Care Home: The White House

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What the care home does well One Standard has been exceeded, `supervision`. The frequency of this exceeds the 6 sessions per month required by this Standard. The residents have been consistent in their views that they liked their rooms and the meals. Residents commented positively about the home, talking about recent outings, singing activities and visitors. At the last announced inspection the residents chose to stay at the home instead of attending their day centres as they wished to participate in the inspection process. This was supported by the home and additional staffing was provided to facilitate this. The residents all have pressure sore risk assessments. This also meets the Standards for Older People, as required. As the home accommodates only three service users over 65, this is seen as good practice for the rest. The bedroom sizes all exceed the minimum standard of 10sqm. Once the condition of registration regarding removing double rooms is implemented, this Standard should be exceeded. See `Conditions of registration`. What has improved since the last inspection? The home has now fully implemented a quality assurance system and an annual development plan, with both involving residents. This increases the involvement of the residents and relatives in measuring improvements in quality. What the care home could do better: To ensure that all needs are known, care plans need to include a reference to religious and cultural needs. Although there has been progress in making relevant policies accessible to the residents, more needs to occur in this area so that all residents can access relevant policies. At least 50% of care staff should be qualified at NVQ Level 2 so that the home can provide more suitably qualified staff. The registered manager should be qualified to NVQ Level 4 in Management and Care to ensure that a suitably qualified manager is running this home. Individual Risk assessments for the risk of scalding from bedroom sinks must be completed and be available during inspections upon request. This will reduce the risk of scalding as the risk will be considered and action taken if needed. CARE HOME ADULTS 18-65 The White House 74 Reddown Road Coulsdon Surrey CR5 1AL Lead Inspector Barry Khabbazi Unannounced Inspection 30th June 2008 09:00 The White House DS0000058633.V367674.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 The White House DS0000058633.V367674.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. The White House DS0000058633.V367674.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The White House Address 74 Reddown Road Coulsdon Surrey CR5 1AL 01737 553 230 01737 553 230 megalen@govindan.co.uk 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) The White House Megalen Govindan Care Home 9 Category(ies) of Learning disability (9) registration, with number of places The White House DS0000058633.V367674.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The certificate is for 9 service users, adults 18-65 with a variation for 3 older adults. A letter is held on file confirming that, if a double room service user moves on, the remaining service user has the right to refuse to have another service user move into the room. 16th April 2007 Date of last inspection Brief Description of the Service: The White House is a detached two-storey house situated in Coulsdon, Croydon. There are three double and two single bedrooms as well as a dining room, kitchen and lounge. The homes stated aim is to create a home with a warm and friendly atmosphere. There is easy access to local shops, library and places of worship. The home offers care to eight people with learning disabilities, some of whom have additional sensory impairments. The home is not adapted for and is not suitable for people with physical impairments affecting mobility. All residents attend local day resources. The fees are from £460 to £2,100 per month. The White House DS0000058633.V367674.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating of the service is 2 star. This means the people who use this service generally experience Good outcomes. This inspection was unannounced and started early in the day to allow the residents to be met, before they went to their day activities. The manager was interviewed, and records, policies, care plans, and the building were examined. As this home was previously a 1 star home the inspection was brought forwards. The manager’s latest self-assessment {AQAA} had therefore only just been received and so was not ready to be used to support findings in this inspection. This self-assessment will however be included in the next inspection report. An increased level of community use was seen at this inspection. One Standard has been exceeded - ‘supervision’. The people who use this service refer to themselves as residents. The residents talked about recent activities and courses they had attended. Where communication was limited by the residents’ disability, those residents appeared relaxed and contented with three smiling and laughing together. Staff were seen to be supportive and responsive to residents’ needs. No areas of serious concern were identified at this inspection. What the service does well: One Standard has been exceeded, ‘supervision’. The frequency of this exceeds the 6 sessions per month required by this Standard. The residents have been consistent in their views that they liked their rooms and the meals. Residents commented positively about the home, talking about recent outings, singing activities and visitors. At the last announced inspection the residents chose to stay at the home instead of attending their day centres as they wished to participate in the inspection process. This was supported by the home and additional staffing was provided to facilitate this. The residents all have pressure sore risk assessments. This also meets the Standards for Older People, as required. As the home accommodates only three service users over 65, this is seen as good practice for the rest. The bedroom sizes all exceed the minimum standard of 10sqm. Once the condition of registration regarding removing double rooms is implemented, this Standard should be exceeded. See ‘Conditions of registration’. The White House DS0000058633.V367674.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. The summary of this inspection report can be made available in other formats on request. The White House DS0000058633.V367674.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 The White House DS0000058633.V367674.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2: People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. Prospective residents needs are assessed before they start at the home to ensure that all their needs are known by the staff. EVIDENCE: The file for the newest resident was examined at this inspection and all the required assessments were present and to the required standard. The White House DS0000058633.V367674.R01.S.doc Version 5.2 Page 9 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): Standards: 6, 7, 8, and 9: People who use this service experience adequate quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. Care plans do not all cover all the areas required. This is needed so that staff, and particularly new staff, know all of a resident’s needs. Residents are supported to make decisions about their lives to maximise their independence and choices. Residents are consulted on and participate in all areas of life at the home. Risk assessments contain all the information required to reduce unnecessary restrictions of liberty but are not avalable for all areas to ensure the safety of the resident. The White House DS0000058633.V367674.R01.S.doc Version 5.2 Page 10 EVIDENCE: Plans of care were available for all residents. At the last key inspection, the requirement for care plans to also contain educational, social, religious, or cultural needs had been met. However, this was not the case at this inspection for the newest resident. The following old requirement that had previously been met therefore now needs to be set again: All care plans must all include a reference to religious and cultural needs. Reviews of care plans were examined and found to be meeting the required rate of every 6 months and on a monthly basis for those residents over 65. In addition, where care plans had been reviewed, and changes identified, these changes had been transferred to the care plan document. The residents are offered the opportunity to participate in the day to day running of the home and to contribute to the development and review of policies and services through the quality assurance system, questionnaires, regular house meetings and individual discussions with their key workers. The last inspection report recorded that Standard 8.2 requires the home to provide service users with accessible information regarding its policies, activities and services, for example pictorial menus and complaints procedures. A requirement was set regarding this to promote equality of access. Although there are now pictorial menus, and pictorial cues to the residents’ guide, more work needs to be done, for example taped policies to facilitate access to those with a visual impairment. To reflect the progress made a recommendation only will be set at this time. The risk assessment form does now contain all the information required under Standard 9.4, in particular details of how training and other options have been explored before any restrictions of liberty are applied, and the involvement of relatives or independent advocates. These had been filled in for all known areas required including restriction of liberty for the protection of the resident. However risk assessments could not be produced for the risk of scalding at bedroom sinks. This creates a minor shortfall under the risk assessment standard but has been addressed with a requirement under Standard 42 ‘health and safety’ and will therefore not be repeated here. See Standard 42 for details. The White House DS0000058633.V367674.R01.S.doc Version 5.2 Page 11 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): Standards, 12, 13, 14, 15, 16, and 17. People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. Residents are now better supported to participate in the local community, with the aim of maximum integration and challenging discrimination. Residents are supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. The daily routines and house rules do generally promote residents’ rights, to ensure equality and that all rights are enjoyed by all residents. Residents receive sufficient access to activities and outings. Residents are supported to continue education, so that they can maximise fulfilment and achievement in their lives. Dietary needs are catered for and a balanced diet is provided, to ensure health and enjoyment of food. The White House DS0000058633.V367674.R01.S.doc Version 5.2 Page 12 EVIDENCE: There was evidence of the home enabling good links with family and friends who can visit and are visited regularly. One resident told us about recent visits from family and another person signed the same. Family and friends are made aware of the home’s visiting policy and there are few restrictions about when family or friends can visit. Friendships exist within the home. The daily routines and house rules do promote independence and choice. Meals for example can be taken where and when residents want and residents go to bed and get up when they want at the weekends. Residents are able to lock their doors and all have keys to their rooms. The home demonstrated choice in providing extra staff to facilitate the residents’ wish to not attend day services but be present at the home during the inspection to meet the inspector. Activities have since been increased particularly community use. Residents told us about recent trips they had been on and in particular, the pub. Residents now have access to a higher frequency and wider range of appropriate activities. Residents have trips out 2 or 3 times per week and at weekends. These included for example, visits to the park, bowling, the cinema and meals out. There are a variety of games, puzzles, and art equipment for the residents to use within the home, as well as equipment for listening to music. The last inspection report contained the following recommendation under Standard 14: Each service user should be offered a seven-day holiday paid for by the home as a part of the contracted price. This had not occurred and this recommendation remains in force. Evidence was provided of residents being supported to attend to continue education. Independent living training occurs at the home and day centre, and is supported by staff and key workers. One resident indicated that they had been recently attending a collage cookery course and showed us her cookery file. Colleges are being used more frequently now for courses and activities. Residents said they like the food. One person said smiling ‘ the food is good, they give us plenty, my plate is piled up with food’. The residents design their menus with staff and assist in preparation where appropriate, with appropriate support from staff if required. Menus were examined and found to be satisfactory. Planned menus are recorded. Snacks and drinks are always available. Nutritional needs are reviewed and monitored {including weight} and residents are referred to dieticians through the G.P if required. The White House DS0000058633.V367674.R01.S.doc Version 5.2 Page 13 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): Standards, 18, 19, and 20. People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ emotional and health needs are met by this home and records of health needs are now better recorded. This ensures that the residents’ emotional health is well maintained and therefore the quality of life experienced is also maximised. Residents’ medication is well managed as staff have had approved and accredited medication administration training to promote safer medication administration. The White House DS0000058633.V367674.R01.S.doc Version 5.2 Page 14 EVIDENCE: Encouragement and guidance are provided to support personal care but direct personal care is limited at this home. Evidence has been presented in discussions with staff of them having knowledge of good practice in providing care and support, and this has been confirmed through observation. The home does not currently provide places for, and is not suitable for, people with a secondary physical or sensory impairment significantly affecting mobility. Healthcare needs were recorded in the residents’ files. The home has actively been promoting regular annual health checks through the GP. Access to audiologists, chiropody, dentists and opticians was demonstrated. Healthcare professionals attend when required and meet residents in private. Residents are supported to attend outpatient appointments and other medical appointments. residents can self-administer medication subject to risk assessment. Records of action taken when a resident loses significant weight are now recorded. The following evidence of good practice was presented: Residents all have pressure sore risk assessments. This also meets the Standards for Older People, as required. As the home accommodates only three service users over 65, this is seen as good practice for the rest. The White House DS0000058633.V367674.R01.S.doc Version 5.2 Page 15 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): Standards 22 and 23. People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. The home manages complaints well so that residents feel their concerns are listened to, and the complaints procedure is now more accessible. The home’s policies and procedures relevant to this Standard currently promote protecting residents from abuse. EVIDENCE: There had been no official complaints made to the home or the Commission since the last inspection. The complaints procedure was clear and contained all of the elements required to meet Standard 22 including a minimum response time of less than 28 days. The complaints procedure is also available in a pictorial format. Policies were observed that protected the resident, and records were in good order. The home has a Restraints Policy, a Whistle Blowing Policy, a Gifts/Gratuities Policy, a Bullying Policy and a copy of the Local Authority Adult Protection Procedure on site. The White House DS0000058633.V367674.R01.S.doc Version 5.2 Page 16 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): Standards 24 and 30. People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. The home is homely and comfortable and promotes a family-like environment. This environment therefore facilitates the residents’ emotional well-being. The home is clean and hygienic which promotes a pleasant environment, the resident’s health, and emotional well-being. EVIDENCE: Residents have commented that they like their rooms and one person has also said they like the home. The home’s premises are accessible to the current resident group, in keeping with the local community, and are suitable for their purpose. At the time of the inspection the premises were well furnished and in an appropriate style. There is a regular maintenance programme with records kept. The White House DS0000058633.V367674.R01.S.doc Version 5.2 Page 17 The building was clean and tidy and was generally free of offensive odours. New non-slip flooring has been installed in the first floor corridor. The home has specific policies covering the disposal of clinical waste, control of infection, use of cleaning materials, hygiene, storage and preparation of food, communicable diseases, disposal of clinical waist, and dealing with spillages. There are Control Of Substances Hazardous to Health data sheets in their own file. Protective clothing was observed to be present. Laundry facilities have easily cleanable non-permeable walls. Washing machines had appropriate programmes over 65 degrees to control risk of infection and a sluicing cycle. The laundry room was positioned so that laundry does not need to be carried through the kitchen. The White House DS0000058633.V367674.R01.S.doc Version 5.2 Page 18 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): Standards: 32, 34, 35, 36: People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. The residents are not supported by a staff group where 50 or more have the required qualifications but are now nearly there. Achieving this will raise the quality of staff, their knowledge and their practices. The home’s recruitment procedures currently protect the residents through rigorous staff vetting. Staff receive induction and foundation training to ensure that they are appropriately trained. The staff are well supervised and receive supervision above the required level. This creates a well supervised staff team. EVIDENCE: The last inspection report contained the following requirement: 50 of staff should have the NVQ2. All the staff who work at the home currently have or are on the NVQ2 course required, as the 50 required has not yet been achieved. The requirement will be changed to a recommendation at this time. The White House DS0000058633.V367674.R01.S.doc Version 5.2 Page 19 A 6-week induction and 6 month foundation training programme, that meets Sector Skills Council training specifications is in place at this home. This home has an equal opportunities recruitment policy. The newest staff member’s file was examined and all the relevant checks were in place except a Criminal Record Bureau check. However the Commission allows this if a POVA 1st check is done, the residents agree, the person does not have unsupervised access to residents, and the Commission has been informed. All the above has occurred and so this meets the required standard. The staff team receive regular supervision, which is recorded on their files. Staff supervision includes translation of the home’s philosophy into work, monitoring work, support and professional guidance and identification of training needs, as required under Standard 36.4. All staff have an annual appraisal where their training needs are discussed. By the time of the last inspection the required frequency for supervision had been exceeded by almost double. Supervision had also exceeded the required frequency at this inspection. This standard therefore remains exceeded. The White House DS0000058633.V367674.R01.S.doc Version 5.2 Page 20 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): Standards: 37, 39, and 42. People who use this service experience adequate quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. Residents benefit from a generally well run home although the manager still needs to complete the registered managers award to be appropriately qualified. Records to confirm the safety of utilities and the home generally were all available and up to date. This helps protect the residents safety. Risk assessments were available except for the risk of scalding with bedroom sinks. These are needed to reduce the risk of scalding as the risk will be considered and action taken if needed. The White House DS0000058633.V367674.R01.S.doc Version 5.2 Page 21 EVIDENCE: The registered manager has a level 3 certificate in community mental health care. The following requirement was previously set. The manager must complete the NVQ 4 registered managers award. As the registered manager is currently doing the NVQ 4 registered managers award. A recommendation only, for the Manager to complete the NVQ 4 registered managers award will be made at this time. To put this in context, the manager has other qualifications which include a small management module, and is currently studying the required NVQ and will have this qualification soon. The last report contained the following requirement: The home must pull together its Quality Assurance tools into a structured Quality Assurance system that makes the service users central to the process. The last report recorded that quality assurance tools currently include service user meetings, user/relatives satisfaction surveys, auditing and a complaints system. Residents and relative satisfaction surveys and an annual development plan were identified as quality assurance tools that were still required. These elements are now in place so the requirement is now met. All of the health and safety policies and procedures relevant to this Standard have been seen to be present. Moving and Handling, Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling and Disposal of Clinical Waste policies are all also included in staff induction. The testing of systems required in Standard 42 were all in place. Records for fire fighting equipment testing and fire alarm testing were seen. Records for Portable Appliance Testing, 5-year wiring testing and the gas safety were also readily available. Thermostatic mixer valves have been fitted to baths but risk assessments could not be produced for the risk of scalding for bedroom sinks. The following new requirement is now set to address this shortfall: Individual Risk assessments for the risk of scalding with bedroom sinks must be completed and be available during inspections upon request. The White House DS0000058633.V367674.R01.S.doc Version 5.2 Page 22 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 x 2 3 3 x 4 x 5 x 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 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 2 x LIFESTYLES Standard No Score 11 x 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 2 x 3 x x 2 x The White House DS0000058633.V367674.R01.S.doc Version 5.2 Page 23 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. 2. Standard YA6 Regulation 15 15[2]b 12[4]b 12 Requirement Timescale for action 01/08/08 YA38 All care plans must all include a reference to religious and cultural needs. Individual Risk assessments for 01/08/08 the risk of scalding with bedroom sinks must be completed and be available during inspections upon request. 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. 4. Refer to Standard YA14 YA8 YA32 YA37 Good Practice Recommendations Each service user should be offered a seven-day holiday paid for by the home as a part of the contracted price. The home must provide service users with accessible information regarding its policies, activities and services. {Previous timescale not met} The home should continue to work towards the 50 of staff with NVQ2 qualification required by the standards. The manager must complete the NVQ 4 registered managers award. The White House DS0000058633.V367674.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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