Inspection on 25/04/05 for New Witheven

This inspection was carried out on 25th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

New Witheven 06/09/06

New Witheven 15/11/05

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 0BX Lead Inspector Alan Pitts Unannounced 25 April 2005 10:00 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 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 Stationary 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service New Witheven Address Jacobstow, Bude, Cornwall, EX23 OBX Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01566 781285 Mr Denzil John Phillips Mrs Gillian Margaret Phillips Care Home 3 Category(ies) of Learning disability (3) registration, with number of places New Witheven Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28/10/04 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 A38 near Bude. The home provides care and accommodation for 3 adults with a learning disability. Accommodation is in single rooms with a shared bathroom. There is a large comfortable lounge and a kitchen/diner, where everyone eats together.There are extensive grounds surrounding the bungalow, which creates opportunities for the service users.Service users keep in contact with their families and friends and go home at regular intervals. There is a 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. New Witheven Version 1.10 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 comfortable and appropriate home for 3 service users. The relaxed family atmosphere, and the evident contentment of the service users impressed the inspector. The Registered Providers must give priority to the 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. What the service does well: What has improved since the last inspection? What they could do better: New Witheven Version 1.10 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. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. New Witheven Version 1.10 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 Standards Statutory Requirements Identified During the Inspection New Witheven Version 1.10 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 standard(s) 1, 2, 3, 4, 5 The inspector has no doubt that the current service users are well informed, but the Registered Providers need to formalise the manner in which information is available and provided to service users and potential 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. The postcode and grid reference is kept by the telephone to enable emergency services to be directed to the home. This information is also in the statement of purpose and service user guide. All of the current service users have lived at new Witheven for approximately 7 years or more. In the event of the home admitting a new service user, a full assessment would be obtained from the relevant agency e.g. Social Services. The Registered Providers advised the inspector that a short respite period would be arranged to allow for an in-house assessment to take place. Arrangements for trial visits should be included in the Statement of Purpose and Service Users Guide. The Registered Providers have developed a care needs assessment form. As discussed, this should show; the name of the New Witheven Version 1.10 Page 9 home; numbered pages; dated; signature and name of assessor, and should be sent to all referring parties, where possible, to ensure that sufficient information is obtained prior to admission to the home. The Registered Providers demonstrated an in-depth understanding of service user care needs and capabilities. Service users were seen to be content, comfortable, and able to fulfil active social and recreational lives. The Registered Providers have developed a Statement of Terms and Conditions, but this should be reviewed to provide greater detail on fees and how they are to be paid, and to show the allocation of room to the individual service user. New Witheven Version 1.10 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 standard(s) 6, 8, 9 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 intervention. EVIDENCE: The Registered Providers have been using the care needs assessments as plans of care. As discussed at the time of the inspection, the assessments are used to determine care needs and the Registered Providers must then 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. The Registered Providers arranged an advocacy service for one service user last year, and all three service users have had contact with this service at some time. The service users were seen to interact comfortably with the Registered Providers. The Registered Providers and the inspector discussed the benefits of ‘house meetings’, which would be minuted, to further involve service users in the day-to-day running of the home. New Witheven Version 1.10 Page 11 The home is aware of each service users’ capabilities and the Registered Providers minimise risk whilst allowing freedom within safe limits. Individual risk assessments are not in place for each service user. The Registered Providers must develop individual risk-assessments for each service 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). New Witheven Version 1.10 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 standard(s) 11, 12, 13, 14, 15, 16 The service users enjoy a full and varied lifestyle, whilst maintaining the right to choose and decline an activity. The Registered Providers should ensure that the service users are entered on the electoral roll. 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. All the service users have family contact. Friends and relatives are welcome to visit at any reasonable time. Visitors can be seen in the privacy of the service users own bedroom or if preferred in the lounge. All service users have access to the telephone. A visitor’s book is not kept within the home. New Witheven Version 1.10 Page 13 The Registered Providers should provide a visitors book. The service users receive mail unopened, and the Registered Providers will discuss the contents with the individual service user where necessary. The Registered Providers should ensure that the service users are entered on the electoral roll. New Witheven Version 1.10 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 standard(s) 20, 21 Medicines, when used are stored securely. There was no medication in use at the time of the inspection. EVIDENCE: The home has produced a medication policy and procedure. The Registered Providers must develop the medication procedure to include the receipt, recording, storage, handling, administration and disposal of medicines. The Registered Providers should give consideration to the location of medicines storage, and seek advice from their supplying pharmacist. None of the service users are currently on medication. A medicines training course has been arranged at a local training centre. The Registered Providers showed and good knowledge of the service users and the likely wishes or preferences of family members. The Registered Providers should ascertain and record service user or representative wishes in respect of dying or death as part of their pre-admission or admission procedure. New Witheven Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 The Registered Providers are aware of adult protection issues, needing only to provide a procedure, which would give staff clear instruction and contact details. EVIDENCE: The home has an adult protection procedure that includes reference to whistle blowing and the Department of health guidance No Secrets. The Registered Providers should review this procedure to ensure that it provides clear reference to local procedures and contact information, such as telephone numbers, for local agencies relevant to a protection of vulnerable adults investigation. New Witheven Version 1.10 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28 New Witheven is in keeping with a family home. It is well maintained and decorated, offering comfortable accommodation for the service users. EVIDENCE: The home is safe, comfortable and suitable for its stated purpose. Being a bungalow there is easy access indoors with no steps. Outside there is plenty of room enabling service users who enjoy working outside to do so with supervision if needed. There is ongoing maintenance and renewal of fabric. Each service user has a good-sized room with enough space to keep their televisions and music centres etc. Service user bedrooms are adequately furnished and personalised to suit their individual needs and lifestyle. The home’s toilet and bathroom facilities meet the needs of the current service users. Service users have their own personal space and a large comfortable shared sitting room. There is an attractive decking area outside where service users New Witheven Version 1.10 Page 17 can sit, weather permitting. The registered providers and their family have their own private areas. New Witheven Version 1.10 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 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: The home must produce a robust recruitment policy that is based on equal opportunities legislation and references Schedule 2 of the Care Homes Regulations. CRB checks have been obtained for all people working in the home, which is currently the Registered Providers and their daughters. New Witheven Version 1.10 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 40 There is no doubt in the inspector’s mind that the Registered Providers know the service users well and the home has functioned effectively for many years. However, 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: 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, but both the Registered Providers recognize that they need to develop a significant number of policies and procedures. As discussed, reference should be made to the National Minimum Standards and Appendix 2. The Registered Providers must develop a significant number of written policies and procedures in order to comply with National Minimum Standard 40. New Witheven Version 1.10 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 3 2 2 Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x x Standard No 11 12 13 14 15 New Witheven 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 2 x x Version 1.10 Page 21 16 17 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 2 2 Standard No 37 38 39 40 41 42 43 Score x x x 1 x x x New Witheven Version 1.10 Page 22 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 1 Regulation 4, 5 Requirement Timescale for action 01/08/05 2. 6 15 3. 9 13 4. 20 13 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. 01/08/05 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. The Registered Providers must 01/08/05 develop individual riskassessments for each service 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). The Registered Providers must 01/08/05 develop the medication procedure to include the receipt, recording, storage, handling, Version 1.10 Page 23 New Witheven 5. 34 19 6. 40 13(6) administration and disposal of medicines. The home must produce a robust 01/08/05 recruitment policy that is based on equal opportunities legislation and references Schedule 2 of the Care Homes Regulations. The Registered Providers must 01/08/05 develop a significant number of written policies and procedures in order to comply with National Minimum Standard 40. 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 2 Good Practice Recommendations should show; the name of the home; numbered pages; dated; signature and name of assessor, and should be sent to all referring parties, where possible, to ensure that sufficient information is obtained prior to admission to the home. Arrangements for trial visits should be included in the Statement of Purpose and Service Users Guide. The should be reviewed to provide greater detail on fees and how they are to be paid, and to show the allocation of room to the individual service user. The Registered Providers should provide a visitors book. The Registered Providers should ensure that the service users are entered on the electoral roll. The Registered Providers should give consideration to the location of medicines storage, and seek advice from their supplying pharmacist. The Registered Providers should ascertain and record service user or representative wishes in respect of dying or death as part of their pre-admission or admission procedure. The Registered Providers should review the adult protection procedure to ensure that it provides clear reference to local procedures and contact information, such as telephone numbers, for local agencies relevant to a protection of vulnerable adults investigation. Version 1.10 Page 24 2. 3. 4. 5. 6. 7. 4 5 15 16 20 21 8. 23 New Witheven Commission for Social Care Inspection John Keay House Tregonissey Road St Austell 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. 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