CARE HOME ADULTS 18-65
Weelsby Hall Weelsby Hall Weelsby Road Grimsby DN39 9RU Lead Inspector
Christina Bettison Unannounced Inspection 15th September 2005 09:30 Weelsby Hall DS0000061153.V251321.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 Weelsby Hall DS0000061153.V251321.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. Weelsby Hall DS0000061153.V251321.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Weelsby Hall Address Weelsby Hall Weelsby Road Grimsby DN39 9RU 01472 241044 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) Linkage Community Trust Sandra Josephine Noon Care Home 18 Category(ies) of Learning disability (18) registration, with number of places Weelsby Hall DS0000061153.V251321.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Risk assessments must be completed for the room and the students occupying bedroom 9 due to the low ceiling heights (1.75m lower and 1.7m mezzanine floor) Risk assessments must be completed for the room and the students occupying bedroom 12 due to the low ceiling heights 1.68m of the mezzanine floor. The lounge, dining room, kitchen and poolroom (currently used by all college students during college hours) must be for the sole use of students residing at Weelsby Hall by 29th April 2005. A maximum of 2 service users aged 15 and those aged 16 and 17 years must not exceed a total of 7 at Weelsby Hall and this is conditional on there being no service users over the age of 25 years of age at the home. 3rd May 2005 2. 3. 4. Date of last inspection Brief Description of the Service: Weelsby Hall is a large detached property situated on a main road in a residential area of Grimsby. It has extensive grounds, which includes a football pitch to the front of the building. Weelsby hall provides accommodation for 18 service users. On the ground floor there are a number of recreational rooms; kitchen, pantry and store, dining room, TV lounge, poolroom, IT Suite, 2 offices, a medication room, rest room, laundry, WC, pay telephone booth and entrance/reception room. On the first floor are 12 bedrooms and 3 staff sleep in rooms, 3 bathrooms of which contain WC, s, a bath, showers and wash hand basins, a shower room with 1 shower, a toilet and a hand basin The hall provides furniture and fittings that are of a domestic style. Weelsby Hall DS0000061153.V251321.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Tina Bettison carried out the unannounced inspection of Weelsby hall over 2 hours on the 15/9/05. Training and NVQ was discussed with Jill Forsythe and Julie O’Neil. Policies and procedures were discussed with Helena Shelton and Jason Storr. Staff and managers were spoken to. A tour of the premises was undertaken and care practices and interactions were observed during the inspection. What the service does well:
Linkage is a good organisation that is well run and managed from the directors to the support workers. They have a lot of policies and procedures (rules) that are regularly reviewed and changed in order to promote students rights and best interests and make sure that the staff know how to do their jobs properly. Students are at the heart of the organisation and their views/wishes are taken into account by the use of questionnaires, learner council meetings and by managers and staff that make sure they are involved. Linkage Community Trust provides an excellent service for young adults with a learning disability and other needs. The primary aim of the college is to enable the young people to develop as much independence as possible, whilst helping them to be more confident. They provide a wide range of educational college courses and training in life skills, they also provide training on the use of buses and road safety. Weelsby Hall is a large detached property situated on a main road in a residential area of Grimsby. It has extensive grounds, which includes a football pitch to the front of the building. The hall is on a bus route making all leisure facilities and shops easy to get to, some students go to work experience placements and pursue hobbies. Linkage do an excellent job of treating students as individuals and making sure they that are listened to and that they have a say in how they live there lives. There is a very active student/learner council and regular student meetings in the houses. Weelsby Hall DS0000061153.V251321.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Weelsby Hall DS0000061153.V251321.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 Weelsby Hall DS0000061153.V251321.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): EVIDENCE: None of these standards were assessed at this inspection; they were all met or exceeded at the previous inspection. Weelsby Hall DS0000061153.V251321.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of these standards were assessed at this inspection; they were all met or exceeded at the previous inspection. Weelsby Hall DS0000061153.V251321.R01.S.doc Version 5.0 Page 10 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): EVIDENCE: None of these standards were assessed at this inspection; they were all met or exceeded at the previous inspection. Weelsby Hall DS0000061153.V251321.R01.S.doc Version 5.0 Page 11 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): EVIDENCE: None of these standards were assessed at this inspection; they were all met or exceeded at the previous inspection. Weelsby Hall DS0000061153.V251321.R01.S.doc Version 5.0 Page 12 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): 23 At the previous inspection the staff team were not fully aware of Protection of Vulnerable Adults policies and procedures and their responsibilities within these therefore strategies are not in place to ensure students are protected from abuse, neglect and harm. EVIDENCE: Linkage has a Protection of Vulnerable Adults policy and procedure and also a Child Protection procedure and has identified a key person within the college set up for all referrals to be made through these procedures. Linkage also has a whistle blowing policy. However at the previous inspection it was identified that some staff were not clear about their responsibilities within the POVA procedures and therefore training must be provided. A training programme has been put in place and some staff have attended this training but at the time of this inspection not all. Linkage are still within the original timescale set and managers assured the inspector that all staff will have completed the training by 31/10/05. Weelsby Hall DS0000061153.V251321.R01.S.doc Version 5.0 Page 13 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): 24,25,26,27,28,30 Students live in a home that is safe, well decorated, maintained and suitable for their needs. The gardens and grounds are well looked after and enable students to enjoy the outside space. Linkage have produced a plan for the refurbishment and redecoration of Weelsby hall that includes timescales for completion. EVIDENCE: The hall provides furniture and fittings that are of a domestic style and is clean and free from offensive odours. However this is an old house with listed building status that has for some years been the main meeting point for the Weelsby college campus. Recently a new education block has been built on the college grounds meaning that all the classrooms and the main kitchen and dining room have been relocated away from the main house. Following this the two lounges were refurbished. The house has been altered and added to over the years and at the previous inspection was looking shabby and dated . Since the previous inspection,
Weelsby Hall DS0000061153.V251321.R01.S.doc Version 5.0 Page 14 linkage has produced a plan for the refurbishment and redecoration of the hall with timescales attached. At the time of inspection the big industrial kitchen has been replaced by a new modern smaller kitchen and an utility room created so that students can practice their cooking and domestic skills. The pool room has been redecorated and the outside of the hall has been redecorated. New dining room furniture has been purchased. It is planned to for 6 bedrooms and the halls, stairs and landing to be redecorated by 31/10/05. It was identified at the previous inspection that a number of the shared bedrooms are awkwardly shaped and three rooms have a mezzanine floor making them feel small and claustrophobic. The majority of students share a room, therefore students are not provided with bedrooms that suit their needs and lifestyles. A requirement was made at the previous inspection for Linkage to produce a plan of how they aim to reduce the numbers of double rooms. This was discussed with the residential services managers and an agreement reached that this would be included in the annual development plan for 2005/2006, which will be completed by 31/12/05. Therefore this remains an outstanding requirement. There are sufficient bathrooms and toilets and adequate shared spaces with 2 separate lounges and large grounds to meet students needs. The hall was observed to be clean and tidy. Weelsby Hall DS0000061153.V251321.R01.S.doc Version 5.0 Page 15 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): 32,35 Students are cared for by a satisfactory number of staff, however inadequate provision of mandatory, service specific training and NVQ is compromising the quality of care provided. EVIDENCE: The registered manager had a training and development plan for the staff team that clearly identified staff training needs and all staff had an individual training and development action plan that was completed annually. A wide range of training is provided by linkage and included mandatory training, DDA, HIV/Aids, POVA and child protection, diabetes, makaton, competence to drive the mini bus, administration of medication, epilepsy, religion and culture, confidentiality, whistle blowing, every child matters, principles of care, managing challenging behaviour and human rights. At the previous inspection staff training was of concern, although training was identified and courses available they were not in enough quantity to enable staff to receive training in a timely fashion, therefore all of the students needs could not be met. Linkage still has very low numbers of staff that are qualified to NVQ level 2 or equivalent and this must be addressed.
Weelsby Hall DS0000061153.V251321.R01.S.doc Version 5.0 Page 16 Since the previous inspection a NVQ co ordinator and a training manager have been appointed. A training audit has been completed and an action plan prepared to make sure that linkage can provide all the training and register staff for NVQ to make sure staff are adequately trained and qualified to do their job properly. Although this is much improved and Linkage are working towards meeting the requirements set at the previous inspection it will be the end of October before the majority of staff will be up to date with mandatory training and have received service specific and POVA training. Therefore requirements relating to training and NVQ remain outstanding. Weelsby Hall DS0000061153.V251321.R01.S.doc Version 5.0 Page 17 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): 37,40 Linkage is a creditable organisation that is well run and managed from the top down, with a wide range of policies and procedures that are regularly reviewed and monitored which promote students rights and best interests. Some of these still need amending and updating. EVIDENCE: A new Residential Services Manager has been appointed since the previous inspection. All conditions of registration have been adhered to. The registered manager is qualified to NVQ level 4 in management and will need to either complete the NVQ level 4 in care by 31/12/05 or be registered and working towards it by 30/9/05. The manager has over 10 years experience in care and in particular this student group. She also has a City & Guilds 7307 teachers certificate stages 1 and 2 and has undertaken a variety of training within Linkage. Weelsby Hall DS0000061153.V251321.R01.S.doc Version 5.0 Page 18 Linkage has policies and procedures that cover a wide range of topics, which are detailed and clear and give staff clear guidance on how to conduct themselves. The policies and procedures were kept under review and since registration a number had been updated and amended and new ones added. However it was identified at the previous inspection that a number of them still require amendment and updating, these are bullying, this policy only related to staff and not service users, sexuality and relationships, recruitment and selection to include the request for CRB clearances, staff disciplinary to include referrals to the POVA list where staff are suspended/dismissed for abuse and use of restrictive physical interventions. The inspector was informed that currently Linkage has separate sets of procedures for residential services and college accommodation and Linkage aims to amalgamate them together to create one set of Policies and Procedures to cover all aspects of the services provided. Therefore the timescale for meeting this requirement has been extended to 31/3/06. Weelsby Hall DS0000061153.V251321.R01.S.doc Version 5.0 Page 19 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 x x x x x Standard No 22 23 Score x 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x x x Standard No 24 25 26 27 28 29 30
STAFFING Score 3 2 2 3 3 x 3 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x 2 x x 2 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Weelsby Hall Score x x x x Standard No 37 38 39 40 41 42 43 Score 2 x x 2 x x x DS0000061153.V251321.R01.S.doc Version 5.0 Page 20 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 YA23 Regulation 13 (6) Requirement The registered person must ensure that all staff have received training in the Protection of Vulnerable Adults. (Still within original timescale) The registered person must provide a plan with timescales of how they aim to reduce the numbers of double rooms. (Timescale not met agreed to extend timescale) The registered person must ensure that all staff receive mandatory training and that this is updated as required. (Still within original timescale) The registered person must ensure that staff receive service specific training e.g. makaton training in time to be able to meet students needs. (Still within original timescale) The registered person must ensure that 50 of staff are qualified to NVQ level 2. The registered person must ensure that the manager has achieved NVQ level 4 in care by December 31st 2005 or be registered and working towards
DS0000061153.V251321.R01.S.doc Timescale for action 31/10/05 2 YA25 23 (2f) and 12 (4a) 31/12/05 3 YA35 18 (1a and ci) 31/10/05 4 YA35 18 (1a and ci) 31/10/05 5 6 YA32 YA37 18 (1a and ci) 9 30/04/06 31/01/05 Weelsby Hall Version 5.0 Page 21 it by September 30th 2005. 7 YA40 24 The registered person must ensure that policies and procedures are reviewed and amended in line with updated legislation and best practice guidance. (Timescale not met agreed to extend the timescale) 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Weelsby Hall DS0000061153.V251321.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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