Inspection on 06/04/06 for Whittington House

This inspection was carried out on 6th April 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Whittington House 24/10/08

Whittington House 01/05/08

Whittington House 11/09/07

Whittington House 05/04/07

Whittington House 12/10/06

Whittington House 15/08/05

Whittington House 29/04/05

Whittington House 15/09/04

Whittington House 24/05/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Whittington House 46 Dongola Road London N17 6EE Lead Inspector Susan Shamash Unannounced Inspection 6th April 2006 01:15 Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 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 Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 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. Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Whittington House Address 46 Dongola Road London N17 6EE 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) 020 8376 9219 020 8379 9219 Mr Francis Cleland Mr Francis George Cleland Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th August 2005 Brief Description of the Service: Whittington House is owned and managed by a private individual, Mr Francis Cleland who owns a number of other similar small homes in the North London area. The home is registered to provide a service to up to three people with mental health problems. Current weekly fees as of 06/04/06 are £670 - £950. The home is located in a densely populated area off Philip Lane, close to shops, pubs, the post office and other amenities. The home was opened in August 1999 and consists of a two-storey Victorian house with a newer, ground floor extension that is used as the kitchen. All the homes three bedrooms are single although none have en suite facilities. It is on an ordinary domestic scale and fits in well with the surrounding area, with a small garden to the rear. The homes aims and objectives state that it provides support for service users to be part of the local community and to develop leisure and social activities. Inspection reports are made available to service users by them being informed when new reports have been received, and that they may ask to see the office copy whenever they wish to. Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection lasted approximately six hours and was carried out as a routine unannounced visit to the home and in order to check compliance with the requirements made at the previous inspection. There were three residents living in the home and it was possible for the inspector to speak to all of them during the course of the inspection. One resident had been admitted since the previous inspection following another resident moving into ‘supported living’ accommodation. One resident’s verbal communication with the inspector was limited, on this occasion, however observation of their relationships with staff and other residents, and records maintained at the home were also taken into consideration in gaining an understanding of their experience at the home. The inspector was assisted throughout by an acting manager in the absence of the registered provider (who is also the registered manager). The inspector also had the opportunity to speak to a staff member who was working in the home. A tour of the premises took place and care records were inspected, however financial records could not be inspected on this occasion due to the registered manager being on leave. It is of concern to the inspector that six of the fourteen requirements from the previous inspection have been restated in this report, and several of these requirements have been restated on a number of occasions. The provider is aware that continued failure to comply with requirements made will result in enforcement action being taken against the home. What the service does well: Feedback from residents indicates that they are happy with the way they are supported at the home. The home’s main strength is at supporting residents who are relatively independent, to maintain and improve their living skills, whilst respecting their privacy. All residents have care plans that are reviewed regularly and are consulted about these as far as possible. Staff members are generally knowledgeable about their role and responsibilities within the home. Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: It remains required that statements of terms and conditions with the home must be updated to cover all the areas specified in the national minimum standards, in order to ensure that residents’ rights are protected appropriately. Evidence must be provided that service users’ finances are being handled appropriately as it was not possible to verify this at the time of the inspection. More choice of activities including occasional day trips should be provided to service users and the provider should also look into the possibility of a holiday for service users. A number of identified maintenance issues in the home must be addressed to ensure the safety and comfort of residents. The home still does not have a fully functioning quality assurance system, and it remains required that an audit be completed to ensure that residents receive a service of a high measurable standard. Failure to comply with this requirement will result in enforcement action being taken against the home. The registered provider and manager must maintain a record of his hours worked at the home, to ensure that adequate cover is provided in the home. The rear garden wall must be made safe to protect residents and staff. Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 7 A current electrical installation certificate must be obtained for the home, and the provider must comply with all requirements made by the local fire prevention authority to ensure the safety of staff and residents in the home. It is recommended that an induction procedure specific to Whittington House be developed for new staff and that an alternative format be used to record weekly fire alarm call point checks for the home. 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. Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5. Sufficient information is available for prospective residents to make an informed choice about the home and an adequate system is in place to assess their needs and goals effectively and ensure that these can be met. Residents’ rights are still not sufficiently protected by contractual arrangements with the home and their local authorities, making them vulnerable to abuse/ exploitation. EVIDENCE: One new resident had been admitted since the previous inspection, following one resident moving out into ‘supported living’ accommodation. At the previous inspection it was required (for the fifth time) that the service users guide be updated to include residents’ views of the home and access to the most recent CSCI inspection report. The service user’s guide for the home had been updated to include photographs of the home and greater detail about services provided. Together with the statement of purpose it now contains the information required for residents. Copies of these documents were provided to the CSCI. The most recently admitted resident advised that they had received all necessary information regarding the home prior to and following admission. Service user plans included assessments with regard to the needs of each individual resident, and residents spoken to confirmed that they were Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 10 consulted with regard to their needs. At the previous inspection it was also required that the content of residents’ statements of terms and conditions with the home be revised to ensure that all necessary information (as specified under Standard 5 of the National Minimum Standards) is included. This includes the room to be occupied, rights and responsibilities, arrangements for reviewing the service user plans, any limitations to the freedom of each resident, and that a copy of each service user’s contract with the local authority be available on their file. Inspection of residents’ files indicated that this had still not been carried out, and this requirement is restated for the fourth time. Copies of local authority contracts must also be maintained on file. Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Residents’ needs and goals are assessed and responded to adequately, to ensure that these are met. However there remains room for improvement in the recording of actions taken to protect residents’ finances appropriately. EVIDENCE: Service users plans were available for all service users, and contained relevant information regarding appropriate areas of support. The signatures of residents were also included indicating their involvement in the care planning process. Residents spoken to confirmed that they were encouraged to be involved in this process. At the previous inspection it was required that all risk assessments be reviewed at least six-monthly and that a risk assessment regarding noncompliance with medication be recorded for one resident. This resident had moved out of the home since the previous inspection, and their file was not available at the home for inspection. As required records indicated that risk assessments for all residents were being reviewed at least six-monthly. At the previous inspection it was noted that a client account had been set up Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 12 for a resident who did not have sufficient identity documents to open their own bank account. The manager also advised that he was also still chasing up back payments of Disability Living Allowance for this resident. Although the use of a client account for the resident has partially resolved the situation, it remains required that the resident’s rights be protected by continuing to pursue his identity documents, and that all actions taken on their behalf must be recorded. As the manager was not available during this inspection, it was not possible to verify compliance with this requirement. It is required that the provider write to the inspector detailing the current situation with regard to residents’ finances looked after by the home, and compliance will be confirmed at the next inspection. The inspector was also concerned to note that a debit card belonging to a resident was being kept in the staff office for safekeeping when not in use. A risk assessment should be undertaken for this resident and records should be maintained of times when the card is with the resident, and when it is returned to the office. A more secure storage site for the card should also be identified to protect the resident and staff members. Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Although provision is made to offer a range of activities to service users, there remains room for improvement in the provision of leisure opportunities to residents. Freedom is provided for residents to engage in personal relationships and maintain contact with family members and friends. Dietary needs of residents are catered for with a balanced and varied selection of food available that meets their nutritional and cultural needs. Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 14 EVIDENCE: The inspector spoke to all three residents and examined each service user plan, as well as discussing residents’ lifestyle choices with staff members on duty and observing routines within the home. Minutes of house meetings and discussion with staff and residents indicated that residents are encouraged to be involved in housework. Two residents attend day services sporadically according to their wishes, and the other continues to require further support in finding meaningful and therapeutic daytime activities. Following support from an occupational therapist, staff had been provided with a selection of therapeutic activities to undertake with this resident, both within and outside of the home. As required previously, there was evidence that staff from the home now maintain their own minutes of meetings regarding residents’ welfare, so that action may be taken promptly. Two residents are very able to maintain social contacts independently and both indicated that they did so on a regular basis. The other resident needs far more support in this area, and does not have opportunities of meeting people of their own age or with shared interests. This is an area that remains to be addressed in conjunction with the occupational therapist. Records indicated, and residents and the staff member confirmed, that a daytrip had been arranged to Brighton last summer, and that this had been very successful. Other activities included shopping trips, walks in the local park and board and card games; however records indicated a reduction in the number of activities provided for residents in the last few months. Residents spoken to indicated that they would be interested in participating in more activities outside of the home. It remains required that the possibility of a short holiday for all residents away from the home be investigated. It is also required that there be an increase in the number of activities available to residents including occasional meals out, trips to the cinema and day trips to places of interest. Records of food served to residents indicated that a varied menu was served and residents spoken to were satisfied with the food available to them including some Caribbean food for residents who request this. The home was adequately stocked with a range of foods including fresh fruit and vegetables. Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 15 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. Residents receive appropriate physical and emotional support and are supported to take their prescribed medicines appropriately according to their needs. EVIDENCE: Service user plans, and feedback from residents indicated that they are treated with respect and that their privacy and dignity are maintained. There was also evidence that residents attended regular health care appointments as appropriate. The inspector noted that the recording of health appointments was significantly improved including details of any treatment or advice given as appropriate. The storage and recording of the administration of medication appeared to be satisfactory. The storage temperature of medicines was recorded daily and was within the specified range, and records of medicines received, administered and disposed of, were up to date as appropriate. Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 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. The home has a complaints procedure in place to ensure that the concerns of residents are acted upon effectively. Procedures and training are in place to ensure that residents are protected from abuse. EVIDENCE: The home has a complaints procedure, an adult protection procedure and guidance for staff regarding whistle blowing. A copy of the Haringey Adult Protection Policy and Procedure is also available within the home. Evidence was available that staff at the home had undertaken training in the protection of vulnerable adults as appropriate. No complaints had been recorded since the previous inspection, however residents spoken to advised that they would feel able to express any concerns or complaints to staff, or the manager, if necessary. Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Service users live in an environment that is generally homely and comfortable, with adequate private and communal space. However an unsafe wall in the rear garden poses a potential health and safety risk and there is room for a number of identified improvements to improve the comfort and safety of the environment for residents. EVIDENCE: Service users spoken to advised that the location and layout of the home meet their needs. There is sufficient communal space for three residents and the cleanliness in the home was of an acceptable standard. Cast iron and wood garden furniture is provided within the garden, and one resident advised that they enjoyed using this area. However the rear garden wall continues to be in a hazardous state, due to pressure applied by the roots of a tree. The manager had informed the inspector that he had been in contact with the local council who owned the property in which the tree is growing. However it remains required that this must be addressed as a matter of urgency. All correspondence regarding this issue must be maintained on file. In the meantime preventative action, e.g. cordoning off the area of the garden that is affected, must be taken to protect the safety of staff and residents using the garden. Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 18 As required the walls and wardrobe in one resident’s bedroom had been repainted. It is required that the linoleum flooring in the first floor bathroom must be replaced, as it was covered in cigarette holes. The carpet in the most newly admitted resident’s room must be cleaned; and polystyrene ceiling tiles on the ceilings of any bedrooms in the home, must be replaced, as they present a fire risk. One resident asked for longer and differently coloured curtains to be provided in their room. The inspector noted that the curtains provided in this room were not of sufficient length to fit the windows appropriately, and a requirement is made accordingly. The inspector was concerned to see that the window restrictor in one resident’s room (a resident with high dependency needs) was not operating effectively, and this must be addressed as a matter of urgency. The acting manager advised that action would be taken to address this issue without delay. Finally it is required that the woodwork on the rear exterior of the home must be repainted/replaced and the rear door of the home (which is damaged) must be repaired or replaced. Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Staff have undertaken a range of relevant training to meet the needs of residents safely and effectively. However there is a need for further training in fire safety to fully protect residents. A recruitment procedure and adequate supervision is in place for staff, which adequately protects residents. EVIDENCE: As noted at the previous inspection, satisfactory enhanced CRB disclosures were available for all staff as required, and staff files included the required information. No new staff had commenced work at the home since the previous inspection. There was evidence that staff training had been undertaken in health and safety, moving and handling, first aid, adult protection, administration of medication, drug and alcohol awareness and dealing with potentially violent Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 20 situations. It remains recommended that an abbreviated induction format specific to Whittington House, be available for agency/bank staff members working in the home for the first time. This should be separate from inductions for other homes, and include important information about the residents accommodated. At the previous inspection a requirement was made regarding the frequency of staff supervision. Inspection of staff files and discussion with staff indicated that regular individual staff supervision sessions are now occurring. As required separate staff meetings (other than house meetings including service users) had also been occurring on a regular basis. Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42. In the absence of a record of the acting manager’s hours and access to residents’ financial records, it is unclear as to whether the home is adequately managed, with the needs of residents in mind. The absence of adequate quality assurance procedures, and a number of safety issues to be addressed, also place residents at an increased risk. EVIDENCE: Concerns remain regarding the availability of the registered provider to manage the home on a daily basis. At the previous inspection the registered person was required to record the hours that he works within the home on a daily basis. Although this was undertaken for several months following the inspection, it had stopped more recently as the provider spent more time within the home. However it is required that the registered manager either specify the hours that he works in the home on the home’s staffing rota or continues to record his hours on a daily basis. This requirement is restated for the third time. Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 22 At previous inspections it was required that a quality assurance audit be conducted for the home. The provider had advised that he was working with an independent consultant to complete this task and had already circulated questionnaires to residents. He was reminded that he also needed to request feedback from health care professionals and other visitors to the home in addition to an internal audit of how the home is functioning. It was agreed that a report of the findings of this audit would be sent to the local CSCI area office by the end of May 2005. However no report has yet been received and this requirement is restated for the third time. Failure to comply with this requirement may result in enforcement action being taken against the home. As required the CSCI had been notified of any serious incidents affecting residents in the home since the previous inspection. At the previous inspection a requirement was made regarding the management of an identified resident’s finances looked after by the home. The inspector had been in contact with the provider regarding this issue. However in the absence of the provider/manager on the day of the inspection, it was not possible to verify whether suitable recording arrangements are in place for this resident. This requirement is therefore restated. COSHH materials were stored in locked facilities as appropriate, and as required hazard analysis sheets were available for COSHH materials used within the home. A current gas and portable appliances testing certificate was available for the home and records indicated that a number of fire safety checks were being undertaken. However the electrical installation certificate for the home had expired and a requirement is made accordingly. Following a fire safety audit undertaken by the local fire prevention officer (as required at the previous inspection) a number of requirements were made including the need for fire safety training, easily accessible emergency exits, weekly testing of each fire call point, and monthly emergency lighting testing. It is required that all these issues be addressed without delay. As required at the previous inspection a fire risk assessment must be undertaken for the home and a copy must be sent to the local CSCI area office. Failure to comply with this requirement may result in enforcement action being taken against the home. It is recommended that a new format be developed for recording weekly fire alarm testing from different call points in the home (to ensure that all are tested regularly) and that more regular health and safety checks be undertaken. Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 1 X 3 2 X Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 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 YA5 Regulation 5(1)(c) Requirement Timescale for action 02/06/06 2 YA9 20 3 YA9 17(2) Schd 4(9) The registered person must ensure that service users’ statements of terms and conditions with the home are updated to include all the information as specified under this Standard, including the room to be occupied, rights and responsibilities, arrangements for reviewing the service user plan and any limitations to the freedom of each service user. Copies of local authority contracts with each service user must also be available. (Previous timescales of 05/11/04, 24/06/05 and 21/10/05 not met). The registered person must 19/05/06 continue to work with the identified service users social worker to ensure that their finances are maintained appropriately. All correspondence, financial transactions and receipts must be maintained accurately on file, with copies sent to the local CSCI area office. The registered person must ensure 05/05/06 that a risk assessment is undertaken for the service user whose debit card is currently being looked after by the home. Records DS0000010799.V288196.R01.S.doc Version 5.1 Page 25 Whittington House 4 YA14 16(2)(m) (n) should be maintained of times when the card is with the service user, and when it is returned. A more secure storage site for the card should also be identified to protect the service user and staff members. The registered person must ensure that regular supervised trips are arranged outside of the home to places of interest to service users, such as trips to the cinema, pub and local cafes/restaurants, and day trips to more distant destinations. These must be recorded in service user files. 19/05/06 5 YA24YA42 23(2bo) 13(4a) 6 YA24 YA42 13(4a) 23(2b) The possibility of a short holiday away from the home for all service users must also be investigated. (Previous timescales of 22/10/04, 01/07/05 and 23/09/05 not met). The registered person must ensure 19/05/06 that the rear garden wall is made safe as a matter of urgency. (Previous timescale of 09/09/05 not met). All correspondence regarding this issue must be maintained on file. In the meantime preventative action e.g. cordoning off the area of the garden that is affected, must be taken to protect the safety of staff and service users using the garden. The registered person must ensure 28/04/06 that the window restrictor in the identified service user’s room is operating effectively. The registered person must ensure that longer curtains chosen by the identified service user are provided in their room. The linoleum flooring in the first floor bathroom must be replaced. The carpet in the most newly 02/06/06 7 YA24 23(2d) Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 26 admitted service user’s room must be cleaned. The rear door of the home must be repaired or replaced. A schedule for repainting/replacing the woodwork on the rear exterior of the home and for removing polystyrene ceiling tiles in any remaining rooms in the home, must be sent to the local CSCI area office. The registered person must record 12/05/06 the hours that he works within the home on a daily basis. (Previous timescales of 01/10/04, 20/05/05 and 23/09/05 not met). The registered person must 02/06/06 undertake a quality assurance audit of the home, and this must be repeated at least annually, obtaining feedback from each service user (with assistance from an advocate where appropriate), care managers, health care professionals and regular visitors to the home. A copy of the findings of this audit must be sent to the local CSCI area office. (Previous timescales of 05/11/04, 10/06/05 and 23/09/05 not met). The registered person must address 12/05/06 all requirements following a fire safety audit undertaken by the local fire prevention officer by 02/05/06 including: - provision of fire safety training to all staff, - ensuring that emergency exits can be easily opened, - testing of each fire call point weekly and Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 27 8 YA37 10 17(2) Schd 4(7) 24 9 YA39 10 YA42 13(4)(a) 23(4cd) - monthly emergency lighting testing. A fire risk assessment must be undertaken for the home and a copy must be sent to the local CSCI area office. (Previous timescale of 21/10/05 not met). The registered person must ensure that a current satisfactory electrical installation certificate is obtained for the home, and that a copy is sent to the local CSCI area office. 11 YA42 13(4a) 26/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA34 Good Practice Recommendations It remains recommended that an abbreviated induction format specific to Whittington House, should be available for agency/bank staff members working in the home for the first time. This should be separate from inductions for other homes, and include important information about the service users accommodated. It is recommended that a new format be developed for recording weekly fire alarm testing from different call points in the home (to ensure that all are tested regularly) and that more regular health and safety checks be undertaken. 2 YA42 Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Whittington House DS0000010799.V288196.R01.S.doc Version 5.1 Page 29 - 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. 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