Inspection on 15/11/06 for Whitewalls

This inspection was carried out on 15th November 2006.

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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Whitewalls 13/12/07

Whitewalls 28/10/05

Whitewalls 07/07/05

Whitewalls 03/02/05

Whitewalls 02/08/04

Whitewalls 08/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Home Farm

Griffin Lodge

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

CARE HOME ADULTS 18-65 Whitewalls Bells Lane Hoghton Lancashire PR5 0JJ Lead Inspector Mrs Julie Playfer Unannounced Inspection 15th November 2006 11:30 Whitewalls DS0000005929.V313943.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 Whitewalls DS0000005929.V313943.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. Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitewalls Address Bells Lane Hoghton Lancashire PR5 0JJ 01254 852288 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) www.care-ltd.co.uk CARE (Cottage and Rural Enterprises Ltd) Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th October 2005 Brief Description of the Service: Whitewalls is a large detached property situated in the village of Hoghton between Blackburn and Preston. The village provides access to local facilities and services and it has good transport links to nearby Preston and Blackburn. Whitewalls is a care home and is registered to accommodate 6 adults with learning disabilities. The home has strong links with Stanley Grange, which is also owned by CARE, some 2 miles away. The two-storey house stands in its own grounds and contains a lounge/dining area, a small conservatory, kitchen, two bathrooms, separate toilet, five bedrooms and a staff room. There is also a self contained flat attached to the home which accommodates 1 service user. The home has a statement of purpose and service users guide, which informs the current and prospective residents about the services and facilities available at the home. According to the information submitted by the home the scale of fees was £600 per week. An additional fee of £12 per hour was charged for one to one support. Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Whitewalls on 15th November 2006. During the visit the inspector looked at written information including policies, procedures and records, spoke to the residents, registered manager and staff and conducted a partial tour of the premises. As part of the inspection process the inspector used “case tracking” as a means of gathering information. This process allows to the inspector to focus on a small group of people living at the home. Prior to the inspection comment cards were sent to the home, which in turn were completed by the residents with the help of an advocate. The acting manager also completed a questionnaire about the home. What the service does well: Residents’ needs were properly assessed and reviewed at regular intervals. This meant the residents were confident that the home could meet their current needs. Ongoing care and support was planned effectively to ensure the residents’ needs were met and there was a consistent approach taken by staff. The residents fully participated in the care planning process and were familiar with their essential lifestyle plans and person centred plans. This gave the residents the opportunity to communicate their views and influence the provision of support. The residents pursued a wide range of meaningful activities both inside and outside the home. This approach enabled residents to participate in the life of the home and gave them the opportunity to meet other people. The residents and staff shared good relationships and there was a friendly atmosphere in the home. One resident commented that the home was “a good place to live – brilliant” and another person said, “I feel safe here”. There were arrangements in place to ensure the residents were listened to and any concerns were acted upon. This was achieved by the means of residents meetings and established arrangements to investigate any complaints or concerns. Staff had access to a wide range of training opportunities, which gave them a good understanding of their role and the needs of the residents. The home had established systems to monitor the service provided for the residents and it was clearly evident that the home was managed in the best interests of the residents. Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 7 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 Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The residents’ needs were fully assessed and they had received a contract, which informed them about the service they received. EVIDENCE: Written information was available for residents in the form of a statement of purpose and service users guide. However, both documents had not been updated to reflect the changes in staff and manager. There was no evidence to indicate that the service user’s guide had been supplied to the residents, who had no knowledge of receiving the document. All the residents had lived in the home for sometime and hence there had been no new admissions since the last inspection. The case tracking process demonstrated that the current residents’ needs had been fully assessed before admission by a social worker and by the staff in the home. The manager also carried out a review of the assessed needs on an annual basis or in line with changing needs. The review encompassed all aspects of the residents’ needs and the format used enabled the manager to clearly identify any changes to existing needs or any new needs. The residents had been issued with a written contract/statement of terms and conditions. The contract was written and presented in an accessible format and Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 9 included information about the level of fees. The contracts had been signed and dated by the residents and the manager of the home. Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents were involved in decisions about their lives and played an active role in planning the care and support they received. EVIDENCE: It was evident from the case tracking process that the residents had an individual essential lifestyle plan, which reflected their personal, social support and welfare needs. The plans included detailed information about the resident’s preferred routines and personal aspirations along with instructions for staff to ensure all needs were met. The residents also had an individual person centred plan (PCP), which was reviewed at least twice a year or in line with changing needs. Prior to the review, the residents prepared pictorial versions of the plans in the form of kites. The residents were fully involved in their plans, one person said “I discuss all the things I need help with and we put it all down” and another person commented “I’ve got my own weekly planner, to let me know what I’m doing each day”. Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 11 It was the practice of the home to support responsible risk taking and policies stated that the role of staff was to facilitate independence wherever possible. Detailed risk assessments and management strategies covered activities indoors for example “home alone” and in the wider community and were included on residents’ files. During conversations with residents, it was evident they were consulted both informally and formally and they were able to participate in life in the home. From the minutes seen of the resident’s meetings, it was evident a wide variety of topics were discussed and contributions had been made by the residents. Prior to the meetings the manager posted an agenda and the residents were encouraged to contribute to the items for discussion. The residents were supported with their financial affairs and detailed written records were maintained of all transactions. A random check of money deposited with the home for safe keeping corresponded accurately to the records. Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The residents were able to make choices about their lifestyle and were supported to develop their life skills. Social, educational and recreational activities met with the residents’ expectations. Residents were provided with a healthy diet, which they enjoyed. EVIDENCE: The individual plans and care records demonstrated that residents had opportunities to maintain and develop practical life skills. Residents were encouraged and supported to participate in the life of the home and carried out domestic tasks commensurate with their abilities and interests. These tasks included tidying bedrooms, helping in the kitchen and light domestic chores, such as dusting and vacuuming. Residents engaged in activities in the local community, which included going shopping and going out for meals to local restaurants. Staff provided assistance with activities as necessary and had knowledge of events in the Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 13 nearby area. Since the last inspection the residents had been away for a holiday in Tenby. All the residents spoken to said that they really enjoyed their holiday and one person said “it was out of this world, a really brilliant holiday”. Staffing levels were reviewed at regular intervals, which enabled residents to pursue individual leisure interests. One resident enjoyed cross-stitching, which was supported by the staff. The residents were supported to pursue various vocational activities. At the time of the inspection two residents were attending the college courses, one person worked part time in a shop and one person worked in a voluntary capacity at a children’s day nursery. In addition, one person worked in a workshop and another person attended a craft course. The residents spoken to said they enjoyed their daytime activities. One person was pleased to show the inspector, gifts she had made for her family at her craft class. The residents were supported to maintain relationships with their families and where necessary the staff assisted with transport. There were no restrictions placed on visitors to the home and the residents said they could have visitors at anytime and could talk to their guests in the privacy of their own room. The residents had unrestricted access to the home and grounds. The residents were also able to use their room at any time should they wish to spend some time in private. It was noted several of the residents spent time in their rooms, when they arrived home for the evening. All residents were entered onto the electoral register and exercised their vote by attending the local polling station or by entering a postal ballot form. The residents were provided with three meals a day and a range of drinks and snacks were available at all other times. Residents spoken to said, the meals were “really nice” and “very good”. A record of meals served was maintained on an individual basis, which detailed the actual food served to the residents. These records demonstrated that the residents were provided with a varied nutritious diet. The residents were encouraged and supported to plan, purchase, prepare and serve the meals. Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The health and personal support provided to residents was based on their individual needs. The principles of respect, dignity and privacy were put into practice. Appropriate records were in place to manage medication within the home and the staff were suitably trained. EVIDENCE: The essential lifestyle plans set out the residents’ personal support preferences and provided details of how this support was to be delivered. Residents spoken to confirmed the staff fully respected their rights to privacy and dignity. One resident confirmed staff always knocked on her door and waited to enter. The routines were flexible and residents were encouraged to have a bath or shower as frequently as they wished. The residents also confirmed they were able to choose the time they went to bed and got up in the morning. The manager and staff ensured consistency and continuity for residents by the use of a named worker system. A record was also maintained of individual likes and dislikes as part of the assessment and care planning processes. The staff spoken to had a good understanding of the needs of the residents and Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 15 were able to provide good examples of how the residents were supported to maximise their independence and control over their lives. Healthcare needs were appropriately assessed and were included in the essential lifestyle plan and the person centred plan. There was considerable evidence to indicate the residents had access to NHS services and the advice of specialist services had been sought as necessary. A health action plan had also been completed with each resident to supplement the information contained in the essential lifestyle plan and the person centred plan. The residents’ health and welfare was reviewed at regular intervals and an overview of medical and health checks was seen on each of the residents’ files. There was a set of policies and procedures in respect of medication and appropriate records were maintained of receipt, administration and disposal of medicines. Pictorial information sheets about all aspects of the medication prescribed for the residents were available for staff reference. Several of the residents were self administering their medication within a risk management framework. All staff designated to administer medication had completed an accredited medication course. However, it was noted that staff were secondary dispensing medication into cassettes for residents visiting their families and there was no specific record made of the number and type of tablets leaving the premises. Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents felt their views were listened to and acted upon. However, in order to fully protect the best interests of the residents, improvements must be made to the complaints and vulnerable adults procedures. EVIDENCE: Both informal and formal arrangements were in place to ensure the manager and staff listened to and acted on the views and concerns of residents. This was achieved during daily conversation, one to one discussion with residents and their named workers and residents’ meetings. A pictorial complaints procedure was displayed on the notice board. However, the procedure did not include information about the timescales for the complaints process and the contact details for the Commission were out of date. It was noted that two of the residents who completed the residents’ survey prior to the inspection were unaware of the complaints procedure and none of the residents spoken to on the day of the inspection were familiar with the procedure. There was no evidence to indicate that residents had been issued with a personal copy of the complaints procedure. However, all the residents said they would speak to the staff and manager if they had any concerns. The home had not received any complaints since the last inspection. The home had a copy of “No Secrets in Lancashire” and staff had access to a whistle-blowing procedure. An internal procedure was available for staff, however, this did not include contact details of the relevant agencies and made no reference to the POVA (Protection of Vulnerable Adults) list. The manager Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 17 had completed a training course on safeguarding vulnerable adults and was aware of the procedures involved in the event of any allegation, suspicion or evidence of abuse or harm. Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Whitewalls provided pleasant and clean accommodation. Residents were able to personalise their bedrooms and create an individual space suitable for their needs. EVIDENCE: Whitewalls is a detached property set in its own grounds. The home is located in the village of Hoghton between the towns of Blackburn and Preston. Accommodation is provided in five single bedrooms and one self contained flat. The shared space is provided in a lounge/dining room and conservatory. The furnishings and fittings were domestic in character and of a satisfactory standard throughout. Since the last inspection the bathrooms and toilets had been redecorated and new beds had been purchased for each bedroom. Some bedrooms were inspected with the permission of the residents. The bedrooms had been decorated according to the personal preferences of the residents. All bedroom doors were fitted with appropriate locks and the residents had been provided with keys. Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 19 The premises were comfortable, clean and free from offensive odours, in all areas seen. The residents were supported to use the washing machine to promote their independence skills. Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service. EVIDENCE: Staff were issued with job descriptions, which set out their roles and responsibilities. It was evident the job descriptions were linked to meeting the needs of the residents. From discussions with staff during the inspection, it was evident they had a good understanding of the residents’ needs and knew the residents well. Staff referred to the residents in respectful terms and were observed to interact in a positive and pleasant way. The staff rotas indicated that the staffing levels were regularly reviewed and additional staff were placed on duty, where necessary, to meet the needs of the residents. There had been no staff recruitment since the last inspection. However, it was evident, the home had an established induction programme, which encompassed the Learning Disability Award Framework standards. A member Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 21 of staff interviewed confirmed that her induction training was thorough and informative. New members of staff were also issued with an Employee Information Pack, which contained copies of relevant policies and procedures and useful information about the person’s employment. It was apparent from viewing the staff files that each member of staff had a training and development profile and assessment. However, an overall training and development plan was not seen for the staff team as a whole. The staff spoken to confirmed they had access to good training opportunities and said they had attended many courses associated with the needs of the residents. At the time of the inspection one person had achieved NVQ level 3, which equated to 33 of the staff team. Staff meetings were held on a regular basis. The meetings gave the opportunity to staff to share experiences and develop teamwork. The manager ensured staff received supervision at least six times a year and had an annual appraisal of their work performance. Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The management approach promoted positive relationships between the staff and the residents and the overall atmosphere was open and friendly. The home had an effective quality assurance system based on the outcomes of the residents. EVIDENCE: Since the last inspection the registered manager had left the home and the former deputy was acting as the manager. The acting manager intends to apply for registration to the Commission. The manager had completed NVQ level 3 and had been working at Whitewalls for 7 years. The management approach was consultative and there were systems in place to consult both staff and residents. Relationships within the home were positive and staff spoke about the residents with respect. In turn the residents described the staff as supportive and approachable. Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 23 The home had an established quality assurance system, which was based on the views of the residents and staff. The residents completed work booklets each year on a variety of topics. The booklets were designed to elicit the residents’ views about all aspects of life in the home, such as activities and health and safety. The outcomes from the work booklets were collated and individual action plans were devised. Following this the manager completed an annual service development plan, which detailed the overall results and the planned developments for the service. Staff received health and safety training, which included moving and handling, food hygiene, first aid and fire safety. The gas and electrical systems were serviced at regular intervals and the home had a valid electrical safety certificate. To minimise the risk of scalding, preset valves were fitted to all water outlets. Arrangements had been made to store hazardous substances in a secure location. Detailed safety checks were carried out on the premises on a monthly basis and risk assessments had been completed on all safe working practice topics. Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 24 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 2 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 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 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 3 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 2 X 2 3 3 X X 3 X Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 25 No 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 YA1 Regulation 5 (2) 6 Requirement Timescale for action 01/01/07 2. YA22 22 (6) (7) 3. YA37 CSA 2000 The statement of purpose and the service users guide must be kept under review and revised as necessary. The service users guide must be supplied to each resident. The complaints procedure must 01/01/07 be supplied to each resident. The contact details of the Commission must be updated. The manager must apply to the 15/12/06 Commission for registration. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations Medication should not be secondary dispensed in cassette boxes for residents spending time away from the home and records should be maintained of the medication leaving and returning to the premises. The complaints procedure should include the timescales for the process. The vulnerable adults procedure should include the contact DS0000005929.V313943.R01.S.doc Version 5.2 Page 26 2. 3. YA22 YA23 Whitewalls 4. YA35 details of the relevant agencies and details about the Protection of Vulnerable Adults list. An overall training and development plan should be devised for the whole staff team. Whitewalls DS0000005929.V313943.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Whitewalls DS0000005929.V313943.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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