Care Home: White Lodge (126)

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What the care home does well 8 out of the 9 staff have a NVQ2 or above, this exceeds the minimum standard of 50% of staff with a NVQ2. This ensures a well qualified staff group. Plans of care are reviewed more often than the minimum standard of twice a year. This ensures that the changing needs of the service users are well known to staff. There are lots of outings and trips, at least 6 times per week. It is expected that future inspections will identify more areas of good practice. What has improved since the last inspection? Questionnaires have been provided to the service users to support quality assurance. A system has been set up to record the outcome of complaints so that any patterns or trends can be identified. A change to the hand drying equipment has ensured that hand drying equipment is now always available where needed. What the care home could do better: Activities in the home need to be better recorded to demonstrate that the service users are appropriately engaged in activities. Supervision records need to be kept up to date to ensure a well supervised work force and that any issues arising in supervision can be followed up. The pictorial service users complaints procedure only includes the Commission as the point of contact for complaints. Other people that a service user can go to if they are worried or unhappy should be included in their complaints procedure. For example the manager or an advocate. To better protect the service users, the wills policy needs to state that staff can not benefit from service users wills. To better protect the service users, the previous recommendation {now a requirement} for staff to attend training in the local authority`s adult protection procedures must occur. To confirm the safety of the gas and know if any maintenance is required, the home needs to obtain a fuller copy of the gas safety certificate. CARE HOME ADULTS 18-65 White Lodge (126) 126 Foxley Lane Purley Surrey CR8 3NE Lead Inspector Barry Khabbazi Key Unannounced Inspection 18th December 2007 08:00 White Lodge (126) DS0000025867.V354375.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 White Lodge (126) DS0000025867.V354375.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. White Lodge (126) DS0000025867.V354375.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service White Lodge (126) Address 126 Foxley Lane Purley Surrey CR8 3NE 020 8763 2586 020 8763 2586 whitelodge@sussexhealthcare.org www.sussexhealthcare.org Sussex Health Care 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) Manager post vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places White Lodge (126) DS0000025867.V354375.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. `Learning disability - Code LD` The maximum number of service users who can be accommodated is: 8 27th April 2006 Date of last inspection Brief Description of the Service: White Lodge is registered to accommodate eight people with learning disabilities, aged between 18 and 65 yrs. The home provides a service that caters for the needs of eight young adults who display behaviours that may challenge the care services that they require. Situated in Purley, on a main road, it is well positioned to access local transport links and amenities. There is large kitchen and communal lounge/dining room and all service users have the benefit of a single room. A conservatory at the back of the house leads out to a large well-maintained garden with lawn and wooden decking area. The home has its own transport to enable service users to access community activities. Fees charged range from £780.00 to £1220.00. White Lodge (126) DS0000025867.V354375.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key Standards identified throughout this report were assessed at this inspection. This inspection also focussed on following up on previous requirements and recommendations, and any new issues arising. 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, time was spent with the service users, and records, policies, care plans, and the building were also examined. The home was found to be generally well run and no areas of serious concern were identified. The requirements and recommendations made, refer to minor shortfalls only. There are no unmet old requirements and there are 4 new requirements and 4 recommendations in this report. During the inspection, service users talked about recent outings they had attended and responded positively to questions about the quality of the meals. Where communication was limited by the service user’s disability, those service users appeared relaxed and contented. When this was not the case staff were seen to be supportive and respond to service users’ needs appropriately. What the service does well: What has improved since the last inspection? Questionnaires have been provided to the service users to support quality assurance. A system has been set up to record the outcome of complaints so that any patterns or trends can be identified. A change to the hand drying equipment has ensured that hand drying equipment is now always available where needed. White Lodge (126) DS0000025867.V354375.R01.S.doc Version 5.2 Page 6 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. White Lodge (126) DS0000025867.V354375.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 White Lodge (126) DS0000025867.V354375.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: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users needs are assessed before they start at the home to ensure that all needs are known by the staff. EVIDENCE: The file of the newest service user was examined and this contained the care management assessment and care plan as required by this Standard. The home’s person centred plan was also present and had been drawn from this, the home’s own assessment of the service user, and the service user’s own input. White Lodge (126) DS0000025867.V354375.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, and 9: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Plans of care record all needs and are regularly updated. Service users are supported to make decisions about their lives. Risk assessments generally contain all the information required as including this information could reduce unnecessary restrictions of liberty for the service users. EVIDENCE: The service users each have a care plan generated from the comprehensive assessment completed by the care manager. All of a service user’s needs and how they are to be met, are recorded in their care plan. Care plans sampled also refer to cultural or religious needs. Care plans sampled had also been reviewed more often than the minimum requirement of a twice a year. This is seen as good practice. White Lodge (126) DS0000025867.V354375.R01.S.doc Version 5.2 Page 10 Person centred plans of care are used to ensure that care needs are written from the service users’ perspective and record their preferences in the way they want their care to occur. These plans also cover all the elements required under this Standard, explain how to work with the service user well, and are a good working document. The plans were kept in a very large and full file with many other documents like letters and contracts. This made their accessibility to me and therefore staff a bit difficult. As this is a good working document that informs staff of a service user’s needs, preferences and communication methods well, it should be made more physically accessible. To promote good practice the following recommendation is therefore made. The person centred plans should be separated from the main file to facilitate better access to them by staff. This would encourage more frequent and efficient referencing of this information by staff and protect other data and confidentiality by staff not having to wade through a whole file to access the plan of care. Service users were observed to be supported by staff to make choices and guidance in making appropriate and informed choices was observed at this inspection. Choices are only limited through involving the service user and relatives where appropriate. This is always through a risk assessment process and recorded in the service user’s file. Risk assessments were present and in order. There were no significant restrictions of liberty to protect the service user. If this is ever the case { for example the need to lock the kitchen to protect service users} risk assessments will need to demonstrate more clearly what other options or training were considered to avoid the restriction. This has been raised with the manager but will not be addressed with a requirement until and unless it becomes necessary due to significant restrictions of liberty being needed. White Lodge (126) DS0000025867.V354375.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although there was evidence of some activities in the home occurring, activities need to be better recorded to demonstrate that the service users are appropriately engaged in activities. Service users have lots of opportunity to be part of the local community. This promotes inclusion and quality of life. Service users are supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. Service users’ rights are respected and responsibilities recognised. The food provided is sufficient in quantity, and it is sufficiently nutritious which is important to ensure good health. White Lodge (126) DS0000025867.V354375.R01.S.doc Version 5.2 Page 12 EVIDENCE: Although there was evidence of some activities in the home occurring, activities in the home need to be better recorded to demonstrate that the service users are appropriately engaged in activities. Some service users did say they had activities at the home but this information was limited. Activities records were examined for 4 service users and other than watching television, only 1 activity was recorded over the last month. The following requirement is now set Activities in the home must be provided regularly and recorded. Holidays are provided to at least 7 days per year. Service users go in small compatible groups and have input into where they go. Outings and trips occur very frequently and this was seen as an area of good practice. Records showed that outings and trips occur at least 6 times a week and the service users spoke positively about these. Where communication was limited, one service user took my hand leading me to the door. Their plan of care recorded that this meant they wanted to go on a trip out. This indicated the expectation of the service user that they could ask to go out whenever they wanted. Records showed that suitable arrangements are in place to enable service users to maintain good links with their families and friends. Staff were observed to be respectful of service users wishes and choices. Daily routines and house rules appear to promote independence and individual choice. Meals, for example, can be taken where and when service users want depending on their own activities planned for the day, and service users go to bed and get up when they want. This is done within the context of enabling service users to attend appointments and other commitments. Menus were observed to provide a reasonably varied diet and this was balanced with informed service user choice. Service users were seen to be able to take their meal when they wanted and to be given as much time as they wanted to finish eating. Choice of where to eat is also provided. Cultural preferences and dietary requirements are catered for as needed. Service users spoken to say that they liked the meals served at the home. White Lodge (126) DS0000025867.V354375.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: Quality in this outcome area is good. 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. Service users’ physical health needs are met by this home. This ensures that the residents’ physical health is well maintained and therefore the quality of life experienced is also maximised. Service users’ are protected by the home’s medication practice and procedures. EVIDENCE: Person centred plans of care are used to ensure that care needs are written from the service user’s perspective and record their preferences in the way they want their care to occur. Staff demonstrated a good knowledge of both the needs and preferences of the service users. Observation of the staff and service users interaction showed that this was also put into practice. White Lodge (126) DS0000025867.V354375.R01.S.doc Version 5.2 Page 14 Personal care is provided in private, and timings of this are also flexible. The home provides consistency and continuity through designated key workers. Service users are registered with a local GP practice and have access to other NHS facilities as necessary such as a dentist, optician, chiropodist, and “well woman” clinic. District nurses and other healthcare professionals attend when required. Evidence was seen of regular monitoring of service users’ health. The service users are registered with a local G.P and have regular check ups. A record of all appointments and check ups are kept. The manager demonstrated knowledge of the health status of individual service users. None of the current service users are able to completely self medicate. However, procedures and a lockable space in service users’ rooms are present to facilitate this where appropriate. All staff who administer medication have had approved medication training. Medication profiles and clear medication administration record sheets were seen in records sampled. Medication and the M.A.R sheets are kept securely in a locked metal cabinet fixed to the wall. There is also a fridge specifically for medication. The local pharmacist provides an audit service. White Lodge (126) DS0000025867.V354375.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: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are generally managed well and there were no complaints since the last inspection. Service users are generally protected from abuse or self harm through the home’s protection policies and procedures and by these being known, although training in the local authority’s adult protection procedures still needs to occur. EVIDENCE: There had been no complaints since the last inspection. The last report contained a requirement for records and outcomes of all complaints to be made available in the home to ensure that residents, their relatives and staff are made aware of any findings and actions taken. A system for this had been set up and this requirement is now met. The home has a complaints procedure that meets all the elements of this Standard including a minimum response time of less than 28 days, details of the Commission and this is also available in more accessible formats. The pictorial service users complaints procedure only includes the Commission as the point of contact for complaints. Other people that a service user can go to if they are worried or unhappy should be included in their complaints procedure. For example the manager or an advocate. The following recommendation is therefore set: White Lodge (126) DS0000025867.V354375.R01.S.doc Version 5.2 Page 16 The pictorial service users complaints procedure should include other people that a service user can go to if they are worried or unhappy. For example the manager or an advocate. The home has a Gifts Policy, a Wills policy, a Whistle Blowing policy, an Aggression and Violence policy, and Restraints policy and guidance, which includes appropriate record keeping guidance. The Gifts Policy does preclude staff from receiving gifts and the Wills Policy does preclude staff from being involved in the making of, but not from benefiting from service users’ wills. To better protect the service users, the wills policy needs to state that staff can not benefit from service users Wills. The following recommendation is therefore set. The wills policy should preclude staff from benefiting from wills and all staff must be made aware of this policy. The home has a copy of Croydon’s Vulnerable Adults Policy but staff have not received training in this policy and associated procedures. The last report contained the following recommendation: All staff should attend Croydon Councils training on adult protection. Although this has not occurred evidence of the training being booked was available. In addition staff have received safeguarding training. This recommendation has been converted into a requirement as follows: All staff must attend training in the local authority’s adult protection procedures. White Lodge (126) DS0000025867.V354375.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment and furniture generally meet the residents’ needs, and the environment does generally promote the residents well being. The home is hygienic and clean. This environment therefore facilitates the service users’ health and emotional well-being. EVIDENCE: The last inspection report contained the following requirement: Hand drying equipment must be available in all toilets and residents must not be made to request these when wanting to use the toilet. A creative change to the type of hand drying equipment has ensured that hand drying equipment is now always available where needed as the new equipment does not encourage misuse of it. White Lodge (126) DS0000025867.V354375.R01.S.doc Version 5.2 Page 18 The premises were bright, airy and clean, and free from offensive odours. There was some cleaning required at the start of the inspection but this was being dealt with as I arrived. There was suitable lighting and ventilation. The grounds were well kept, and accessible to the current service user group. There are ramps on the ground floor where required and this floor is reasonably wheelchair accessible. Maintenance for the home is provided on an as required basis. The overall condition and décor of the home was reasonable. The home has specific policies covering the disposal of clinical waste, control of infection, use of cleaning materials, storage and preparation of food, and dealing with spillages. Protective clothing was observed to be present. Laundry facilities have easily cleanable non-permeable floors and walls. Washing machines had appropriate programmes over 65 degrees to control risk of infection and a sluicing cycle. There is a separate sluice. The laundry room was positioned so that laundry does not need to be carried through the kitchen as there is an alternative rout. White Lodge (126) DS0000025867.V354375.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users are supported by a staff group where 50 or more have the required qualifications. Achieving this raises the quality of staff, their knowledge and their practices. In fact this standard is well exceeded. The home’s recruitment procedures protects the residents through vigorous staff vetting. Staff receive induction and foundation training to ensure that they are appropriately trained, however the frequency of supervision does not meet the minimum standard require which may reduce the quality of the service provided. White Lodge (126) DS0000025867.V354375.R01.S.doc Version 5.2 Page 20 EVIDENCE: 8 out of the 9 staff have a NVQ2 or above, this exceeds the minimum standard of 50 of staff with a NVQ2. This ensures a well qualified staff group. This Standard is exceeded. All elements of Schedule 2 {staff files} were available for inspection. Staff recruitment documents were examined and these included CRB checks, references and proof of identification. No shortfalls were identified in the staff recruitment process. All newly recruited staff undertake induction within the first six weeks and foundation training within the first six months of starting employment and this training is to Sector Skills Council workforce training targets and specifications. The last report contained the following requirement: All staff need training on autism and alternative communication methods to ensure that service users specific needs are more fully understood. Staff have now received training in alternative communication methods. Plans of care include communication methods and were of practical use to me in helping me understand the non verbal communication methods of some of the service users. Staff did demonstrate a good understanding of how to interpret the non verbal communication methods of the service users. This part of the requirement is therefore met. Although training on autism has been set up it has not occurred yet. To reflect the progress in meeting the above requirement, it will be withdrawn and replaced with the following reduced requirement: All staff need training on autism. Supervision records were not up to date and did not meet the minimum of 6 sessions per year. One staff member had only 2 recorded for 2007 and another only 4. The following requirement is therefore now set: All supervision sessions must be recorded and occur at least 6 times per year. White Lodge (126) DS0000025867.V354375.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39, and 42: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home and the current registered manager has the required qualifications and experience. The home’s quality assurance system involves the residents, and provides feedback to them, to allow them to be involved in improvements and measure improvements in the home for themselves. The home generally promotes the health and safety of the residents, so that practices and the environment do not place their health and safety at risk White Lodge (126) DS0000025867.V354375.R01.S.doc Version 5.2 Page 22 EVIDENCE: The current registered manager has the required NVQ 4 Registered Manager’s award and is suitably experienced to manage the home with over 10 years management experience in this field. The last key inspection contained the following requirement: In view of recent events in the home and staff changes, the registered provider should carry out a general survey to seek the views of all service users, their families and other relevant stakeholders. Questionnaires have now been provided and the results fed into the home’s own annual development plan where applicable. This requirement is now met. There is a quality assurance system, which involves service users. The quality assurance tools include the complaints system, service user meetings, provider inspection visits, user satisfaction surveys, and an annual development plan open to service users through house meetings. There is also a professional quality assurance system. All of the health and safety policies and procedures relevant to this standard were 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 also present and inspected. These included fire fighting equipment testing, fire warning testing, Portable Appliance Testing, 5-year wiring testing and Bacterial analysis and testing of the water supply. Although certificates of all the testing of systems required in Standard 42 was present a record of attendance was only present for the gas safety tests. To confirm the safety of the gas and know if any maintenance is required, the home needs to obtain a fuller copy of the gas safety certificate. The following recommendation is therefore now set: The full gas safety certificate must be sent to the Commission. {a record of attendance was however available hence the recommendation only} White Lodge (126) DS0000025867.V354375.R01.S.doc Version 5.2 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 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 4 33 x 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 2 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 x x 3 x White Lodge (126) DS0000025867.V354375.R01.S.doc Version 5.2 Page 24 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 YA14 YA23 Timescale for action 16(2) n Activities in the home must be 01/04/08 regular and be recorded. 13(6) All staff must attend training 01/04/08 in the local authority’s adult protection procedures. {This had been booked} 18(1a)(c)19(5 All staff need training on 01/04/08 b) autism. {This had been booked} 18((2) All supervision sessions must 01/04/08 be recorded and occur at least 6 times per year. Regulation Requirement 3. 4 YA35 YA36 White Lodge (126) DS0000025867.V354375.R01.S.doc Version 5.2 Page 25 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 YA6 YA22 YA23 YA42 Good Practice Recommendations The person centred plans should be separated from the main file to facilitate better access to them by staff. The pictorial service users complaints procedure should include other people that a service user can go to if they are worried or unhappy e.g. the manager or an advocate. The wills policy should preclude staff from benefiting from wills and all staff must be made aware of this policy. The full gas safety certificate must be sent to the commission. {a record of attendance was however available hence the recommendation only} White Lodge (126) DS0000025867.V354375.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 White Lodge (126) DS0000025867.V354375.R01.S.doc Version 5.2 Page 27 - 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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