Care Home: Whitwell

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What the care home does well Service users live in a clean and comfortable home, and they can choose the decoration and furniture that they want. They can make their own choices and decisions about what they want to do with their time, and they get information and support to help them do this. The information is put into pictures so that everyone can read it. Service users have the privacy that they need and want, and staff treat them with respect and dignity. The provider makes sure that their differing needs and wishes are met, and they are helped to understand their rights. Staff have good training and support so that they can help and protect service users in the best way, and there are good care plans to tell staff how service users like to be supported. What has improved since the last inspection? Since the last visit to the home, some information has been put into a picture format, such as the service user guide. The acting manager is also putting the statement of purpose into pictures at the moment. There is now a food choice booklet, which is also in pictures so that service users can choose what they want to eat more easily. Staff are helping service users to make their own person centred plans, so that they can show what their hopes are, and what they want to achieve. Some parts of the home such as a bedroom and the lounge have been decorated, and service users were able to choose how this was done. The provider has also developed a Family Charter so that families and carers know what services they can expect, and they have reviewed the policy about supporting service users with their personal money. CARE HOME ADULTS 18-65 Whitwell 2a Albert Street Boston Lincs PE21 8PE Lead Inspector Wendy Taylor Announced Inspection 21st July 2008 09:30 Whitwell DS0000002388.V368901.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 Whitwell DS0000002388.V368901.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. Whitwell DS0000002388.V368901.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitwell Address 2a Albert Street Boston Lincs PE21 8PE 01205 350946 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.mencap.org.uk Royal Mencap Society Care Home 6 Category(ies) of Learning disability (2), Learning disability over registration, with number 65 years of age (1), Physical disability (3) of places Whitwell DS0000002388.V368901.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th September 2006 Brief Description of the Service: Whitwell is a detached house in a residential area in the town of Boston. Royal Mencap Society provides the support to service users, and a housing association owns the property. They share maintenance responsibilities for the property. Whitwell provides a home for up to six residents, all of whom have a learning disability. At the time of the visit four people were living at the home. There is a garden to the back and side of the property and an enclosed courtyard to the front. Visitors’ car parking is on the main street. Boston has a range of shops and facilities and the home is close to the towns park. Service users have their own single bedrooms, and two are located on the ground floor. There is not a lift so any residents who have rooms on the first floor must be able to manage the stairs. Service users are supported with day activities by staff that are part of the Royal Mencap Society’s community support service. A protocol has been drawn up to ensure that there are clear arrangements as to how this service will operate within the home. For example whenever activities are taking place in the home a member of the homes staff is present. Information provided at the time of the visit indicated that the fees currently start at £556:00 per week. This is subject to the person’s needs, and fees may be higher depending upon the outcomes of individual assessments. Additional charges are made for personal items such as special toiletries, some holiday costs, and some leisure activity costs. Information about these costs as well as the day-to-day operation of the home, including a copy of the latest inspection report, is available in the main office of the home. Whitwell DS0000002388.V368901.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 stars. This means that the people who use the service experience good quality outcomes. This key announced inspection took place over one day in July 2008, and lasted for approximately 8 hours. The care and support received by two of the four service users was followed in detail, using a method called ‘case tracking’. This method involved talking to the service users, and observing the care and support they receive. We couldn’t get the views of all of the service users by talking to them, so we used other ways to get the information. We did things like looking at their care plans, medical records and daily notes. We looked at some of the general house records, and staff records. We spoke to staff and the acting manager, and used information already held by us, such as a self-assessment and notifications, as part of the process. At this visit we also used a method of working where an ‘expert by experience’ was an important part of the inspection team, and they helped the inspector to get a picture of what it is like to live in the home. The term ‘expert’ used in this report describes a person whose knowledge about social care services comes directly from using them. The expert met and talked to service users and staff on their own, and looked around the house with them. Some service users told us, and others indicated that they were happy and comfortable living at the home, and that they were treated very well. What the service does well: What has improved since the last inspection? Whitwell DS0000002388.V368901.R01.S.doc Version 5.2 Page 6 Since the last visit to the home, some information has been put into a picture format, such as the service user guide. The acting manager is also putting the statement of purpose into pictures at the moment. There is now a food choice booklet, which is also in pictures so that service users can choose what they want to eat more easily. Staff are helping service users to make their own person centred plans, so that they can show what their hopes are, and what they want to achieve. Some parts of the home such as a bedroom and the lounge have been decorated, and service users were able to choose how this was done. The provider has also developed a Family Charter so that families and carers know what services they can expect, and they have reviewed the policy about supporting service users with their personal money. 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. Whitwell DS0000002388.V368901.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 Whitwell DS0000002388.V368901.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): 1, 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is enough information to help people choose where to live, and the assessment process ensures that the home can meet the service users needs. EVIDENCE: There is a clear statement of purpose and service user guide in place, and both documents are up to date. The service user guide contains photographs and pictures so that it is easier for people to read. The manager showed us that she is also making the statement of purpose easier to read by putting in pictures, and this will be finished soon. Both documents and a copy of the last report are in the main office, and a copy of the service user guide is in each service users file. The service user guide tells people where they can get a copy of the last report. Pre inspection information shows us that there is now a document called a Family Charter, which tells families and carers what services they can expect to receive. There have been no new admissions to the home since the last inspection. The previous report shows that the admission process was satisfactory, and pre inspection information tells us that the process includes everyone who is important in the person’s life. The assessment format covers a wide range of Whitwell DS0000002388.V368901.R01.S.doc Version 5.2 Page 9 issues, including things like religion, culture and leisure. Records show that the placing authority also carries out assessments, and these are usually updated every year. There is a clear referral and admissions policy in place. Whitwell DS0000002388.V368901.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported in a respectful and dignified way, and care plans reflect their individual needs. EVIDENCE: Each service user has a care plan that matches the needs identified in their assessment. Care plans cover needs such as communication, personal care, household chores, mobility, medication, and leisure. They show that service users are supported to be as independent as possible. They tell staff how service users prefer things to be done, like looking after their privacy, and they say what service users like and don’t like. They also say how service users make choices, however we said that they should contain information to show that recent legislation about decision-making has been considered. There is information for staff about the new legislation but they have not had any training about it yet (see Standards 31-36). Whitwell DS0000002388.V368901.R01.S.doc Version 5.2 Page 11 Risk assessments are carried out for things like bathing, communication, mobility, and epilepsy; and each service user is being supported by their key worker to make a person centred plan. This is a plan that shows what their hopes are, and what they want to achieve in their lives. Records show that care plans and risk assessments are reviewed at least once a year with the placing authority, and also once a month by staff. Service users told us that they know about the care plan, and pre inspection information shows that they are involved in the planning and reviewing of their care. Minutes of house meetings show that service users are able to say what they want about issues like shopping, holidays and leisure activities. The expert found that service users are supported to understand their rights, and make choices and decisions. They saw that service users could move around their home freely, and that they were treated well. Service users told them that staff made sure they had privacy when they needed it, and the expert saw that staff did this. We spoke to staff and watched them doing their jobs, and they showed us that they respected service users. They were seen knocking on doors before going in, asking permission before carrying out tasks, and using people’s preferred names. They also showed us that they knew all about the service users needs, such as who they liked to have support them, and how they liked choices presented to them. The provider company employs a person called a ‘Diversity Officer’, who can give advice and support about meeting different needs and wishes, and making sure that service user’s rights are upheld. Whitwell DS0000002388.V368901.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 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 being able to join in with a wide range of activities that help them to develop their skills, and live their preferred lifestyle. EVIDENCE: Service users each have an individual daily activity plan, and there are risk assessments for things like accessing the community. During the daytime there are extra staff to help service users do the things that are in this plan. Plans include things like computer training, gardening, bowling, baking, and exercise. During the visit some service users went to computer classes, some went shopping, and one service user was baking. One service user showed us the garden, and where they grow vegetables and herbs. The service users also told us about a garden fete that is organised for the near future, and they talked about their holidays. They told the expert that they can go to the pub or out for meals, they use local buses to get around, and their friends and family Whitwell DS0000002388.V368901.R01.S.doc Version 5.2 Page 13 can visit when they wish. They also told the expert that they could have some private time on their own when they wish. The expert found that service users decide what they want to eat, and they now have a picture book to help them choose different kinds of foods. They choose what they want to eat at each meal. Service users and staff told us that they go to local shops such as the butchers and green grocers, as well as to local supermarkets, and they choose what they want to buy. During the visit service users chose their own lunch and they each had different things. Records show what service users have had to eat, and this helps to make sure that they have a balanced and healthy diet. It also allows staff to make sure that special diets are being followed. Information about healthy eating and special diets are available in the house, and care plans show why a person needs to have a special diet. Whitwell DS0000002388.V368901.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 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 clear arrangements for ensuring that health and personal needs are met. EVIDENCE: Health action plans are in place for each service user. They cover needs such as medication, communication, general health, dental, and hearing. They show how service users tell people about their needs and feelings, and there are pictures to support the words so that everyone can read them. One person’s health action plan was not fully completed, and the manager said that it would be completed in the near future. There is clear information in care plans and personal files about individual medical conditions such as epilepsy, and everyone that is involved in developing the health action plans has signed to show their input. Plans also show how service users prefer to be supported with their personal needs. Some of the service users were able to tell us that they can see their doctor when they want to, and that staff take them to hospital if they need it. Whitwell DS0000002388.V368901.R01.S.doc Version 5.2 Page 15 Records show when they have been to see a health professionals such as their GP or psychiatrist. Care plans have lots of information about medication that the service user takes. The information says why the service user is taking the medication, and what the side effects are. There is a policy in place to tell staff how to give medication in a safe way, and records show that they are trained to this. The manager assesses their skills before they are allowed to give out medication. There are also instructions to tell staff what to do if they make a mistake with medication. Medication recording charts were signed properly with no gaps, however a prescribed item that is no longer used was printed on one chart, and one medicine was not clearly labelled to be taken only when necessary. The recording charts are pre printed by the local pharmacy, and staff said that they had highlighted these issues to them. The manager said that she would speak to the pharmacy again to make sure that the recording charts are printed correctly. Staff demonstrated that they knew how, when and why the ‘when necessary’ medicines are given, however we said that there should be clear written instructions in place which contain this information, so that service users are given their medicines consistently. Storage was satisfactory. The local pharmacy inspected the medication arrangements in March 2008, and they did not highlight any issues. Whitwell DS0000002388.V368901.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users feel safe living at the home. They are now protected by policies, procedures and a knowledgeable staff team. EVIDENCE: Since the last inspection there have been six referrals to the Local Authority Safeguarding Adult Team. Because of this we changed our inspection plan, and carried out this key visit earlier than we intended. The issues that were highlighted by investigations showed us that people who lived there had been placed at risk because things like policies and procedures had not been properly followed. The new acting manager, and the providers senior managers have told us about the actions that they have taken to make sure that service users are kept safe in the future. There have been no complaints or safeguarding adult referrals since the new manager has been in post. Service users told us, and the expert, that they feel safe living at the home. Staff said they have training to understand what abuse is, and how to protect service users. They demonstrated this when we spoke to them. There is also a whistle blowing policy in place, which staff are aware of. There is an up to date copy of the Local Authority guidance about safeguarding adults available, and an up to date complaints policy is kept in each service users personal file. The complaints policy is in a picture format so that Whitwell DS0000002388.V368901.R01.S.doc Version 5.2 Page 17 everyone can read it. Minutes of house meetings show that service users are reminded how to make a complaint if they ever needed to. The manager said that if they receive a complaint, the details would be kept in service users personal files. We suggested that there is a reference log for complaints and safeguarding referrals, to show where information is kept and to show an audit trail of the responses. Risk assessments are in place for things like vulnerability and personal finances. Service users told the expert that they can decide how to spend their money and staff will help them with this. As an outcome of the safeguarding adult referrals, the policy about supporting service users with their money has been reviewed and updated. Staff showed us that they understand the new procedures. Service users keep there own money in lockable storage and one person showed us that the money they had matched with the records that are kept. Whitwell DS0000002388.V368901.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users enjoy living in a clean, and comfortable home that meets their needs. EVIDENCE: The expert found the home to be neat and tidy, and good for the health and safety of service user (see also Standards 37-43). Service users told the expert that they could choose the decoration in their bedrooms and say how they wanted the rooms furnished. They have lots of personal items in their rooms such as TV’s, computers, pictures and photographs. Two service users showed us around the house, and told us about the living room being newly decorated, and how they had helped to choose the decoration. They told us that they think their home is comfortable and that they help to do some of the housework. They said that they like to sit in the patio area to relax sometimes, and they showed us the garden where they help to grow vegetables. Whitwell DS0000002388.V368901.R01.S.doc Version 5.2 Page 19 Some of the communal areas like the hallways and kitchen have not been decorated for a long time, and the manager has recognised that some parts of the home are in need of updating. She said that at the moment they are getting quotes to have all of the windows replaced. We suggested that they have a programme for things like regular maintenance tasks and decorating, so that they can keep the home comfortable and safe for service users. Records show that repairs and general maintenance tasks are done in a timely way, and we saw that substances that could be harmful to people are kept locked away when not being used. We saw staff washing their hands properly when they needed to, and gloves are available if they need them. Whitwell DS0000002388.V368901.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by recruitment procedures, and a well trained and supported staff team. EVIDENCE: We looked at records for three staff members. Their recruitment records included criminal record bureau checks, application forms and references. A reference for one new member of staff is currently held at the provider’s head office, however the manager said that she has requested that a copy is sent to her. Staff files also contain identification and interview records. Records show that staff have an induction when they start work, and they have an experienced member of staff allocated to help them. The induction training helps them to learn about the provider and the home, and their work is assessed to make sure that they are doing their job well. Records also show that staff have training in subjects such as medication, report writing, fire safety, infection control, and moving and handling. Training plans for the rest of this year include subjects such as working with families, first aid, Whitwell DS0000002388.V368901.R01.S.doc Version 5.2 Page 21 supervision, and working alone. We said that staff should also learn about new legislation, which helps service users with decision-making. Staff told us that the training programme is very good, and it meets the needs of the service users. They also talked about being able to work towards nationally recognised qualifications. The expert felt that staff are well trained and committed to the work that they do. Staff said that there are enough of them on duty each day to meet service users needs, and rotas show that there is a consistent staff team. They said that having day service staff on duty helps to make sure that service users can do all of the things they want to. Staff said that they have regular supervision, and there are records kept to show this. They said that they find supervision is now a positive process that helps them to develop their skills, and gives them time to express their views. They said that they could also express their views in staff meetings (see Standards 37-43). Whitwell DS0000002388.V368901.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed, which means that service users receive a good standard of care and support. They are protected by health and safety arrangements, and are happy with the services they receive. EVIDENCE: Since the last inspection a new acting manager has been appointed. She is currently in the process of registering with us. At the time of the visit she had been in post for approximately six months, and there has been no other staff turnover in that time. She has worked for many years managing services for older people and people with learning disabilities, and she has certificates in management, training, and care. Whitwell DS0000002388.V368901.R01.S.doc Version 5.2 Page 23 Staff said that the manager is very supportive and approachable, and she listens to what they have to say. The minutes of staff meetings show that they talk about things like about person centred planning, house maintenance, service users finance issues, training opportunities, and quality assurance. Staff also said that if the manager is not available and they need advice or support, there is a good on-call manager system in place. Our records show that the manager tells us about anything that affects the health, safety or welfare of service users, for example, if a service user has an accident. We also know from our records that the provider makes sure that there are a range of policies in the home about health and safety. Risk assessments are available for things like fire safety, staff working on their own, and using the lawn mower safely. There are records in the home to show that fire safety equipment and water temperatures are checked regularly. There is also safety information about substances that could cause harm to people. A new quality monitoring system has been put in place since the last visit. It is called a ‘Continuous Improvement Plan’. All of the things that are identified for improvement are in this plan, and the manager said that she and the area manager review it every month. The plan shows that targets are being met within the set timescales. The need for improvements are identified through activity such as monthly quality review visits carried out by the area manager, service reviews by the provider’s quality assurance team, and monthly audits by the manager. Records show that these activities cover areas such as finance, health and safety, environment, care plans and risk assessments, and how dignity and respect is maintained. The manager said that service users are encouraged to be a part of the quality assurance process through house meetings, and by completing surveys. She said that surveys are carried out once a year, and a new survey is due to take place in the near future. Service users told us that they are happy living at the home, and the expert observed that service users have choices, they are respected, and they are free from discrimination. Whitwell DS0000002388.V368901.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 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 3 33 X 34 3 35 3 36 3 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 4 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Whitwell DS0000002388.V368901.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 Refer to Standard YA7 Good Practice Recommendations It is recommended that care plans include reference to the Mental Capacity Act, 2005 and the effects it has upon the service users lives. This is to ensure that their rights and choices are protected. It is recommended that there are protocols in place to show how and when medicines that are taken only when necessary should be used. This is so that service users receive their medication in a safe and consistent manner. It is recommended that there is a reference log for complaints and safeguarding referrals. This is so that relevant information can be found easily, and there is an audit trail of the responses from the provider. It is recommended that a programme of maintenance and renewal be developed for things like decorating and furniture, so that the home can be kept comfortable and safe for service users. It is recommended that staff receive training about the Mental Capacity Act, 2005. This is to ensure that service DS0000002388.V368901.R01.S.doc Version 5.2 Page 26 2 YA20 3 YA22 4 YA24 5 YA35 Whitwell users rights and choices are respected. Whitwell DS0000002388.V368901.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Whitwell DS0000002388.V368901.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. 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