Inspection on 15/11/05 for New Witheven

This inspection was carried out on 15th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

New Witheven 06/09/06

New Witheven 25/04/05

New Witheven 28/10/04

New Witheven 14/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 New Witheven Jacobstow Bude Cornwall EX23 OBX Lead Inspector Kerensa Livingstone Unannounced Inspection 15th November 2005 10:00 New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service New Witheven Address Jacobstow Bude Cornwall EX23 OBX 01566 781285 01566 781285 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Denzil John Phillips Mrs Gillian Margaret Phillips Care Home 3 Category(ies) of Learning disability (3) registration, with number of places New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th April 2005 Brief Description of the Service: New Witheven is a bungalow situated in a quiet rural area. It is approached by a narrow lane approximately 2 miles from the main A39 near Bude, where there is a hamlet with a shop and public house. The home provides care and accommodation for 3 younger adults with a learning disability. At the time of inspection, accommodation is in single rooms with a shared bathroom. This is being upgraded and six purpose built new rooms with ensuite facilities are due for completion prior to the end of the year. There is a large comfortable lounge and a kitchen/diner, where everyone eats together. There are far reaching countryside surrounding the bungalow. The Providers own the surrounding area, which creates opportunities for the service users. The Registered Providers aim to increase their registration to seven younger adults with a learning disability. There will be wheelchair access. Service users keep in contact with their families and friends and go home at regular intervals. There is an irregular bus service from the main road into Bude, but generally the service users are dependant on transport from the home if they want to go into town e.g. Taxi, Providers transport. New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. New Witheven is a small ‘family-run’ home, which provides a homely and supportive environment for the three Service Users who have all lived at the home for many years. The Registered Providers are aware of the importance of giving priority to the outstanding requirements and recommendations identified in this report, which are of a managerial nature, especially with the proposed application for an increase in registration to 7 beds. The home, Service Users and Providers are currently preoccupied with the purpose built extension that is being built and aiming to be completed by the end of the year. There will be six new rooms, which the Inspector has been advised will comply with the new environmental standards. The Providers are improving the one existing room that will be used by adding an ensuite facility. Service Users have all chosen their new rooms. Therefore this inspection was focused on the proposed plans and the need to ensure that documentation complies with the legislation. The Registered Providers are committed to making the required changes, this will need to be done within the timescales. What the service does well: What has improved since the last inspection? What they could do better: New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 Page 6 The Registered Providers must take note of the requirements and recommendations identified in this report to better demonstrate the work they put in, and the care needs and capabilities of the service users. The Registered Providers must prioritise the management aspects of the home, such as developing policies and procedures (e.g. employment), especially in view of their proposed application for an increase in registration. Registration of these rooms could be delayed if the required information is not completed and submitted to the Commission for Social Care Inspection, as part of the application. 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. New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 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 New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&5 The Registered Providers need to finalise the draft documentation and make available to Service Users to inform choice. This information must be provided to service users and potential Service Users, particularly in view of the plan to increase the registration to seven service users. EVIDENCE: The home has developed a Statement of Purpose and Service Users Guide. The Registered Providers must review and amend these documents to ensure that they contain all the information specified in Schedule 1 of the National Minimum Standards and Regulations. All of the current service users have lived at New Witheven for over eight years. The Registered Providers have developed a care needs assessment form. This will be completed including the information detailed in National Minimum Standard (NMS) 2.3 for all prospective Service Users. The Registered Providers demonstrated an in-depth understanding of service user care needs and capabilities. Service users live a comfortable and active life. The Registered Providers have developed a draft Statement of Terms and Conditions, this should include a breakdown of how the fees are to be paid, by whom and to show the allocation of room to the individual service user. The Inspector has provided comments regarding the draft of the Contract, which New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 Page 9 should include the information listed in NMS 5.2. Evidence that these have been signed by the Service Users and/or their representative will be inspected at the next inspection. New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 & 10 The Registered Providers possess an in-depth knowledge of the service users, which is evident in conversation. The Registered Providers need to improve their documentation of care needs, risk-assessment and review. EVIDENCE: Service Users are encouraged to maintain their independence and are supported to do this. All Service Users attend structured daytime activities or employment for at least four days per week. Clear information is being added into the Service Users Guide about what information is required on admission to the home, that a relative or advocate can come to support the Service User, how this information is shared. Evidence of how Service Users contribute to the running of the home e.g. house meeting will be required at the next inspection. The Registered Providers advised the Inspector that the risk assessments and Service User plan to direct the delivery of care have yet to be completed. The care plans must be reviewed at least 6-monthly with the involvement of the service user, or their representative. These must be prioritised. New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 Page 11 New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14 & 17 The service users are able to determine their own lifestyle within the parameters of their own capabilities and risk, documentation must clearly reflect what these risks are. A balanced and varied diet is provided for the Service Users. EVIDENCE: The service users attend various external resources; including day centres and work placements, leaving weekends free for leisure activities. Leisure activities include shopping, trips to local inns, takeaway meals, swimming, trips to the beach, and attendance at a club once a week. One service user orders magazines from a local shop. The Registered Providers advised the inspector that the service users are able to determine their own lifestyle within the parameters of their own capabilities and risk. The Service Users are provided with a nutritious and varied diet. Records must be kept to provide evidence of this and demonstrate that a choice is made available. There is a pleasant, large kitchen with a dining area where the New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 Page 13 Service Users sit for a meal together, often accompanied by members of the family. Service Users are provided with a packed lunch or given a hot meal when they are attending daytime activities or employment. Personal likes and dislikes are recorded, however evidence of Service Users influencing menus will be explored at the next inspection e.g. house meeting. There is no record of visitors to the home. The Registered Providers must provide a visitors book. The Registered Providers have ensured that the service users are entered on the electoral roll since the last inspection. New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 19 Service Users personal, physical and emotional needs are met in an individualised manner. Record keeping must demonstrate this. EVIDENCE: The Service User plans of care are due to be reviewed to ensure that they direct care. Service Users make choices about how they live their lives, these choices must be incorporated into the Service User plan. Support and guidance is provided in a sensitive way, whilst continuing to promote independence. The routines within the home are flexible; during the week the Service Users are usually attending structured activities. This allows the weekends free for leisure activities and outings. All Service Users are registered with a General practitioner and due to have a medical check up. Health needs are assessed and specialist interventions would be sought on an individual basis. Since the last inspection family members have undertaken training on the safe handling of medicines, which they are due to complete. However no Service Users within the home are currently taking any prescribed medication. The Registered Providers are developing the medication procedure to include the receipt, recording, storage, handling, administration and disposal of medicines. The importance of a lockable facility, consideration of drugs fridge, Home New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 Page 15 Remedies agreement with the local General Practitioner, controlled drugs cupboard and controlled drugs register were all discussed, in light of the plan for an increase in the number of Service Users. New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The Registered Providers are aware of the issues relating to complaints and adult protection. Policies and Procedures must clearly direct care staff so they are aware of the action to be taken to protect Service Users. EVIDENCE: The home has an adult protection policy and a Whistle blowing policy. The Inspector recommended that the home obtain a copy of the Department of health document No Secrets. The Registered Providers must review the procedure to ensure that it provides clear reference to local procedures and provides contact information, such as telephone numbers for local agencies e.g. Social Services Care Manager as the lead agency and the Commission for Social Care Inspection. Two carers are due to attend the POVA training in January 2006. All staff must receive training to ensure that they are aware of the action to take if an allegation of abuse was to be made. The Home has a complaints procedure, this must include that the contact details for the Commission for Social Care Inspection and that the complainant may contact them at anytime. This procedure must be made available to all staff and Service Users and a record of all complaints must be kept. New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 & 30 New Witheven is in keeping with a family home. It is comfortably decorated, offering a homely accommodation for the service users. This accommodation is being totally upgraded and building is almost complete. EVIDENCE: Specialist equipment would be sought on an individual basis depending on an individuals needs. The home was observed to be clean and hygienic on the day of the unannounced inspection. The surrounding land and lane is muddy, however at this time there are major building works in progress, therefore undoubtedly the home and grounds will quite different at the next inspection. Six new rooms are all nearing completion, the existing room is to be upgraded to provide an ensuite facility. A new lounge and dining area is being created. One Service User spoke about how he was looking forward to his new accommodation. New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 Page 18 There is an attractive decking area outside where service users can sit, weather permitting. There is parking area to the front and side of the property. Assisted access is being provided to the home within the extension. New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 35 & 36 The Registered Providers and their daughters provide the care at new Witheven, but consideration must be given to recruitment procedures, especially with the proposed application for an increase in registration. EVIDENCE: There are currently no staff employed at the home. Service Users attend a different part of the site for day care and this is staffed separately. Criminal Records Bureau checks have been obtained for all people working in the home, which are currently the Registered Providers and their daughters. A review of the staffing needs is to be undertaken by the Registered Providers to accompany their application for registration. No one under twenty one is left in charge of the home at anytime and no one under the age of eighteen is providing personal care. The home must produce a robust recruitment policy that is based on equal opportunities, current legislation and Schedule 2 of the Care Homes Regulations. For example an application form, evidence of interview, references, Criminal Records Bureau checks, induction, job description, duty rota, training plan, staff meeting minutes, General Social Care code of conduct and supervision records will be required for all of the care team. New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 Page 20 All the Service Users have resided at the home for many years and have a clear understanding of the roles and responsibilities within the home, however this will change with the introduction of four new Service Users and the appointment of staff. Training of all staff to ensure that they have the skills and experience was not assessed at this inspection. The Registered Providers are aware that this is a period of change and of the importance of robust recruitment processes. New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The Registered Providers know the service users very well and the home has functioned effectively for many years. The Registered Providers recognise that there is a need to prioritise managerial aspects of care, especially with a view to the proposed application for an increase in registration. EVIDENCE: There is evidence of clear leadership within the home, the home is managed on a day-to-day basis by the Registered Providers. There is an open and inclusive atmosphere within the home. The Inspector and Providers discussed the need for the managerial aspects of the home to be formalised for example a registered person to undertake the National Vocational Qualification Level 4 in Care and Management. An annual development plan must be developed for the home reflecting outcomes and aims of the Service Users. Internal audit would form a part of this with Service Users and other stakeholder’s views being sought, at least annually. The results of the Service Users surveys must be published and made available to the Service Users, other interested parties, the Commission for Social Care Inspection and included in the Service Users Guide. New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 Page 22 The Registered Providers are able to demonstrate that the correct course of action would be followed for the areas discussed at the time of the inspection, work has been undertaken on the Statement of Purpose, Service Users Guide and Policies and Procedures since the last inspection. This must be completed to include all those detailed in the National Minimum Standards and Appendix 2. Record keeping must comply with the Care Homes Regulations 2001 as detailed in Schedules 2, 3 and 4. Information is provided in the Service Users Guide about how Service Users wish to access the information held about them. There is clear evidence of reinvestment in the home with the six new rooms being built onto the property. New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 X X X 2 Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 2 X X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 3 2 X 3 N/A CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 New Witheven Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 3 3 2 X 2 3 3 DS0000009043.V254707.R01.S.doc Version 5.0 Page 24 YES 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. Standard YA1 Regulation 4, 5, Sch.1 Requirement The Registered Providers must review and amend the Statement of Purpose and Service Users Guide to ensure that they contain all the information specified in Schedule 1. Previous timescale not met 01/08/05. Timescale for action 14/12/05 2. YA5 5 3. YA6 15 The Registered Providers are required to develop terms and conditions between the Service User and the home. The Registered Providers must develop a care plan, which informs the carer about the interventions needed to maintain or improve the service users capabilities and independence. The care plans must be reviewed at least 6-monthly with the involvement of the service user, or their representative, where possible. Previous timescale not met 01/08/05. As above 01/01/06 01/01/06 3. 4. YA7 YA9 15 13 01/01/06 01/01/06 The Registered Providers must develop individual riskassessments for each service DS0000009043.V254707.R01.S.doc New Witheven Version 5.0 Page 25 user, which reflect capabilities and any risk inherent in activities and/or their environment (these must also include any action to be taken in response to an identified risk). Previous timescale not met 01/08/05. 5. 6. YA17 YA20 17(2), Sch. 4 13 The Registered Provider must ensure that records required are kept e.g. Food records. The Registered Providers must develop the medication procedure to include the receipt, recording, storage, handling, administration and disposal of medicines. Previous timescale not met 01/08/05. 14/12/05 01/01/06 7. YA23 13(6) 8. YA39 24 9. YA40 13(6) 22 10. YA41 17(2) Sch. 4 The Registered person shall make arrangements to prevent Service Users being harmed or being placed at risk of harm or abuse. The Registered Provider must ensure that there is a system for reviewing and improving the quality of care provided in the care home. A report will be provided to the Service Users and the Commission for Social Care Inspection. The Registered Providers must develop a significant number of written policies and procedures in order to comply with National Minimum Standard 40 e.g. Complaints, POVA. The Registered Providers must ensure that the records required are kept e.g. Visitors Book. 01/01/06 01/01/06 01/01/06 14/12/05 New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 Page 26 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. Refer to Standard YA20 YA21 Good Practice Recommendations The Registered Providers should give consideration to the location of medicines storage, and seek advice from their supplying pharmacist if required. The Registered Providers should ascertain and record service user or representative wishes in respect of dying or death as part of their assessment. New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI New Witheven DS0000009043.V254707.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!