Inspection on 20/11/06 for Whitehaven Lodge

This inspection was carried out on 20th November 2006.

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

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

Other inspections for this house

Whitehaven Lodge 15/05/09

Whitehaven Lodge 15/05/08

Whitehaven Lodge 16/05/07

Whitehaven Lodge 18/05/06

Whitehaven Lodge 16/02/06

Whitehaven Lodge 22/09/05

Whitehaven Lodge 03/02/05

Whitehaven Lodge 01/06/04

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

CARE HOMES FOR OLDER PEOPLE Whitehaven Lodge Buttermere Close Maybush Southampton Hampshire SO16 9JR Lead Inspector Chris Johnson Unannounced Inspection 10:00 20 /21st November 2006 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitehaven Lodge Address Buttermere Close Maybush Southampton Hampshire SO16 9JR 023 8078 4839 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) Southampton City Council Mrs Lorraine Tew Care Home 55 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (55) of places Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of eight service users in the category DE(E) may be accommodated at any one time. Three service users in the DE category may be accommodated between 60 and 64 years of age. 18th May 2006 Date of last inspection Brief Description of the Service: Whitehaven Lodge is a large purpose built residential home providing care and support to 55 elderly persons, some who are frail and have dementia relating to their old age. The home is located in Millbrook, the west of Southampton, approximately 2 ½ miles from the city centre and is managed by Southampton City Council. The building is laid out over two floors with a passenger lift access to the first floor. It was built in 1981. Recent renovations to the home now allow residents to be accommodated in single rooms. Bedrooms are arranged in 6 separate living units. On the ground floor there is one large dining room and four smaller lounges, one of these is a smoking lounge. There are 3 separate unit-living facilities available on the first floor, each with its own kitchen and dining facilities should residents wish to prepare drinks or snacks and retain or regain their independent living skills. The home has a pleasant garden, which incorporates a raised sensory flowerbed and a lawn. Garden furniture and a handrail enable residents to enjoy the garden to the full, particularly during the warmer months. The home also has its own shop, which is open twice a week, and on request from residents, however residents when staffing levels allow are supported to go out to the local shops if they wish. There is a library area, an arts and hobbies room and hairdressing facilities. The cost of living at the home ranges from £371 - £434 a week. The cost of a short stay is £189 a week. Additional charges are made for chiropody, hairdressing and newspapers and the cost of these varies. Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second key inspection of the home carried out for the year April 2006/07. Following a notification from the home that a resident had been given the wrong medication a random inspection by a pharmacist inspector was carried out on 22nd September 2006. Following this visit one immediate requirement, four requirements and three recommendations were made and this outcome area was judged as being poor. The purpose of this inspection was to assess how well the home is doing in the meeting of all key National Minimum Standards and compliance with regulations and previous requirements. During this visit a tour of the premises was completed that included looking at service user’s bedrooms and all communal areas of the home. Staff and care records were inspected; staff, residents and relatives were spoken with and staff were observed during their day-to-day interactions with residents. All regulatory activity since the last inspection was reviewed and taken into account including notifications sent to the Commission for Social Care Inspection. What the service does well: What has improved since the last inspection? Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 6 The manager and staff team have worked hard to comply with many of the previous requirements and to improve the service. Improvements have been made to the monitoring of residents’ daily care needs. This provides more safeguards and less chance of needs going unrecognised or of not being met. Improvements have been made to the care planning process. Whilst this has not been completed within the previously agreed timescale the care plans that have been reviewed provide a lot more detail and provided much more specific and personalised instructions than they did previously. When completed they should ensure that care needs are fully recognised and met. Improvements have been made to the management of residents’ medication although further improvements are still required. Improvements to the physical environment are ongoing and action taken to meet previous requirements has made the home a more comfortable place to live. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4 and 6 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The opportunity for prospective residents to visit the home prior to moving in are good and are assessments are completed at this stage to ensure that their needs can be met. Improvements have been made to the monitoring of residents’ daily needs. This provides more safeguards and less chance of needs going unrecognised or of not being met. EVIDENCE: Whitehaven Lodge does not provide intermediate care. This standard is therefore not applicable and was not assessed. The files of four residents were examined during the visit to the home. All contained signed and dated contracts informing them of their rights’. These had been revised since the last inspection to take into account fee increases introduced earlier in the year. Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 9 Pre admission assessment and care notes were looked at for one resident who had recently moved into the home. These confirmed that the home continues to carry out thorough assessments before offering someone a place at the home. This includes a day assessment at the home enabling the prospective resident to decide if the home is right for them as well as providing the home the opportunity to assess whether they can meet the person’s needs. Staff involved in carrying out assessments commented that they felt this process would be further improved if the assessment at the home included an overnight stay. They commented that this would allow an overall and more accurate picture of the person’s needs. Staff provided examples of where this would have been helpful in determining the person’s full care needs. Evidence was seen during the visit that residents’ needs are kept under review. This was supported by documented evidence received by the Commission for Social Care Inspection since the last inspection to demonstrate that the home liaises and consults other agencies and families as appropriate. All residents spoken with said that they considered their needs to be met. Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Improvements have been made to the care planning process. Whilst not yet complete, the level of information recorded has improved and when completed they should ensure that care needs are fully recognised and met. Staff treat residents with respect and dignity and ensure that their health care needs are met. Improvements have been made to the management of residents’ medication. Further improvements are needed to ensure that correct and safe procedures are carried out at all times. EVIDENCE: A requirement had been made at the last inspection that all care plans be reviewed. That they must be more detailed and provide specific support instructions and fully address all assessed and identified needs. Four care plans were examined on this occasion. Two of these had been reviewed as per the requirement. In discussion with the manager it was explained that a care coordinator had been this given task. At the time of this visit eighteen care plans had been completely reviewed. Two of these were no Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 11 longer relevant as the people were no longer living at the home. This left a balance of twenty-four. The care plans that had been reviewed were a lot more detailed and provided much more specific and personalised instructions than the plans that had not been reviewed. They also reflected the person’s abilities as well as their needs and this helps to maintain and promote independence. They also accurately reflected residents assessed needs. Included in each plan is a detailed personal history of the resident, a daily living plan giving an overview of the person’s daily care needs and a night care plan describing the frequency of nightly checks needed. Risk assessments had also been reviewed and there was plenty of evidence that these are appropriately managed. Whilst the previous deadline to review all care plans had not been met it was clear that to do them thoroughly and to the required standard, additional time was needed. The home must however prioritise care plan reviews to ensure that those with higher more complex needs are completed first. Residents said that they had access to a range of services such as GPs, dentists, chiropodists and district nurses. Residents said that staff contacted healthcare support as and when they needed it, that it was dealt with for them and that they were supported to attend appointments. Evidence documented in residents’ files would substantiate this. At the last key inspection two requirements were made regarding medication. Following a notification from the home that a resident had been given the wrong medication a random inspection by a pharmacist inspector was carried out on 22nd September 2006. Following this visit one immediate requirement, four requirements and three recommendations were made and this outcome area was judged as being poor. At this visit it was found that action had been taken to address all of the requirements and recommendations made at the random inspection. The inspector observed a senior member of staff while they administered medication. The staff member was observed to speak with each person individually and as confidentially as possible. Medication was administered in a systematic, orderly way. The medication administration records were checked for several residents during the site visit. From examination of these records it was evident that staff were following correct administration recording procedures and medication was stored safely and correctly. Several residents have been prescribed ‘as required’ (PRN) medicines and not all files contained guidance to inform staff regarding the use of these. However overall the majority now did contain this information. Risk assessments to determine whether it is safe for residents to manage their own medication had been revised and were in place for all those case tracked. In discussion with residents they said that they had been given the opportunity to look after their own medication although most of them chose not to do so. A revised medication policy and procedure had been introduced and all staff had signed to say that they had read and understood it and all staff had either completed or were due to complete training in the revised procedures. Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 12 Whilst there has been an improvement in the handling of medication more care needs to be taken when recording medicines received into the home, as some errors were found. Observation of staff medication practices during the visit to the home showed that staff do not always follow correct procedures. One staff member was observed to handle medicines by popping them from the blister pack into her hand and to use the same pot for several residents. The requirement regarding ‘as required’ (PRN) medicines issued at the key inspection in May 2006 had not been fully complied with. It was reported at the last key inspection that when there was only one senior member of staff on duty at weekends the administration of medication could be difficult. This situation had not been rectified at the time of this visit. Staff reported that it takes up to two hours to administer medication at weekends. They said that if an incident arose needing their attention at the same time as they were administering medication they have to stop what they are doing and deal with the situation. This clearly impacts on residents and could increase the risk of errors occurring. In discussion with the manager she agreed that staff cover was inadequate at weekends and that she had raised this with senior management. As a result, the services manager has visited the home and observed the difficulties that staff face. All residents spoken with said that their privacy was respected and the inspector observed this to be the case throughout the visit to the home. Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The meals in the home are good, offering both choice and variety. The opportunity for residents to receive visitors is good and residents are free to make their own decisions about how they spend their time and are supported to engage in a variety of activities. EVIDENCE: All residents spoken with said that they enjoyed the activities available at the home. Staff support residents to engage in a variety of activities within the home and the wider community. Activities include; cookery, weekly bingo sessions, musical evenings, sing-along sessions, church services, pub meals and seasonal activities such as boat trips in the summer and pantomimes at Christmas. The manager had also organised for flowers to be donated to the home on a regular basis, as several residents were keen to take up flower arranging. Staff were also observed to spend time with residents individually. Regular resident meetings are held giving residents the opportunity to make decisions, have their say, to discuss activities and decide on venues for outings. These meetings are also used to convey information and discuss Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 14 health and safety issues such as fire evacuation procedures and to enable residents to input into menu planning. The opportunity for residents to keep in contact with their friends and relatives is good. Relatives spoken with said that they could visit the home whenever they wished and that they were made to feel welcome. Residents confirmed that could receive visitors as and when they wished. Some commented that visitors could stay for a meal and that they thought this was particularly good. From observation and discussion with residents it was clear that people are able to make the their own decisions and lifestyle choices. One person stated, “You are free to come and go as you please, they leave you alone and you can do as you like”. All residents agreed with this statement. Residents told the inspector that they liked the fact that since the new fire doors had been fitted they could now leave their bedroom doors open during the day if they chose. The home offers a varied, healthy and balanced diet. Several choices of meal are available including vegetarian and diabetic alternatives. Observation of mealtime was that they were unhurried and residents were seen to have choice. Residents spoken with on the day had chosen different things from the menu and reported to be generally happy with the standard of food. Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Satisfactory systems are in place for residents to address any concerns or complaints that they may have and staff receive appropriate training in adult protection procedures. EVIDENCE: The inspector asked a group of residents about how well they thought complaints and concerns were dealt with in the home. They all said that although they did not have any complaints if they were unhappy with anything they would go to the manager and tell her. All had confidence that she would deal with it appropriately and to their satisfaction. Residents are provided with information on how to make a complaint when they move in. There was a complaints log maintained in the home and this evidenced that concerns and complaints are dealt with and responded to appropriately. The inspector also saw several compliments made by family members thanking the home for the care that they had provided to their relative. Adult protection training is organised for all care staff and the inspector saw from staff training records that refresher training is provided and implemented into the training plan for all staff. Adult protection issues were discussed with staff and they were able to demonstrate that they were aware of reporting procedures. The home follows correct adult protection procedures and makes referrals as necessary with clear records maintained. Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 16 All residents spoken with reported that they felt safe and well looked after by the staff. Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Good standards of hygiene are maintained throughout the home. Improvements to the physical environment are ongoing and action taken to meet previous requirements has made the home a more comfortable place to live. EVIDENCE: Some aspects of the physical environment had been improved since the last inspection and other improvements are planned for the near future. All previous requirements regarding the environment had been met within the agreed timescale. This included the replacement of garden furniture, providing safer and additional outside seating. The hairdressing salon has been redecorated and some beds have been replaced and the manager has scope within her budget to continue renewing these as necessary. All doors within the home including bedroom doors are now linked to the fire alarm system. Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 18 The manager reported that all carpets in the communal areas of the home were due to be replaced. All areas seen of the home were clean, bathrooms and toilets contained paper towels and liquid soap and this helps to minimise cross infection. There were no unpleasant odours present. Residents said that they were happy with the standard of cleanliness maintained. Some said that they liked to keep their own rooms clean and do the dusting. They said that that this was their choice as domestic staff would it keep clean for them. A number of bedrooms were looked at. All had been personalised and reflected the occupant’s individuality. Bedrooms were clean and contained adequate furnishings. All residents spoken with said that they were happy with their rooms. People are free to spend time in their rooms as they please and residents said that since all of their doors had been linked to the fire system they liked it as it meant that they could leave their doors open if they chose during the day time and did not feel shut in. People said that they felt at home in their rooms and that they liked spending time in there. One person commented, “I have grown to love it”. Accessible call bells were in place in all rooms seen so that staff could be summoned in an emergency. Overall residents felt that the home environment met their needs. Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Staff are well trained, caring and helpful and are provided with good support and supervision. Staffing levels are however compromised and at times staffing levels are not sufficient to meet residents’ needs. EVIDENCE: Staffing levels remain at the same level as at previous inspections. In discussion with staff it became clear that cover is not always available to cover courses and sickness. From examination of the rota it would appear that at times there are less care coordinators on shift than the rota indicates are needed. As previously discussed additional staff are needed at weekends to assist with medication administration. Residents’ care and dependency needs do not change at weekends and therefore adequate staffing is just as vital at weekends as at any other time. Residents said that they felt well cared for, that the staff treated them well, that they liked living at the home and felt safe there. During a discussion with a group of residents one person commented, “ You can have a laugh and joke with the staff”. The rest of the group reiterated this. Residents said that they each had a key worker and said that they could discuss their care needs with them. Staff receive appropriate support, supervision and training. New staff follow a structured and recognised induction course and a high number of staff have Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 20 achieved a NVQ level 2 or above. This was confirmed through speaking with staff and from examination of staff files. The recruitment records of two members of staff appointed since the last inspection were examined. In respect of one member of staff these records were incomplete. Initially the manager was not able to demonstrate that the person had been satisfactorily checked against the Protection of Vulnerable Adults list or that a Criminal Records Bureau check had been completed. This was later rectified. The manager explained that all recruitment documents are held at personnel and that personnel photocopy copy them and then send them to her. Unfortunately this information is sent too late. There is no reason why this information should not be held at the home and this in breach of the regulations. Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37 and 38 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The manager and staff team have worked hard to comply with previous requirements and to improve the service. Safety is promoted within the home. The standard of record keeping regarding staff records held at the home needs to be improved to ensure that residents’ best interests are safeguarded. EVIDENCE: Several requirements were made at the last key inspection and the subsequent random inspection. The manager and staff team have worked within the resources available to them to address most of these. Those outstanding are being addressed satisfactorily. The exception to this being staffing levels and this will require additional resources that are at present unavailable to the manager. It was reported that the manager is accessible and approachable to residents and staff. Staff said that they received a good level of support and had regular Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 22 supervision and appraisals. This was substantiated through examination of staff files. The home has corporate policies and procedures in place provided by the local authority. Systems are in place to measure the effectiveness of the service these include; resident questionnaires, resident meetings, team meetings and statistics are gathered to track and identify trends and occurrences. The appointed person visits the home monthly to undertake a tour of the building and to examine a sample of records and audit various aspects of the home and to speak with service users. A copy of the report is then written and forwarded to the Commission for Social Care Inspection. Currently managers from different homes within the organisation are reviewing and looking at ways to improve and standardise all aspect of the care delivered to residents. As part of this they are reviewing the current quality assurance systems. The home does not manage any of the resident’s monies. The local authority manages these in individual accounts and the manager receives a statement every month for all service users as to the balance they have in the account. Generally record keeping is maintained to a satisfactory standard. Records were stored correctly, securely and confidentially. The exceptions to this being staff recruitment records and records of medicines received into the home. Safety is promoted within the home. Evidence seen in residents’ files showed that fire precautions are explained to them when they move into the home and safety issues are regularly discussed at residents meetings. Regular testing and servicing of the home’s fire detection and fire-fighting equipment is carried out. One care coordinator has overall responsibility for health and safety. Maintenance records are maintained and any faults are identified and rectified. Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 3 Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 25 STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 (2) (b) (c) Requirement All care plans must be reviewed. They must be more detailed and provide specific support instructions and fully address all assessed and identified needs including the identification of any risks and how these are to be managed. (Previous timescale of 31/08/06 not fully met) Written guidance must be produced in respect of any resident prescribed PRN medication. This must be incorporated into their care plan. (Previous timescale of 31/08/06 not fully met) The registered manager must ensure that staff follow correct and safe medication procedures at all times. The registered manager must ensure that sufficient staff are on duty to make certain that safe and accurate procedures are followed when administering medication. (Previous timescale of 31/07/06 not met) The registered manager must ensure that staffing levels are maintained at all times. (Previous timescale of 31/07/06 not met) All staff records must be held in the home. DS0000039153.V314836.R01.S.doc Timescale for action 31/01/07 2 OP9 13 (2) 15/01/07 3 OP9 13 (2) 31/12/06 4 OP9 OP27 13 (2) 31/12/06 5 OP27 18 (1) (a) (b) 31/12/06 6 OP29 OP37 17 (2) Schedule 4 31/12/06 Whitehaven Lodge Version 5.2 Page 26 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 OP7 Good Practice Recommendations Priority should be given to ensure that the care plans of those people with higher needs or at the greatest risk are reviewed first. Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Whitehaven Lodge DS0000039153.V314836.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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