have been refurbished and decorated, that some rooms have had Whitehaven DS0000048443.V342813.R01.S.doc Version 5.2 Page 21 new carpets and flooring, and that six bedrooms have had new wash hand basins and vanity units. We visited four bedrooms and found them to be comfortably furnished. The manager advised that the person’s bedroom is individualised to reflect their needs, interests and preferences. Garden furniture has been purchased, and the garden was noted to be being well maintained and people were sitting in the garden and playing ball games there. Other improvements to communal areas include a new dining room carpet, and the setting up of a temporary activities room and a sensory room. Staff indicated that both these rooms are well used and have had therapeutic benefits for the people living in the home. We discussed with the manager that these are facilities which will be much missed by people if the areas revert to being bedrooms and no alternative area suitable for these activities is provided. We looked at the monthly risk assessments of the building which are undertaken together with the maintenance worker for the home. Records of work needed and actioned are held in the maintenance file, and on the day of the visit new furniture was being put together in one bedroom. The manager has told us that regular cleaning of carpets by an external contractor takes place. There are cleaning schedules for the kitchen, bathrooms and toilets. We sampled the cleaning records for the kitchen which indicated that this area is being regularly cleaned. All areas of the home visited were found to be clean and hygienic. Whitehaven DS0000048443.V342813.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are at present meeting the needs of people living in the home, although it is to be noted that the context for this is a smaller number of residents being accommodated at the time of the inspection. Staff recruitment procedures are robust and help protect people living in the home from harm. Staff in the home are undertaking qualifications which will improve the quality of care provided. Staff training records are not adequate, and the training needs of staff are not being audited at present. There is a lack of evidence that staff are trained in the tasks they will be carrying out in the home. EVIDENCE: Whitehaven DS0000048443.V342813.R01.S.doc Version 5.2 Page 23 Staff we interviewed where English was not their first language were found to have good language skills, and provided good examples of how they support people living in the home with their communication needs. The manager said that language courses for staff whose first language is not English have helped managers to ensure that staff know what is expected from them and to better understand their roles and responsibilities. The previous inspection report highlighted a need for staff to receive training in specific conditions such as autism and mental health which are relevant to the care of the people being accommodated. Training records seen indicated that since December 2006 nine staff have undertaken training in challenging behaviour and five in mental health awareness. Some training in autism had been undertaken since the previous inspection, but as full training records were not in place at the time of the inspection visit, it was unclear if managers were able to identify what staff were in need of training or updating particular training. . Training certificates in staff files sampled did not provide evidence that staff are undertaking all the training in core topics, health and safety topics, and specialist practice issues which are relevant to the responsibilities they are expected to carry out. It was noted that senior staff are presently updating training records. However, at the time of the inspection visit there was a lack of evidence that managers were able to identify what staff were in need of what training or updating training. The manager said that there is now more training in place for staff, which includes training sessions provided weekly, and that this has recently included training in record keeping and report writing. She said that the previous training provider had been failing to provide certificates for some of the training undertaken, so a new training provider was now in place. Information provided by the manager indicated that 50 of staff employed in the home have undertaken food hygiene training, although most staff will be involved in food preparation in the home. The manager said that in view of this, the home may seek to bring forward the date planned for staff training in food hygiene. Whitehaven DS0000048443.V342813.R01.S.doc Version 5.2 Page 24 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is being managed better for people who live there, and has a good atmosphere. A manager needs to be registered for the service to ensure that improvements to the service are consistent and continued. Some of the responsibilities of quality self-audit and annual planning are not being carried out in the home. The provider is therefore failing to monitor that the home is serving the best interests of the people living there. A safe environment is being provided for people living in the home and staff. Whitehaven DS0000048443.V342813.R01.S.doc Version 5.2 Page 25 EVIDENCE: There is a manager for the home who commenced in March 2007, but who has not yet submitted an application for registration. The manager told us that she is NVQ level 4 and registered manager award qualified, and has previously worked as deputy manager in the home. She said she is awaiting the return of statutory checks which she applied for in July 2007, after which her application will be submitted. The manager told us that a survey has been carried out of the views of people living at Whitehaven, their relatives, and external professionals, and that suggestions made by people living at Whitehaven have resulted in changes such as the purchase of a bird table, and changes to the menu, and that in response to a suggestion made by relatives and staff an equipped sensory room has been set up in a vacant bedroom. During the visit, an annual development plan for the home was not available. We looked at reports of the monthly provider visits, and found only one visit record since the previous inspection. There was therefore a lack of evidence that the provider is monitoring the quality of care provided in the home. A survey has been carried out of the views of people living at Whitehaven, their relatives, and external professionals. The manager told us that no summary of the findings and resultant action points has been published. A recent inspection visit by the fire service made no requirements. The acting manager has advised us of the most recent services and checks of equipment which have been carried out. Whitehaven DS0000048443.V342813.R01.S.doc Version 5.2 Page 26 Closer monitoring of accident records is now in place to ensure that the subsequent action plan has been carried out. The previous requirement made in respect of this is now assessed as met. There are good monthly safety checks in place, and records for these were sampled. Staff interviewed advised that maintenance work is also carried out during these checks. Whitehaven DS0000048443.V342813.R01.S.doc Version 5.2 Page 27 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 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 3 27 x 28 3 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 3 2 x x 3 x Whitehaven DS0000048443.V342813.R01.S.doc Version 5.2 Page 28 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 YA39 Regulation 26 (2) (3) 24 (1) Requirement Timescale for action 26/10/07 2. YA37 8.1 3. YA35 18.1 (c) 4. YA6 15.2 The registered person must establish and maintain a system for evaluating the quality of the services provided to ensure that the care home is serving the best interests of the people living there. To ensure the future safe 26/10/07 management of the service, the Registered Provider should ensure that a manager is recruited and registered as a matter of urgency. The previous timescale for this requirement of 30/01/07 has not been met. The provider must ensure that 30/11/07 all staff are trained in the tasks they will be carrying out in the home. Care plans must better reflect 20/12/07 the changing needs and personal goals of people living at Whitehaven, and to provide more accessible guidance for staff. Whitehaven DS0000048443.V342813.R01.S.doc Version 5.2 Page 29 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 Whitehaven DS0000048443.V342813.R01.S.doc Version 5.2 Page 30 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.V342813.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!