Inspection on 19/08/08 for Westhall Park

This inspection was carried out on 19th August 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westhall Park 24/09/07

Westhall Park 22/06/06

Westhall Park 21/04/05

Westhall Park 24/08/04

Westhall Park 05/05/04

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Insight - Eastchurch

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/06/2011.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Westhall Park 4 Westhall Park Warlingham Surrey CR6 9HS The quality rating for this care home is: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Ruth Burnham Date: 1 9 0 8 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 35 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 35 Information about the care home Name of care home: Address: Westhall Park 4 Westhall Park Warlingham Surrey CR6 9HS 01883 621359 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): westhall.park@theavenuestrust.co.uk The Avenues Trust Ltd Name of registered manager (if applicable): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 0 0 care home 6 learning disability Additional conditions: The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD). The maximum number of service users to be accommodated is 6. Date of last inspection 1 9 0 8 2 0 0 8 Care Homes for Adults (18-65 years) Page 4 of 35 A bit about the care home Westhall Park is a registered care home for up to six adults with learning disabilities, challenging behaviour and complex needs. The Avenues Trust Limited operate the home. The building is a spacious detached two storey Edwardian house in a residential area. The home has an enclosed garden and private parking area. Service users all have single bedroom accommodation that is on both floors. The village of Warlingham and local public transport are both within walking distance. Larger shopping facilities and a wide range of social and leisure activities are easily accessible in nearby towns. The home is near to the Kent and Surrey borders providing convenient access to countryside and parkland. The fees at this service range from # 1743.40 per week to # 2478.91 per week. Care Homes for Adults (18-65 years) Page 5 of 35 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home Care Homes for Adults (18-65 years) Page 6 of 35 How we did our inspection: This is what the inspector did when they were at the care home The Commission has since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the Service was an unannounced Key Inspection. The Inspector arrived at the Service at 08.00 and was in the Service for five hours. It was a thorough look at how well the Service is doing. It took into account detailed information provided by the Services owner or manager and any information that CSCI has received about the Service since the last inspection. This information included responses returned by 5 members of staff, 6 residents, (completed by staff on their behalf) 1 health care professional and a visiting therapist. Of the surveys returned staff surveys returned were largely positive. Of the 6 residents surveys returned, 2 were positive, the other 4 contained largely negative responses. The therapists responses were positive and the health care professional was largely positive but contained some critical comments which have been included in the report. There have been no complaints about the home since the last inspection. There are ten Required Developments in this Report. The quality rating for this service is 1 star,. This means the people who use this Care Homes for Adults (18-65 years) Page 7 of 35 service experience adequate quality outcomes. What the care home does well People who are considering moving into the home can be confident their needs will be fully assessed and understood before any decision is made about whether the home will be suitable for them. People who live in the home are supported to take part in a wide variety of in house, leisure and community activities according to their individual interests and abilities. They can be confident their personal and healthcare needs will be met in a way which upholds their privacy and dignity and promotes independence. People are listened to and protected from abuse. The cleanliness of the premises and facilities provided enhance the quality of life of people who live in the home. People who live in the home are supported by a staff team who understand their care needs. Robust selection and recruitment policies and procedures protect people who live in the home. They are protected form harm by safe working practices. Care Homes for Adults (18-65 years) Page 8 of 35 What has got better from the last inspection What the care home could do better Individual care plans should be person centred, up to date and easily accessible to staff to provide clear guidance for staff on how to support people who live in the home. Behaviours which could result in serious injury should be fully risk assessed and clear guidance provided for staff on how to manage these. Personal information such as daily records should be stored securely, available solely to authorised and appropriate people. Health care planning and records should be maintained to provide staff with up to date information and guidance to meet peoples healthcare needs. Carpets should be clean. Damage to walls, fixtures and fittings should be repaired and the garden should be maintained to a reasonable standard. Doors to communal areas such as the kitchen, bathrooms and garden should not be routinely locked unless individual risk assessments clearly demonstrate this is necessary. Care Homes for Adults (18-65 years) Page 9 of 35 The Trust should provide an action plan to show how They intend to ensure at least 50 of staff will have a National Vocational Qualification within a reasonable timeframe. They should also The Trust should provide an action plan to show how They intend to ensure at least 50 of staff will have a National Vocational Qualification within a reasonable timeframe. The Trust should appoint a manager who meets the criteria set out by the Commission in respect of relevant qualifications. Internal quality and assurance system must be effective in ensuring requirements are met. If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Ruth Burnham The Oast Hermitage Court Hermitage Lane Maidstone Care Homes for Adults (18-65 years) Page 10 of 35 Kent ME16 9NT 01622724950 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries.southeast@csci.gsi.gov.uk or by telephoning our order line - Care Homes for Adults (18-65 years) Page 11 of 35 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 12 of 35 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People who are considering moving into the home can be confident their needs will be fully assessed and understood before any decision is made about whether the home will be suitable for them. Evidence: Most of the people who live in the home moved there when it opened 9 years ago. Two people have moved into the home since then, no one has moved in since the last inspection. The service manager and person in charge were fully aware of the the shortfalls in assessment and recording processes noted at the last inspection and have produced a development plan to ensure the requirement made following that inspection will be met should anyone move into the home in the future. Procedures are in place to ensure people who may consider moving into the home have a detailed assessment of their needs to ensure the home will be suitable for them. They are fully involved in the assessment process in accordance with their wishes and abilities. The service is developing a person centered approach to assessment and works with the Care Homes for Adults (18-65 years) Page 13 of 35 persons Local Authority care manager and relevant health care professionals where appropriate to ensure all necessary information is obtained before any decisions are made. Families are also involved at this stage, subject to the agreement of the person being assessed. Wherever possible, people who are thinking of moving in are visited at their current home by a member of the Trusts management team. There are also invited to visit and meet staff and other people who live in the home so they can experience what life will be like there. An individual plan of care is developed, with the involvement of the person to take account of their individual needs, wishes and aspirations. This care plan is based on the care manager assessment and care plan. Care Homes for Adults (18-65 years) Page 14 of 35 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The ineffective organisation, maintenance and the inaccessibility of peoples personal care files mean that staff may not understand or support people with their care needs in a consistent manner in accordance with their individual preferences and aspirations. Inadequate risk management systems may fail to protect people from harm. Language and cultural barriers between staff, people who live in the home and external agencies do not promote good communication and understanding between all parties. Evidence: People who live in the home all have individual plans of care. People have limited verbal communication skills, the service manager said each person is involved as far as possible in setting up their care plans according to their wishes and abilities. Two peoples personal folders were examined in detail. The large lever arch folders contain a lot of documents which make it difficult to locate specific information. Some very good, person centered and detailed documentation relating to care was located within the folders however much of this was not dated or signed making it impossible to know which information was up to date. Staff therefore cannot easily access relevant and current guidance on how to provide support and personal care in a consistent Care Homes for Adults (18-65 years) Page 15 of 35 manner. The service manager confirmed that changes in senior staff and management approach in the home has resulted in important information being lost. There has not been a registered manager running the home for over 2 years. The service manager and person in charge have already identified these problems. They have drawn up and are working through a development plan to improve care planning and the accessibility of information to ensure better outcomes for people. They explained how they intend to adopt a more actively person centered approach to meeting peoples needs and how they intend to improve the organization and accessibility of information for staff in the coming weeks. Where people who live in the home have behaviours which challenge the service and could place themselves or others at risk of harm, strategies are in place with clear guidance for staff to follow to support and protect people in these circumstances. However these documents are not easily or immediately accessible to staff, this could lead to inconsistency of approach which in turn could place people at risk of harm. All the staff, with the exception of the person in charge are from different ethnic backgrounds to the people who live in the home. Staff who were working in the home during the visit were very busy and did not always appear to understand the questions we asked them. It was observed that staff on duty were more focused on carrying out specific tasks such as; ensuring the kitchen was clean; preparing and making sure people ate their breakfast, went to the toilet or had a bath, rather than in interacting with people who live in the home in a warm and meaningful way. The service manager was advised to review staffing levels, particularly early in the morning, to ensure there are always sufficient, suitably qualified and competent staff on duty to have the time to interact with each person in a way which promotes their emotional, social and psychological wellbeing rather than just focusing on immediate physical needs. The service manager said people who live in the home and their families where appropriate, are fully involved in planning their care. Others such as health care professionals are also involved. People are helped to understand their individual plan through the use of simple language and pictures. Each person who lives in the home has a designated member of staff who acts as their keyworker. This member of staff is fully involved in care planning processes and supports people in regular reviews of their care. Personalised communication support is available to help people make decisions about their daily lives. Staff support people to make choices through a variety of means, for example photographs of different foods are used to help people choose what they would like to eat although these were not in use during breakfast. Staff support people to manage their personal allowances. Planned limitations on choice are designed to promote peoples best interests and protect them from harm. Peoples safety is promoted through risk management systems which include individual risk assessments. Examples of these were seen in peoples personal folders. Where risks are identified individual risk assessments provide clear guidance for staff on how to support people to undertake activities in as safe a manner as possible whilst respecting peoples individual rights. People are encouraged and supported to develop life skills designed to promote their personal safety and avoid unnecessary restrictions Care Homes for Adults (18-65 years) Page 16 of 35 on their preferred activities and choices. There was some concern where we observed one of the people who live in the home repeatedly inserting a small Sharp piece of wood in his ear and walking around with it inserted. When we drew this to the attention of a member of staff they intervened to remove the item. The member of staff was not aware of any relevant risk assessment although they said this was a regular pattern of behaviour. A requirement to assess risks in order to protect residents was made following the last inspection, this requirement has not been met. People who live in the home cannot be confident their confidentiality will be maintained. Personal daily record files were seen on a table in the lounge along with other personal information. This was drawn to the attention of the service manager who immediately removed them and placed them in a secure area of the home. Care Homes for Adults (18-65 years) Page 17 of 35 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People who live in the home are supported to take part in a wide variety of in house, leisure and community activities according to their individual interests and abilities. Evidence: People who live in the home are encouraged and supported to take part in valued and fulfilling activities. People make use of local community facilities such as the library, shops, pubs, the leisure centre and cinema. One resident is a member of the local rambling club and enjoys regular walks with the support of staff. The home has its own transport; a minibus and a car. People are also supported to use local transport and taxis Staff at the home and local day centre staff support people with a variety of activities outside the home and staff rotas are planned to take account of individual activity programmes. People are able to choose how they wish to spend their time and are supported to pursue own interests. In house activities include music, films, TV, games, puzzles, painting and gardening.People have not been away on holiday so far this year, the Care Homes for Adults (18-65 years) Page 18 of 35 service manager said this would be chosen and planned with residents shortly. Everyone is involved in some kind of activity outside the home. These include music therapy, cookery, gardening, rambling and woodwork. An Aromatherapist visits the home to provide therapy for two people. People are supported to maintain links with family and friends. Visitors are welcomed at reasonable times and, where necessary, staff support people to visit families and friends. Routines in the home are flexible and relevant. People are supported and encouraged to help with the running of the home according to their individual wishes and abilities. Staff said some people like to help prepare meals and do their own laundry. One resident enjoys working in the garden. Meals are served in the dining room adjacent to the kitchen. People who choose to do so are involved in planning and preparing meals. The service manager said a dietician provides advice to the home as required. Records are maintained of all meals served in the home. Care Homes for Adults (18-65 years) Page 19 of 35 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People who live in the home can be confident their personal and healthcare needs will be met in a way which upholds their privacy and dignity and promotes independence. Inadequate records and healthcare planning and language barriers may mean staff do not have the information or skills to meet some specialist healthcare needs effectively. Evidence: People who live in the home can be confident their personal and healthcare needs will be met in a way which upholds privacy and dignity and promotes independence. Daily routines are flexible in accordance peoples preferences and plans of care. People are supported to choose their own clothes and hairstyle to suit their individual personalities. The service manager said people are supported to access additional specialist support as necessary from a variety of health care professionals such as opticians, dentists, chiropodists and psychiatric services. Some evidence of contact was seen in letters in peoples individual folders. However no records could be found of the outcomes of visits to healthcare professional other than psychiatric services. The service manager said the home works closely with the local surgery. One of the GPs visits the home every week and the home liaises with a designated community Care Homes for Adults (18-65 years) Page 20 of 35 nurse to provide the best possible service to residents. People who live in the home all receive an annual health check. One health care professional who responded to our survey had some concerns about failure to follow up advice or recommendations about individual needs. They expressed the view that this may be due to staff not always understanding due to language/cultural barriers or inadequate training. The service manager and person in charge are working on updating health action plans and records as part of their development plan, to improve communication and guidance for staff and ensure all staff are aware of any changes to peoples healthcare needs. People are protected from harm through the safe handling of medication. None of the people who live in the home are able to manage their own medication. Records are kept of all medicines received, administered and disposed of. Staff who handle medication have been trained to do so safely. Storage facilities are suitable and secure and records seen were well maintained and up to date. Care Homes for Adults (18-65 years) Page 21 of 35 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People who live in the home are listened to and protected from abuse. Evidence: The service manager said people are listened to and encouraged to offer comment or complaint. There is a clear complaints procedure. People who live in the home have varying degrees of communication difficulties. Interaction observed during the inspection showed staff take appropriate action when people who live in the home express dissatisfaction or unhappiness. There is a complaints procedure which has been produced in simple language with pictures to make it easier for people to understand. There is also a copy displayed in the home. The home has clear procedures for responding to complaints and a log is in place to record any complaints received. No complaints have been recorded since the last inspection. Some discussion took place about the way in which a complaint is defined and when the home should record unhappiness or dissatisfaction expressed by residents as a complaint. People who live in the home are protected from abuse. There are clear procedures for responding to suspicion or evidence of abuse or neglect including whistle blowing policies. Staff and management have received training in safeguarding adults and know how to recognise warning signs. Physical or verbal aggression by people who live in the home is understood and dealt with appropriately and staff are trained to handle these situations. Care Homes for Adults (18-65 years) Page 22 of 35 There are good systems and procedures in place where staff help people to manage their monies. Records seen were well maintained and up to date with receipts of all transactions. Care Homes for Adults (18-65 years) Page 23 of 35 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The cleanliness of the premises and facilities provided enhance the quality of life of people who live in the home. Locked door policies, uniformity of decor, the unkempt garden and damaged walls detract from the homeliness of the environment. Evidence: People who live in the home benefit from the spacious accommodation. Each person has their own bedroom, these are well proportioned and airy and have been personalised according to individual needs and tastes. There is a large lounge and separate dining room. A small conservatory provides additional communal space. The premises are comfortable and reasonably furnished. Given the higher than usual levels of wear and tear in this home some discussion took place about whether furniture in the dining room was robust enough to withstand this, there was a broken chair on the work top in the dining room at the time of the visit. Further discussion took place about how the premises could be made more homely, the majority of walls are painted in a pale cream colour and many areas show varying degrees of damage.Some tiles in bathrooms are cracked and carpets in the hallway are badly stained. The service manager said improvements have been made to the garden since the last inspection however further work is needed make this area a pleasant place for people to enjoy in the better weather. There was further concern about blanket locked door policies which mean people are unable to access some areas of the home or go outside without asking a member of staff unlock the door. This gives the home an institutional feel and may mean there are insufficient staff to supervise people adequately. The Care Homes for Adults (18-65 years) Page 24 of 35 service manager agreed to review these policies to ensure people have unrestricted access to all communal areas, including the garden, within a clear individual risk management framework. People benefit from the cleanliness of the environment. All areas seen during the visit were clean and fresh. There is a well equipped laundry which is suitably located away from the kitchen. There are procedures in place to ensure people are protected from risk of infection, staff are provided with protective clothing as required. Care Homes for Adults (18-65 years) Page 25 of 35 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People who live in the home are supported by a staff team who understand their care needs. Robust selection and recruitment policies and procedures protect people who live in the home however the staff group does not reflect the cultural background of the people who live there. Only 4 members of staff have a National Vocational Qualification, the staff team may not therefore be suitably qualified or competent to meet peoples needs. Evidence: There were 3 members of staff on duty at the beginning of the visit. They were supporting residents to have breakfast and get washed and dressed to prepare for the day. It was noted that staff are approachable and comfortable with residents however the early morning is a very busy time with staff getting people ready, preparing food, cleaning and administering medication at the expense of meaningful and sensitive interaction with people who live in the home. An additional member of staff came on duty at 9 am and during the rest of the visit the situation improved with staff able to support residents individually with activities. The service manager agreed to review staffing levels early in the day to ensure there are sufficient staff on duty at this time. Staff know residents well and understand their individual care needs. The Annual Quality Assurance Audit completed by the service manager before the inspection shows that only 4 out of 20 staff have a National Vocation Qualification, 4 more staff are working towards this qualification. The Trust has its own learning and Care Homes for Adults (18-65 years) Page 26 of 35 development department and arranges a variety of specialist training to help staff understand the specific needs of people who live in the home including training in managing challenging behaviours in a sensitive and effective manner. The staff group does not reflect the cultural background of people who live in the home, they may not be able to provide support in with sensitivity, knowledge and understanding of these issues. There are robust selection and recruitment policies and procedures to protect people who live in the home. All staff are checked through the criminal records bureau before appointment. Two written references are obtained and all staff are provided with relevant codes of conduct. Three staff files were examined, these contained all the information required. People who live in the home can be confident staff are well supervised. All staff have regular one to one supervision sessions, seniors and management staff observe practice on a day to day basis and all staff attend team meetings. All staff have an annual appraisal when individual training and development needs are identified. Care Homes for Adults (18-65 years) Page 27 of 35 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People who live in the home are protected from harm by safe working practices. Lack of consistent and competent management and ineffective quality assurance systems in the last 2 years have had a negative impact on outcomes for people who live in the home. People are at risk where fire doors are being wedged open in spite of a requirement having been made on this issue following the inspection in 2007. Evidence: There has been no registered manager in the home for over 2 years and inspections show that this has had a negative effect on outcomes for the people who live there. The last person in charge resigned at the beginning of the year. A new person in charge has been recruited and has been in post since June, an application for registration is being submitted. It was of some concern that the person in charge has no qualifications however the service manager is overseeing management of the home at this time. The new person in charge, along with the service manager, has produced a development plan to address areas of concern identified in this and last years inspection report. The service manager completed the Annual Quality Assurance Audit for us before the Care Homes for Adults (18-65 years) Page 28 of 35 inspection. This contained most of the information we needed. In this the service manager said an annual stakeholders questionnaire is sent to health professionals and families. Person centred Planning Meetings are held six monthly. Policies and Procedures are reviewed regularly. Service Users views are sought through meetings and opportunity sessions. The Trusts representative visits the home monthly to carry out an internal audit and list actions required. Given that a three out of the five requirements made following the last inspection have not been met we must conclude that internal quality assurance systems have not been effective. People who live in the home are protected from harm through safe working practices and the regular maintenance of equipment and installations. Staff are trained in infection control, health and safety, basic food hygiene, first aid, moving and handling and fire safety. However some fire doors are still being wedged open in spite of a requirement having been made on this issue following the inspection in 2007. Care Homes for Adults (18-65 years) Page 29 of 35 Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action 1 9 13 (4) (c) Risks to service users must 22/10/2007 be assessed, to ensure they are safeguarded and enabled to take risks as part of an independent lifestyle. 2 42 13 (4) (a) Doors which are designed to 08/10/2007 close automatically must not be wedged or propped open. Care Homes for Adults (18-65 years) Page 30 of 35 Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No Standard Regulation Description Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action 1 6 12 The registered person shall 30/09/2008 ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users. In that individual care plans should be person centered, up to date and easily accessible to staff to provide clear guidance for staff on how to support people who live in the home. 2 10 17 The registered person shall 30/09/2008 ensure that records are kept securely in the care home. Personal information such as daily records should be stored securely, available solely to authorised and appropriate people. Care Homes for Adults (18-65 years) Page 31 of 35 3 19 12 The registered person shall 30/09/2008 ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users. In that health care planning and records should be maintained to provide staff with up to date information and guidance to meet peoples healthcare needs 4 24 13 The registered person shall 30/09/2008 ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated In that doors to communal areas such as the kitchen, bathrooms and garden should not be routinely locked unless individual risk assessments clearly demonstrate this is necessary. 5 24 23 The registered person shall 31/10/2008 having regard to the number and needs of the service users ensure that the physical design and layout of the premises to be used as the care home meet the needs of the service users. the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally. Care Homes for Adults (18-65 years) Page 32 of 35 In that carpets should be clean. Damage to walls, fixtures and fittings should be repaired and the garden should be maintained to a reasonable standard. 6 32 18 The registered person shall, 30/09/2008 having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. The Trust should provide an action plan to show how They intend to ensure at least 50 of staff will have a National Vocational Qualification within a reasonable timeframe. 7 33 12 The registered person shall 30/09/2008 ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users. The Trust should provide an action plan to show how it intends to ensure the staff group reflects the culture and background of people who live in the home. Care Homes for Adults (18-65 years) Page 33 of 35 8 37 9 The registered person shall appoint a person to manage the care home who is suitably qualified to do so 30/09/2008 In that they should appoint a manager who meets the criteria set out by the Commission in respect of relevant qualifications. 9 39 24 The registered person must 30/09/2008 show how they have responded to recommendations made or requirements imposed by the Commission in relation to the care home over the period specified in the request. In that the internal quality and assurance system must be effective in ensuring requirements are met. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 34 of 35 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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