Care Home: New Witheven

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What the care home does well The residents are able to choose whether to participate or decline an activity. Service users informed the inspector that they liked the food provided; they liked having meals out and a take away meal too. A balanced and varied diet is provided for the Service Users. The residents have a choice of activities such as day centres and work placements, this leaves weekends free for leisure activities. There are a wide variety of leisure activities available including shopping, trips to local public houses, takeaway meals, swimming, trips to the beach, and attendance at the Gateway club once a week. Residents are able to assist in feeding the pigs, ducks, ferrets and geese on site. Holidays have taken place and planned to include visits to Scotland, Blackpool and Dartmouth. Individual residents have also attended art and computer courses. Residents said that they like the lifestyle that is offered and the variety of things to do. New Witheven is in keeping with a family home. However this has been enhanced by the addition of six en-suite rooms which have been added in apurpose built extension. It is very homely and the residents obviously benefit from the standard of accommodation. Two staff have now completed LDAF Training and the records indicated that staff had received First Aid, Fire, Food Hygiene, Moving and Handling, Protection of Vulnerable Adults training. What has improved since the last inspection? Information obtained for prospective residents and ongoing maintenance of care planning has improved. Evidence of formal annual reviews of care plans to include the input of all interested parties was available. The overall standard of record keeping is satisfactory. The standard of accommodation that is available has improved significantly over the past few years and the providers continue to upgrade as deemed necessary. Policies and Procedures for the home and the recruitment processes have improved since the last inspection. What the care home could do better: The providers are in the process of introducing a new care planning format. This is to be welcomed as it should show better distinction between assessment documentation and the actual care plan itself. Care plans must be reviewed in house at monthly intervals. Further NVQ training for staff should be considered. Where applicable all policy and procedure documents should contain the CSCI contact address at : Fourth Floor, Colston 33, 33 Colston Avenue, Bristol BS1 4UA, tel. 01179307110 CARE HOME ADULTS 18-65 New Witheven Jacobstow Bude Cornwall EX23 0BX Lead Inspector Mike Dennis Unannounced Inspection 26th August 2008 09:30 New Witheven DS0000009043.V367768.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 New Witheven DS0000009043.V367768.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. New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service New Witheven Address Jacobstow Bude Cornwall EX23 0BX 01566 781285 01566 781762 new-witheven@btconnect.com 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) Mr Denzil John Phillips Mrs Gillian Margaret Phillips Manager post vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2006 Brief Description of the Service: New Witheven is a bungalow situated in a quiet rural area. It is the Registered Provider’s home, they live on site and it operates like a family unit. A long narrow lane approaches the home approximately 2 miles from the main A39 at Wainhouse Corner, where there is a hamlet with a shop and public house. The home provides care and accommodation for up to 8 younger adults with a learning disability. At the time of the inspection there were 6 service users living in the home. The accommodation has been improved and upgraded in the past few years to include en-suite rooms and extended communal facilities. There are far reaching countryside views surrounding the bungalow. The Providers own the surrounding area, which creates opportunities for the service users with a variety of animals. There is wheelchair access. Day care is provided separately on site, service users have access to these opportunities depending on their needs. These services are not inspected by the Commission for Social Care Inspection. However the inspector visited and was very impressed with the new ‘chalet’ style facilities that have been provided to replace the previous accommodation. Service users keep in contact with their families and friends and go home at regular intervals. There is an irregular bus service from the main road into Bude, but generally the service users are dependant on transport from the home if they want to go into town e.g. Taxi, or by way of the home’s two minibuses. New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes The inspection took place on the 26th.August 2008 and was carried out as a key unannounced inspection. The inspection took place over the hours of 09:30 to 1700. The Registered Providers assisted us during the course of the day and we thank them for their help and co-operation. We observed staff caring for one resident in a sensitive and appropriate manner. The opportunity was taken to tour the premises, look at the records and documents about the care home. The key core standards that include, care planning and health and safety were considered. The registered providers have submitted written information about the services and facilities before the inspection as requested. What the service does well: The residents are able to choose whether to participate or decline an activity. Service users informed the inspector that they liked the food provided; they liked having meals out and a take away meal too. A balanced and varied diet is provided for the Service Users. The residents have a choice of activities such as day centres and work placements, this leaves weekends free for leisure activities. There are a wide variety of leisure activities available including shopping, trips to local public houses, takeaway meals, swimming, trips to the beach, and attendance at the Gateway club once a week. Residents are able to assist in feeding the pigs, ducks, ferrets and geese on site. Holidays have taken place and planned to include visits to Scotland, Blackpool and Dartmouth. Individual residents have also attended art and computer courses. Residents said that they like the lifestyle that is offered and the variety of things to do. New Witheven is in keeping with a family home. However this has been enhanced by the addition of six en-suite rooms which have been added in a New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 6 purpose built extension. It is very homely and the residents obviously benefit from the standard of accommodation. Two staff have now completed LDAF Training and the records indicated that staff had received First Aid, Fire, Food Hygiene, Moving and Handling, Protection of Vulnerable Adults training. What has improved since the last inspection? What they could do better: The providers are in the process of introducing a new care planning format. This is to be welcomed as it should show better distinction between assessment documentation and the actual care plan itself. Care plans must be reviewed in house at monthly intervals. Further NVQ training for staff should be considered. Where applicable all policy and procedure documents should contain the CSCI contact address at : Fourth Floor, Colston 33, 33 Colston Avenue, Bristol BS1 4UA, tel. 01179307110 New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, 5. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Admission to the home is based on an assessment of prospective residents so that they can be assured the home will be suitable to meet their needs. They are given sufficient information about the home prior to admission. EVIDENCE: A comprehensive document to include the information required has been compiled as a combined Statement of Purpose and Service User’s Guide. A copy is provided to any prospective resident and a copy is available in each room. Three of the current residents have lived at New Witheven for over eleven years. The Registered Providers have developed a care needs assessment form. We were provided with evidence that comprehensive admission information had been gathered for the newest admission to the home. This information forms the basis of an individual plan being developed and agreed with the resident and staff. The Registered Providers demonstrated an in-depth understanding of residents’ care needs and capabilities. Residents live a comfortable and active life. New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 10 Prospective residents have the opportunity to visit the home to meet residents, staff, have a meal, view the room, see the kinds of records kept about residents and discuss how the home can meet their requirements. Unplanned and emergency admissions should be avoided. Contracts including written terms and conditions between the resident and the home are in place. Residents are provided with contracts from Adult Social Care that detail their terms and conditions, although there are often considerable delays in this information being provided the inspector was informed. New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Registered Providers have a detailed knowledge of the residents and there is clear evidence that individual needs and choices are met. Some improvement is required in the documentation of care needs, risk-assessment and review. EVIDENCE: The registered providers are in the process of developing a new care planning format for all residents. The completion of this task should be given priority. Care plan information is available but tends to be somewhat disorganised and the new system should eradicate this problem. The care of residents’ is formally reviewed annually, by the home and the responsible local authority. Regular in house reviews should take place at monthly intervals. New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 12 Risk and hazards are identified in most cases. Personal safety is addressed on an individual basis. Unexplained absences are acted upon promptly. Residents are encouraged to maintain their independence and are supported to do this. We were informed that they were able to make decisions about how they live their lives. Residents attend structured daytime activities or employment for at least four days per week. New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are able to take part in a range of activities in and out of the home, which are appropriate to their ages, individual needs, interests and cultural backgrounds so that they develop their skills and confidence. They are supported to maintain valued social relationships so that they are not isolated or institutionalised. They are informed of their rights and responsibilities so that they are aware of what is expected of them. They are provided with a wholesome and varied diet so that they enjoy their meals and stay healthy. EVIDENCE: The residents have a choice of activities such as day centres and work placements. This leaves weekends free for leisure activities. There is a day centre on site, which is available to the residents if they are not otherwise engaged. New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 14 Leisure activities include shopping, trips to local public houses, takeaway meals, swimming, trips to the beach, and attendance at the Gateway club once a week. Residents are able to assist in feeding the pigs, ducks, ferrets and geese on site. There are plenty of opportunities for local walks and gardening. Residents have enjoyed both group and individual holidays away from the home. The Registered Providers advised us that the residents are able to determine their own lifestyle within the parameters of their own capabilities and risk. The residents said that they like the lifestyle that is offered and the variety of things to do. Residents are encouraged to maintain links with their families. Friends and family are welcome to visit the home. Residents choose who they see and when and are able to receive guests in their room. All residents have locks on their bedroom door with a key provided. Staff knock when they wish to enter and wait for the service user to ask them to come in. Residents informed the inspector that they are able to participate in socialising within the home or spend time alone in their own rooms, without question. A nutritious and varied diet is provided. The menu changes fortnightly, although the Provider informed the inspector due to the size of the home the service users usually accompany the Providers on the weekly shopping trip, so it can be varied. Records are kept to provide evidence of this. There was evidence that a clear choice for main course and desert is available. There is a large well equipped kitchen with adjacent lounge and dining area containing a fridge, microwave and sink to give the residents more privacy and promote independence. A bowl of fruit was available for anyone to help themselves to. The main meals continue to be prepared in the main family kitchen. Some residents like to keep their own snacks and drinks in their kitchen facility. Residents are provided with a packed lunch or given a hot meal when they are attending daytime activities or employment. Personal likes and dislikes are recorded. New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ personal and healthcare needs are well met so that they are able to live full and active lives in and out of the home. There are systems in place to support them with medication. EVIDENCE: Residents indicated that they were pleased with the way the providers offer the care and support they require. It is clear that positive and trusting relationships have been established and that residents are supported to be as independent as possible. Residents’ health needs are well met and medical services are promptly accessed when required. The providers support residents to attend any appointments and residents are also offered an annual health check. New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 16 Residents are able to administer their own medication when it is safe to do so but the providers will offer assistance where required. A satisfactory policy and procedure is in place and medication is stored in secure facilities. Where the providers assist with medicines records are maintained and suitable arrangements are in place to safely dispose of any unwanted medication. Medication is supplied by the local pharmacy. There are currently two residents in receipt of medication. Medication records were inspected and found to be satisfactory. New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are listened to and respected so that their views, concerns and complaints are taken seriously and acted upon. There are formal and informal systems in place to ensure that they are able to feel safe in the home. EVIDENCE: The providers or Commission have not received any complaints since the last inspection. The providers have established good arrangements to deal with complaints and residents are encouraged to raise any concerns or issues. A suitable policy and procedure is in place and residents said there are no apparent barriers to raising issues with the providers. Residents were also confidant that any concerns or issues would be dealt with promptly and satisfactorily. Appropriate arrangements are also in place to deal with allegation of abuse. Any allegations would be reported to the statutory authorities and formally investigated where required. New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 18 A clear reference to the Department of Adult Social Care should be included in the Abuse policies and procedures to include address and telephone number so that people are clear as to whom a referral may be made. New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home’s environment provides residents with a homely, domestic setting so that they can develop their skills and independence in a non-institutional setting. It is safe and clean so that residents are protected from risks of crossinfection. EVIDENCE: The home was observed to be very clean and hygienic on the day of the unannounced inspection. There has been a significant reinvestment in this home over the last few years. The new extension provides light, airy and very comfortable environment that meets and exceeds the environmental standards. All of the rooms have spacious en-suite facilities are well appointed. We were told that residents were delighted with their accommodation New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 20 The residents choose the colour of paint for decorating their individual room. All rooms are lockable and the residents have their key. All bedrooms are comfortably furnished, well ventilated and have under floor heating. The Providers have given great consideration ensuring that the rooms have all the required furniture. Rooms are lockable and some residents like to take advantage of being able to secure their rooms. A portable call bell is provided to each room depending on individual need, this is important as the rooms are sound proofed and the residents need to be able to call for assistance. All rooms have ensuite bathrooms with baths or showers depending on what the resident wanted at the time of the building work. The communal bathroom has had the bath removed and a shower put in as it was felt this would be used more. A new comfortable combined lounge/dining room has been provided with a fridge, microwave and sink to give the service users more privacy and promote independence. There are private areas available for consultations and a designated smoking area outside the home. There is an attractive decking area outside where residents can sit, weather permitting with far reaching countryside views. There is parking area to the front and side of the property. Assisted access has been provided to the side of the home. Overall the premises present to a high standard. New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff team at New Witheven is a relatively stable team offering continuity to the residents. Recruitment procedures are satisfactory. Training is ongoing and supervision of the staff team is taking place. EVIDENCE: There are clearly defined job descriptions and it was evident that staff fully understood their roles and responsibilities. Service Users attend a different part of the site for day care and this is staffed separately. One member of staff has completed their LDAF training. One has their NVQ Level 3 training and another NVQ level 2. More staff should obtain NVQ level 2 to achieve the required standard of at least 50 having this qualification. We were informed that staff have received First Aid, Fire, Food Hygiene, Moving and Handling, Protection of Vulnerable Adults training, as was verified from the staff records. New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 22 There are no staff employed solely for the home. The Providers and their daughters run the home on a day-to-day basis and the staff from the day service cover for set shifts. Currently there are two staff on duty or contactable if the home is empty i.e. all the service users attending their day care or employment. At night there is one waking member of staff plus sleeping in staff. No one under twenty one is left in charge of the home at anytime. There is a rolling duty rota. Residents spoke very positively about the Providers and other staff in the home. Criminal Records Bureau checks have been obtained for all people working in the home. Staff meetings take place and a record of minutes kept. Recruitment Policies and Procedures based on equal opportunities, current legislation and Schedule 2 of the Care Homes Regulations are followed. Four staff files were examined and found to contain the required information e.g. application form, references, Criminal Records Bureau checks, induction, job description etc. All staff have appropriate contracts of employment. New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,41,42. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is competently managed for the benefit of residents. There are formal and informal systems in place to ensure that residents’ views are taken into account in the ongoing management of the home. The home is maintained to a good standard to ensure that it is safe for all those who live, work and visit the home. EVIDENCE: The Registered Providers manage the home on a day-to-day basis. There is evidence of clear leadership within the home; the home is managed on a dayto-day basis by the Registered Providers. There is an open and inclusive New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 24 atmosphere within the home. This must be underpinned with continuing training and development. Appropriate arrangements are in place to promote residents’ health and safety and provide a safe environment. The providers have established a range of policies and procedure to guide and direct the actions taken and to make sure good safety standards are maintained. Records required by legislation are in place and are under constant review. A good standard of record keeping exists. Staff are provided with training in First Aid, Fire and Moving and Handling of medicines. Records are being kept of Visitors to the home as required. All accidents are recorded in the home’s accident book. Water is regulated to 43 degrees. Emergency lighting is regularly checked and weekly fire tests. All residents have a copy of the fire procedure and have been advised of the action to take if the alarm should go off. Residents benefit from competent and accountable management of the service. New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 25 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 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 3 3 3 X New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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. 2 3 Refer to Standard YA6 YA23 YA32 Good Practice Recommendations Implement the new care plan format as a priority and ensure it is regularly reviewed. Add the contact details of the Department of Adult Social Care to the Abuse policies and procedures. At least 50 of the staff team should obtain a NVQ qualification. New Witheven DS0000009043.V367768.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI New Witheven DS0000009043.V367768.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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