Inspection on 24/11/05 for Whiteladies Residential Home

This inspection was carried out on 24th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Whiteladies Residential Home 21/08/07

Whiteladies Residential Home 03/07/06

Whiteladies Residential Home 18/05/05

Whiteladies Residential Home 01/03/05

Whiteladies Residential Home 01/09/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE Whiteladies Residential Home 22 Redland Park Redland Bristol BS6 6SD Lead Inspector Sandra Gibson Unannounced Inspection 24th & 29th November 2005 13:15 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 Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Whiteladies Residential Home Address 22 Redland Park Redland Bristol BS6 6SD 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) 0117 9739083 0117 9237662 Whiteladies Residential Home Ltd Mrs Carol Verlander Care Home 25 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (2), Old age, of places not falling within any other category (23) Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to two persons with a Mental Disorder over 65 years of age 18th May 2005 Date of last inspection Brief Description of the Service: Whiteladies Residential Home is a privately owned home registered by The Commission for Social Care Inspection to provide personal care to twenty-three older people and two older people with mental health needs. It is situated in a busy urban area in the city of Bristol and can be accessed by car or bus. The home is a converted older property providing single room accommodation on three floors, all of which can be accessed by a lift. A suitable number of bathrooms and toilet are available and have been adapted to meet the care needs of people in the home. Each room has an alarm call system. The home is situated in its own grounds with gardens to the rear. Visitors are welcome at any time and refreshments are readily available. In-house activities and entertainments are also provided. Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a Thursday between the hours of 1.15 pm and 6.00pm. Evidence was gathered from: talking to residents, talking to staff, talking to a visitor, talking to the nominated responsible individual, observation, viewing the premises and examining records and policies and procedures. The manager was not present during the inspection. The inspector was unable to follow up some concerns raised prior to the inspection. Consequently, an additional planned visit to the home was conducted on the 29th of November 2005 in the presence of the registered manager. A subsequent report was completed following the visit. There are a number of outstanding requirements from the previous inspection. The manager and responsible individual are advised that these must be addressed in the timescales given. Otherwise enforcement action may take place. What the service does well: What has improved since the last inspection? What they could do better: Information to prospective residents is not completely accurate and may be misleading. Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 Page 6 The process in place to assess residents’ needs prior to admission is basically satisfactory but it must be developed further to ensure that resident needs are fully assessed prior to moving to Whiteladies. This will ensure that prospective residents needs can be met at all times. Residents and their representatives are not fully consulted prior to staff completing care plans. Consequently residents’ needs are not always fully identified and met. Improvements to the complaints procedure have been made, but further improvements are necessary to ensure that all residents and their representatives are confident that their concerns will be listened too. Arrangements for protecting residents from harm have improved considerably since the last inspection but further development is necessary to ensure residents are protected from abuse. Gaps in the recruitment system mean that residents may not always be fully protected at all times. The systems in place for staff training has improved considerably since the last inspection but further improvement is needed if residents are to continue to be cared for by experienced trained staff Residents and members of staff are beginning to benefit from the positive developments with in the leadership team. Further development needs to continue however to ensure that the management of the home becomes more transparent so that residents, their representatives and staff feel that they are listened to. The security arrangements in place to protect residents personal possessions has been improved but are still not satisfactory and need to be improved further to safe guard residents and staff belongings at all times. There has been no improvement in the system for accessing records that must be available for an inspection. The system in place is not satisfactory, as it does not promote residents best interests. The systems in place to promote and protect the health and safety of service users, staff and visitors to the home must be improved to ensure the safety of residents, staff and visitors 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. Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 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 Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 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): 1,3,4,5 Information to prospective residents is not completely accurate and may be misleading. The process in place to assess residents’ needs prior to admission is basically satisfactory but it must be developed further to ensure that resident needs are fully assessed prior to moving to Whiteladies. This will ensure that prospective residents needs can be met. EVIDENCE: The statement of purpose was examined and it was noted that it had not been reviewed as required at the last inspection. There was no information about providing care to two residents with mental health needs or details of any specialist training the staff have attended to meet these residents’ needs. Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 Page 9 It was noted however that following the last inspection that the service user guide had been updated with details of how to contact the Commission for Social Care Inspection to make a complaint. The needs assessment documentation was examined and it was observed that there were gaps in the information held. The gaps included, carer/ family involvement, social interests, personal safety /risk, foot care and medication usage. On the day of the inspection it was noted that a social worker was looking around the home on behalf of a prospective resident. A relative confirmed that she had had the opportunity to view Whiteladies prior to her relative moving in and that where possible arrangements are made for residents to view the home. Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 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 Residents and their representatives are not fully consulted prior to staff completing care plans. Consequently residents’ needs are not always fully identified and met. The health care needs of residents continue to be promoted and well met . This ensures that residents have access to health care sevices which meet their assessed needs. EVIDENCE: A sample of care plans was seen and was found to be lacking in detail. One resident told the inspector that she had very fragile skin and that she had recently sustained an injury when lying in bed. There was no information held about this risk in her care plan. Another care record stated that a resident refuses to eat but there was nothing in the care plan to explain how this residents dietary needs could be met. A couple of care plans identified that residents were at risk of falling but did not give detail on how to manage that risk or how to support that person when walking. Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 Page 11 There was also no indication that the resident or their representative had been involved in putting these plans of care together as required at the last inspection. This was confirmed by some relatives who raised concerns about the care of their relative and the lack of detailed information provided to staff. These concerns were raised with the manager of the home in an additional visit to the home on the 29th November 2005. A sample of individual care records confirmed that residents are appropriately refered to health professionals and commmunication with the staff team is good. This was confirmed by several residents seen who talked about vists from the GP or District Nurses. Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 Page 12 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, Whiteladies continues to provide residents the opportunity to experience a stimulating and varied life where various informal activities are regularly made available and are kept under review EVIDENCE: Whiteladies employ an Activities Coordinator who visits twice a week for two hours. During her visits she organises a variety of activities including reading short stories, reading poetry and holding discussions with a group of residents by request. It was noted that other activities available in the home include games such as cards, scrabble etc. Activities with staff include chatting to individual service users, armchair exercise, reading letters and newspapers and sing a longs etc, outings include visits to a pantomime or play and visits to a garden centre. One of the senior members of staff told the inspector that the key working time was currently being reviewed following a change in staff and that recently the staff team had not always made the opportunity to spend time talking to residents. This was confirmed in a resident’s questionnaire dated November 2005 where 85 of residents said that staff are not able to sit and talk with them. Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 Page 13 One resident who lives in the top part of the home told the inspector that s/he was very happy at Whiteladies but preferred spending the majority of time in her/his room. S/he said that s/he frequently felt isolated as there was very little staff presence in the top part of the building during the day and that this had changed during the last year. The resident in question said that s/he would feel more secure and happier if staff popped in to see her/him and talk to her/him more often. It was noted that there were arrangements in place for staff to spend more one to one time with residents starting in January 2006. An ex member of staff now visits the home once a week as a volunteer and spends time playing board games with residents or escorting them on shopping trips. A hairdresser visits the home once a week and makes herself available for all residents. A local minister also visits the home once a month and takes private communion services for residents if they prefer. Records confirmed that social outings take place. A member of staff told the inspector about the activities organised for Christmas including an Xmas Play called Cinderella with a party to follow. A sing-along had been arranged with old music and a carol service had also been organised for residents to join in. Two residents spoken to said that “there was enough going on to keep them occupied” One visitor confirmed that she was made very welcome in the home and that staff were very approachable. The outcome of a residents questionnaire dated November 2005 confirmed that a majority of 85 residents living in the home thought that there was choice of entertainment and leisure activities and that 80 felt that they could choose to join in or not Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Improvements to the complaints procedure have been made, but further improvements are necessary to ensure that all residents and their representatives are confident that their concerns will be listened too. Arrangements for protecting residents from harm have improved considerably since the last inspection but further development is necessary to ensure residents are protected from abuse. EVIDENCE: Several residents and one visitor spoken to told the inspector that they were comfortable talking to the manager or one of the senior care staff about any concerns or if they wished to make a complaint. It was noted that there had been no formal complaint made to the manager or Commission for Social Care Inspection since the last inspection. However prior to the inspection concerns about care planning and gaps in training were raised with the Commission for Social Care Inspection. Some of the issues raised were looked at during this unannounced inspection plus an additional visit was made to the home on the 29th of November 2005 in order to follow up the concerns with the manager. Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 Page 15 The home’s complaints procedure contains details of The Commission for Social Care Inspection and is given to all residents and their families. However, the copy in the dining area remains out of date despite it being highlighted at the last inspection. It gives details of the National Care standards Commission, which no longer exists. It was noted that the manager and deputy manager have recently attended local authority Adult Protection training for managers. However none of the other staff have received this training and one member of staff consulted was unclear to whom they would need to report an allegation of abuse to if left in charge of the home. A copy of No Secrets in Bristol (Local authority Adult Protection procedure) is in place in the home. However the abuse and whistle blowing guidance in the home have not been reviewed as required at the last inspection. The policies and procedures do not link in with the Local Authority guidance. Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24,25,26 A comfortable, clean, safe standard of accommodation is provided for the residents of Whiteladies. EVIDENCE: The environment is well maintained and suited to residents needs. Disabled access is available in the lower ground floor. There is a five-person lift available in the home so residents can access each floor. Whiteladies is decorated and furnished to a good standard which creates a comfortable homely atmosphere. There are a number of lounges through out the home in the care home which residents and relatives were seen using and appeared comfortable and relaxed. Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 Page 17 Residents’ bedrooms looked homely and were personalised with residents’ personal possessions and furniture. Residents confirmed this during the inspection. The home smelt fresh and all the rooms viewed were cleaned to a high standard. There was evidence of regular domestic support in the home. During the inspection the nominated responsible individual told the inspector that there were ongoing issues with the central heating and hot water system that he was in the process of reviewing. On the day of the inspection there was no hot water in the kitchen area with the result that chef was heating water up by other means for use in the kitchen that day. The inspector was told that the problem with the hot water was confined to the kitchen area only and the residents’ bedrooms and bathrooms were not affected. The inspector noted that the home was very hot on the day of the inspection despite it being very cold outside. Staff members confirmed this information during the inspection. However no residents complained that they were too hot. The responsible individual confirmed that he had contacted the plumber that day to investigate the problem and subsequently repair the system as necessary. Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 Page 18 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): 28,29,30 Gaps in the recruitment system mean that residents may not always be fully protected at all times. The systems in place for staff training has improved considerably since the last inspection but further improvement is needed if residents are to continue to be cared for by experienced trained staff EVIDENCE: The staff files of four staff members/ volunteer employed indicated that the home had not always undertaken all the necessary recruitment checks to ensure the protection of residents. For example two references had been requested for two members of staff but on each occasion only one had been a professional one. The other reference had been from a friend. It was also noted that one member of staff had worked for a care agency and a care home (Nursing) but had not given dates and the reasons for leaving had not been explored before appointment at Whiteladies. Records confirmed that staff receive induction training, which includes first aid, fire regulations and emergency action, lifting and food hygiene and kitchen. It was pleasing to note that the majority of staff have received dementia care training since the last inspection. Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 Page 19 However they have yet to receive mental health training despite the home now being registered for two residents with mental health needs. The manager informed the inspector that mental health training had recently been requested from the Community Psychiatric service and that this training would take place for all staff during the next couple of months. As already discussed none of the staff except the manager and deputy manager have received up to date adult protection training. NVQ training started in this home a number of years ago. However, due to staff changes it was noted that the Whiteladies Residential care staff team would not reach the national minimum target of 50 of the care staff being trained to NVQ2 by December 2005. This situation exists despite a new deputy manager being appointed six months ago to provide in house training and NVQ assessment. Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 Page 20 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): 32,35,37,38 Residents and members of staff are beginning to benefit from the positive developments with in the leadership team. Further progress must continue to ensure that the management of the home becomes more transparent so that residents, their representatives and staff feel that they are listened to. The security arrangements in place to protect resident’s personal possessions have been improved but are still not satisfactory. These arrangements need to be improved further to safe guard residents and staff belongings at all times. There has been no improvement in the system for accessing records that must be available for an inspection. The system in place is not satisfactory, as it does not promote residents’ best interests. The systems in place to promote and protect the health and safety of service users, staff and visitors to the home must be improved to ensure the safety of residents, staff and visitors at all times Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 Page 21 EVIDENCE: The nominated responsible individual told the inspector that the new deputy manager position was working well and supported the manager’s role. As discussed previously this person is now responsible for staff training/ NVQ assessment. The management team have recently attended Quality Assurance training and have started to set up a quality assurance system in the home. The resident survey was conducted in November 2005 as part of this process. It was noted that further projects are due to be developed over the next few months focussing on dementia care and social and emotional care needs. The Commission for Social Care Inspection also receives monthly reports from the nominated responsible individual. Security measures had been put in place to safe guard residents’ medication when they self medicate and any personal item they wish to care for themselves. It was observed that the system in place was not adequate. Discussion took place about how security arrangements could be improved further. Some records that must be available for inspection continue to be held separately from the home and are made available only when the manager, deputy manager or administrator are present. On the day of the unannounced inspection neither the manager, deputy manager or administrator were available. However, the nominated responsible individual made himself available during the inspection and arrangements were made for the inspector to check the staff personnel files, complaints records and residents’ financial records, and fire log. The nominated responsible individual told the inspector that one other member of staff has access to this information when the manager, deputy manager and administrator are not present. Unfortunately this member of staff who was on duty on the day of the inspection did not have access to a key. It was observed that the fire log does not contain details of who has been involved in fire safety training. This information is held with staff individual training records. It was noted that this information was not easily accessible unless all personnel files were examined. A small number of residents’ finances are looked after by the home. However it was noted that these residents continue to only be able to access their own money when the manager, deputy manager or administrator is present. A member of staff who said that she had used her own money to pay for a residents taxi confirmed this Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 Page 22 Following a security incident in the home during the summer months it was noted that visual deterrents and extra security lighting has been installed in the grounds of the home. A Home statement was also noted to be in place. There was evidence to confirm that a member of staff had been disciplined following a breach in the home’s security arrangements. The emergency procedures and staffing levels at night were also discussed with the nominated responsible individual. However the discussion was not conclusive as the manager was not present. As discussed previously arrangements were made for an additional visit to take place with the manager present on the 29th of November 2005. During this additional visit the emergency procedures and staffing levels at night were also discussed and were asked to be formally reviewed by the manager. It was observed during the unannounced inspection that there was no visitors’ book in the home. The manager notified the inspector during the additional visit to the home on the 29th of November 2005 that relatives had previously told her “that they did not want such a book as it felt it would be a check on how often they visit…. like Big Brother”. A discussion took place about promoting the safety of residents, staff and visitors and that a visitors log was required to be maintained for security and health and safety reasons. It was noted during the unannounced inspection that a relative was visiting the home and the staff on duty were not aware that this person was present in the building. The procedures in place in case of a fire in the home were examined. It was noted that there was no mention of visitors in this procedure or what staff need to do at night if there is a fire. Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 x 2 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 3 3 x x 3 3 3 3 STAFFING Standard No Score 27 x 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 2 3 x 2 x 2 1 Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 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. Standard op1 Regulation 6 Requirement Timescale for action 31/01/06 2 OP3 14 3. op7 15 4. op16 22(7) The statement of purpose must be reviewed and information updated to ensure that it is accurate. This requirement is ongoing from previous inspection 18/05/05 The needs assessment document 24/02/06 must contain information as outlined in NMS 3 (Older People) All needs assessments must be carried out in consultation with the resident and their representative Care plans must be completed in 31/01/06 consultation with residents and their representatives families where appropriate This requirement is ongoing from previous inspection 18/05/05 Complaints procedure in dining 31/01/06 area must be up dated with details of The Commission for Social Care Inspection This requirement is ongoing from previous inspection 18/05/05 Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 Page 25 5. op18 13(6) 6. op18 13(6) 7. OP29 19 8. op28 18 The home must have an adult protection policy and procedure in place which links with No Secrets In Bristol (Local Authority Adult Protection guidance) This requirement is ongoing from previous inspection 18/05/05 All staff must receive Adult protection training that includes the information on the Local Authority Adult Protection guidance This requirement is ongoing from previous inspection 18/05/05 All information in Schedule 2 Care Home Regulations must be obtained before a member of staff is allowed to work in the care home. This must include two written references from previous employer / professional. All gaps in employment and reasons for leaving a job fully explored A plan of when 50 of care staff are going to receive NVQ 2 must be sent to The Commission for Social Care Inspection Staff must receive specialist training in mental health needs Secure Lockable storage facilities must be provided for all residents who self medicate and residents personal possessions This requirement is ongoing from previous inspection 18/05/05 All records required for inspection must be available at any time This requirement is ongoing from previous inspection 18/05/05 Residents must be able to access any money held for them when they choose to This requirement is ongoing from previous inspection 18/05/05 DS0000051206.V267160.R01.S.doc 24/02/06 24/04/06 24/02/06 24/02/06 9. 10 OP30 OP35 18 16(2)(l) 24/04/06 24/03/06 11 op37 17 31/01/06 12. OP35 12 31/01/06 Whiteladies Residential Home Version 5.0 Page 26 13. op38 23(4)(c) 14 15 OP37 OP38 17(2) 23(4) The fire log must be available for 31/01/06 inspection at any time (Including fire safety training) This requirement is ongoing from previous inspection 18/05/05 A visitors book must be 24/02/06 maintained in the home The fire procedure must be 31/01/06 reviewed to ensure that a clear reference to visitors is made and the procedure must identify what staff must do when visitors are present in the event of a fire both during the night as well as day time 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 Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Whiteladies Residential Home DS0000051206.V267160.R01.S.doc Version 5.0 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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