Inspection on 21/04/05 for Westhall Park

This inspection was carried out on 21st April 2005.

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

The inspector 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

Westhall Park 19/08/08

Westhall Park 24/09/07

Westhall Park 22/06/06

Westhall Park 24/08/04

Westhall Park 05/05/04

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

CARE HOME ADULTS 18-65 Westhall Park 4, Westhall Park Warlingham Surrey CR6 9HS Lead Inspector Mrs S McBriarty Announced 21 April 2005 st 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. Westhall Park h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Westhall Park Address 4, Westhall Park Warlingham Surrey CR6 9HS 020 8308 2900 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) The Avenues Trust Ltd Rebecca Croft LD - Learning Disability 6 Category(ies) of LD - Learning Disability (6) registration, with number of places Westhall Park h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Of the 6 persons accomodated, the home may accommodate 1 named service user, who in addittion to a primary condition of Learning Disability has Dementia (DE) and Sensory Impairment as a secondary condition Date of last inspection 24th August 2004 Brief Description of the Service: Westhall Park is a registered care home for six adults with learning disabilities, challenging behaviour and complex needs. The current service users are all male. The building is a spacious detached two storey Edwardian house in a residential area. The home has a secluded 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. The home is near to the Kent and Surrey border providing convenient access to countryside and parkland. The home is operated by Avenues Trust and has a full time manager in post. Service users and the staff benefit from the support and expertise of professionals and services. Westhall Park h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, the first inspection for 2005 – 2006 and the second inspection with a new manager in place. Previous inspection reports are available form CSCI on request. During the course of the inspection 4 staff were seen and two spoken to at length, 3 service users were met however none were spoken to regarding their experience of the home. On the day of this inspection the service users were very busy going out, including going on a spontaneous picnic. The service users in this home have complex needs and have communication needs. A tour of the home took place and documents including care plans, risk assessments, policies and procedures and personnel files were sampled. The manager had completed a pre-inspection report, it was unfortunate that no comment cards had been received from either service users their families or other professionals by CSCI for this home. What the service does well: 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 Westhall Park h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 Page 6 contacting your local CSCI office. Westhall Park h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 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 Westhall Park h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 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) ,2,3,4,5 The organisation has introduced a new policy for assessing and admitting new service users. The last admission was very positive for both the service user and staff. Good progress has been made in providing individual contracts. The homes Statement of Purpose and Service User Guide remain accessible but require some change in order to ensure service users have the information they need. EVIDENCE: The home’s service manager had done a great deal of work regarding assessing and admitting new service users. A previous experience had not been positive however it had been recognised that change was needed. The service manager said that it might now take up to three months for a new person to move in. Any new person will be assessed and their views and wishes taken into account. The opportunity to visit the home including staying overnight is offered and meetings arranged with all those involved to ensure that a moving plan is provided. The last person admitted received a moving in party given by the other service users as a welcome ‘home’. All the service users now have individual contracts that have been signed by the registered person and the manager of the home. The manager is seeking ways to provide the contract in an accessible format to see if the service users can understand and sign or mark the documents for themselves. Westhall Park h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 Page 9 The Statement of Purpose and Service User Guide need some updating to show the change from National Care Standards to Commission for Social Care Inspection. Westhall Park h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 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, 7, 9, 10 The service users living at this home have significant needs and it is difficult to know how much they might understand making choices and taking decisions. All the service users have up to date care plans and most now have the beginnings of an accessible person centred plan. The home encourages service users to take risks as part of their daily lives and progress is being made with regard to making choices within the home. All confidential information is held appropriately. EVIDENCE: The plans in place reflect the person’s previous history including where they use to live and where they live now, as well as their likes and dislikes. The new person centred plans use pictures; symbols and words to show who is important to them and what they do to show people what they need. The new plans take a great deal of work with each person and it will be a while before they are all complete. During this visit a service user was observed asking permission to do something, the managers response gave a positive message “ if that is what you want to do”. It was felt that this would enable this person to begin to accept that they did not always have to ask permission to do something they wished to. The staff team note changes in behaviour in order to seek to understand what the service users would prefer to happen. Westhall Park h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 Page 11 Decorative changes within the home are beginning to take place and the service users are taking part in making decisions. This is noted further in the environment section. The opportunity to take risks continues to grow. Some service users can now get their own breakfast without support, although monitoring takes place. It was not possible to gain the views of the service users during this visit. They are not able to talk about their feelings and wishes as well as some others might. In addition the staff were responding to service users throughout the day and taking them where they wished to go. This included time initially set aside to meet with the service users, when they decided they would prefer to go for a picnic at the local park as the weather was so good. All information about the service users is kept in a lockable room or cupboard. The service users have access to their own care plans. Westhall Park h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 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) 12, 13, 14, 15, 16, 17 The staff team continue to make good progress in encouraging the service users to take part in a wide variety of activities. The arrangements for service users meals were adequate. All the current service users are white, British and there are no additional verbal language needs. One person is supported to visit his family and attend the church of choice. Not all of the service users at the home know who their family are but those that do retain contact. The staff team and service users have built good relationships. EVIDENCE: The home provides a wide range of activities both within and away from the home. Most of the service users have access to a local day centre as part of their support needs. Other activities include swimming, arts and crafts (see environment) growing plants and some vegetables, as well as going shopping, cinema, library and watching television. The home has also changed their conservatory into a sensory room. The home has joined the local community group that meets on a regular basis to discuss any issues about the road they live in. Most pleasing was a Westhall Park h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 Page 13 neighbour who went to them for help, showing that they are a part of the community and are seen as such by their neighbours. The staff team are actively encouraged and supported by the manager to work with service users and to suggest new ways of helping them to communicate. This has included a member of staff taking photographs of various activities and important options for one service user. The staff member will be making a communication wall to help that person make choices and decisions about their daily life. Wherever possible the staff have risk assessed a situation to help individuals what they want to do and encourage them to actually do it. Throughout this visit the staff team were observed communicating in a calm respectful manner to the service users. It was clear that there was a warm trusting relationship between staff and service users. A new menu system is in the design stage. The home is seeking to provide the service users with pictures of food so they can make their choice from the photograph. The menus seen offered a varied and nutritious diet, given the flexibility of when food is available the food was not seen or sampled on this visit. The home is in the process of developing a new menu system. Throughout this visit the rights and responsibilities of the service users was discussed. The manager acts as receiver for two of the service users and it was recommended that this role be checked as changes are planned with the Court of Protection. Westhall Park h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 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) 18, 19 The service users are well served by the local community health teams and the staff team are rostered in a way that supports choice and flexibility. The current care plans and those in the process of change reflect the preferred options of service users. EVIDENCE: Current service users are all white, British males whose mobility has not been severely restricted. The staff encourage individuals to make choices about what they wear. There is now a stable staff team of mixed gender and ethnicity that offers the service users more choice about their preferences. The manager spoke of having to change some key workers as the service users built relationships with other staff and were quietly showing their own preferences. The local community team have strong links with the home and access to; for example, dieticians and speech therapists are excellent. The community nurse for people with a learning disability has just introduced the home to health action plans and the teams will be working closely with the service users to complete these. The home uses the local health care team including the doctor to meet the needs of the service users. The requirements made at the last inspection for Westhall Park h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 Page 15 the dental appointment to be kept and medical appointments made for a health check have been met. It was not possible to speak in depth to the service users or staff during this visit as they were very busy going out and about during the day. The manager and service manager said that less ‘as required’ medication was being used, however this was not checked during this visit. Westhall Park h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 The home has a complaints procedure and an adult protection policy in place. Both require some changes. Progress continues to be made with service users to encourage them to make their views known. EVIDENCE: An incident during the course of the last year indicated that letting others know when something is not right is acceptable. The management team dealt with the matter appropriately. The complaints policy has been put into an accessible format for service users and they are able to let staff know through either a change in behaviour or some verbal skills that there is a problem or they are not happy. The complaint policy requires updating to show the change to Commission for Social Care Inspection (CSCI). All staff receive training in recognising and reporting adult protection concerns. The organisation has a policy and procedure in place to ensure that the staff knows what to do and who to inform if they have a concern. The policy needs updating to show the change to CSCI. In addition wording within the document requires some change. At one point it discusses the possible need for the use of physical intervention and uses the wording “physical force” the use of this language should be reviewed. Westhall Park h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 30 There are some areas of the home that require attention. There were areas within the home that had received individual attention by the staff and service users. EVIDENCE: The home is a detached property with a separate lounge and dining area. Each of the service users had their own room. A tour of the home was taken during the visit and all the areas were seen. The home was seen to be clean and hygienic. The furniture in the living area had one chair with a large hole in the arm. It was reported that a new suite is due to be ordered and will be available within the next few months. New curtains will also be ordered. The manager and service manager were delighted that the service users behaviours were more settled and they felt that they could now seek to provide ‘proper’ curtains. Initially they used external electronic blinds, then moved to the current provision of light curtains attached to magnetic holders. The planned change reflects the progress made with the service users. Westhall Park h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 Page 18 Each of the bedrooms has been personalised to the extent that the service users could accept. For some this is minimal, and still has to include pictures being screwed to the wall in view of some behaviours that challenge the service. However, for others the manager said that progress has been made and some people now like having their own belongings in their room. Those rooms that need repainting are in the planning stage and service users are being taken to the local DIY shop to choose the colour of the paint. There are enough bathrooms and toilets for use by the service users. The dining area is currently being changed. A member of the staff team has started to draw around each of the service users. These outlines will be filled with pictures about each person and chosen by each person. A mural will cover the remaining wall. There were projects that the manager said the service users were very excited about. These areas will be monitored by CSCI. Westhall Park h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, 36 The staffing levels were observed to be adequate to meet service users needs and staff were properly recruited and trained. However some changes are required in respect of where records are currently being kept. EVIDENCE: During this visit staff files were seen and some changes are required. The files hold a copy of the Criminal Record Bureau (CRB) checks were being held. In addition there was no information confirming the identity of any member of staff. The manager and service manager said that the Human Resources Department held the original CRB checks and evidence of identity. A requirement has been made that all the information relating to staff members be held at the home. This will ensure that CSCI can check the CRBs and make sure the home is checking the identity of the staff team. The staff files do have each staff member’s job description. A new induction programme has been introduced that staff have to complete by finding the information required to answer the questions. This was considered to be good practice. The manager keeps a training plan that shows which staff has attended a particular course. Training included first aid, health and safety (including infection control), challenging behaviour, communication, management of aggression and others. The manager also ensures that training is provided to Westhall Park h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 Page 20 staff according to individual service users needs, for example epilepsy and rectal medication. There are twenty staff working at the home, five have applied to do their NVQ Level 3, two are finishing their NVQ Level 2 and two of the senior care staff has applied for their NVQ Level 4. Since the last inspection there has been an improvement in the provision of supervision to staff and staff appraisals were also seen. Staff rosters were seen and the home has 3 staff on the early shift, 4 on the late shift and 2 waking night staff. During the day an extra member of staff works between 9.30am and either 1.30 or 4.30pm depending on the needs of the service users. The home also has two staff who work with service users to provide activities. Westhall Park h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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) 37, 38, 40, 41, 42 The new manager continues to make good progress is ensuring the home has an open management style. Progress is required with regard to updating policies and procedures. EVIDENCE: The manager has continued to add to her learning and had completed her NVQ Level 4 and was part of the way through her registered managers award. It was clear from the discussions during the visit and the changes taking place within the home that staff are encouraged to be creative in their approach to service users and how the home might look. This included service users taking part in the decorating of the dining area to staff listening to service users requests to ‘do something’. On the day of the visit this included the picnic. Staff record all the necessary temperatures including bath water and the fridge and freezers temperatures. One of the staff had introduced a new form to make the fridge and freezer temperatures easier to keep and see. Westhall Park h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 Page 22 On the day before this inspection the fire safety officer had been and made several recommendations and these were being actioned by the manager. The CSCI will monitor the outcome of these recommendations. The pre-inspection report showed that the health and safety checks required had been made and were up to date. The visit from the fire safety officer had been the remaining check needed. The health and safety information that needed updating at the last inspection was completed in March of this year. A number of the organisations policies and procedures have not been updated for some time, for example recruitment (2000), smoking and alcohol (also 2000). The organisation has a policy and procedure review group and two staff from this home are involved in the group. A requirement has been made to ensure that policies and procedures are updated on a regular basis. Westhall Park h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 3 3 3 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Westhall Park Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 3 3 x h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 Page 24 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 22 Regulation 22(7)(a)( b) 13(6) Requirement The registered person must ensure that the complaints procedure is reviewed and updated. The registered person must ensure that the organisations adult protection procedure is reviewed and updated The registered person must ensure that all records relating to staff employed at the home are retained in the care home. The registered person must ensure that the homes policies and procedures are kept up to date and reviewed regularly The manager must ensure that the homes statement of purpose and service user guide are updated to note the change from NCSC to CSCI. Timescale for action 31st May 2005 31st May 2005 31st May 2005 30th June 2005 31st May 2005 2. 23 3. 34 17(2) Schedule 4 (6)(f) 12(1)(a)( b) 17 (3)(a)(B) 4, 5 4. 40 5. 1 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 h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 Page 25 Westhall Park 1. 12 It is recommended that the manager seeks further information regarding receivership and the responsibilties required for that role. Westhall Park h09-h58 s52104 v213406 Westhall Park stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey, GU7 2QN 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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