Inspection on 24/09/07 for Westhall Park

This inspection was carried out on 24th September 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westhall Park 19/08/08

Westhall Park 22/06/06

Westhall Park 21/04/05

Westhall Park 24/08/04

Westhall Park 05/05/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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 Sandra Holland Unannounced Inspection 24th September 2007 11:00 Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 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 Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 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. Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westhall Park Address 4 Westhall Park Warlingham Surrey CR6 9HS 01883 621359 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) westhall.park@theavenuestrust.co.uk glebe.house@theavenuestrust.co.uk The Avenues Trust Limited To be confirmed Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Of the 6 persons accommodated, the home may accommodate 1 named service user, who in addition to a primary condition of Learning Disability has Dementia (DE) and Sensory Impairment as a Secondary Conditions 22nd June 2006 Date of last inspection Brief Description of the Service: 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. Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out by the Commission for Social Care Inspection (CSCI) under the Inspecting for Better Lives process. A full analysis of all information held about the service was carried out prior to this site visit. Mrs Sandra Holland, Regulation Inspector carried out the inspection over six and a quarter hours. The recently appointed manager was present representing the service. A number of records and documents were sampled including service user’s individual plans, medication administration records, policies and procedures and staff training records. A full tour of the home was carried out. All six service users and four members of staff were met with. Due to communication difficulties, the responses of some service users were assessed by observing body language, facial expressions and interactions with staff. An Annual Quality Assurance Assessment (AQAA) was supplied to the home, but this was not returned within the requested timescale. A copy of the completed AQAA was supplied at the inspection, although some information requested in the AQAA was provided later. Information supplied in the AQAA will be referred to in this report. Information supplied in the AQAA indicated that equality and diversity are incorporated into the service by promoting equality of opportunity, fairness, consistency and by valuing diversity of all kinds. All service users have a cultural assessment and it is aimed to promote a truly diverse workforce which reflects the local community. The inspector would like to thank service users and staff for their hospitality, time and assistance. What the service does well: Service users are encouraged to be active members of their community and are supported to increase their independence. Service users are supported to take part in a wide range of activities, to learn new skills, to meet new people and to enjoy their leisure time. The health care needs of service users are very well met, and are supported by the involvement of a specialist community nurse for people with learning disabilities and a very understanding general practitioner (GP). Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 6 Support is provided to enable service users to make their rooms personal with their own belongings and to show their interests. What has improved since the last inspection? What they could do better: The needs of service users must be assessed before they are admitted to the home, and the assessment should be signed and dated to indicate who carried out the assessment and when. An individual plan must be drawn up to guide staff to the support and care needs of service users and all information regarding service users should be held in their individual plan. Any risks to service users or others must be identified and assessed. The assessments must be kept up to date and reflect the current levels of risk. To maintain confidentiality, it is recommended that all information relating to individual service users are kept together in their individual plans. Medication must only be administered with reference to the medication administration record (MAR) chart. The MAR chart must be an accurate record of medication administered, so gaps in the record must not occur. A complaints and compliments record must be kept in the home and must record any outcomes and actions taken. Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 7 The manager and deputy manager should receive the local authority multiagency training in Safeguarding Adults and two staff should record all transactions of service users’ monies, as required by the Avenue’s Trust record sheets. The garden should be maintained more often and the unwanted furniture in the garden should be disposed of, to ensure that the garden is a safer and more pleasant space for service users. The specified records regarding staff recruitment and staff induction must be held in the home as required. Doors designed to close automatically must not be propped open. 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. The summary of this inspection report can be made available in other formats on request. Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 8 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 Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The needs of prospective service users must be fully assessed and recorded, before they are admitted to the home, to ensure that these can be met. EVIDENCE: The majority of service users moved into the home when it opened eight years ago, staff advised, although two service users moved to the home more recently. Most of the service users have complex needs and may display behaviours that challenge, staff stated. The file of the most recently admitted service user was sampled and it was not clear if an assessment of the service user’s needs had been carried out prior to their admission. A detailed assessment report was held on file, but as this had not been signed or dated, it was not possible to know who had carried out the assessment, when it was carried out, or if it had been carried out before the service user was admitted, as is required. A signed and dated copy of this assessment was subsequently supplied, and the manager stated that the assessment had been carried out by a representative of The Avenue’s Trust who is responsible for assessing all prospective service users. Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 10 Information contained within the individual plans indicated that service users’ placements at the home are supported financially by local authorities. Where this is the case, an assessment is usually arranged under the care management process, but no care manager assessments were noted in the files seen. From speaking to staff and from records seen, it was clear that the prospective service user had made a number of visits to the home to see if it suited their needs, and to enable staff to more fully assess the prospective service user. The visits were of increasing length and included staying for meals and overnight. A requirement has been made regarding Standard 2, that the needs of prospective service users must be assessed before they move into the home. Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual plans and assessments of risks to service users have been drawn up for most, but not all service users, to guide staff in their support. Information relating to service users must be stored to maintain confidentiality. EVIDENCE: Service users’ individual plans were sampled and it was noted that one was very detailed and provided comprehensive guidance to staff to the support needs of the service user, and many areas of the individual plan were in a format that made it more accessible to the service user. The service user’s individual plan was divided into separate folders for their general information, person centred plan and a separate health action plan, whilst the record of daily notes was recorded elsewhere. It is recommended that all information relating to each service user is included in their individual plan, as this is a more person centred way of working and ensures that all the information is available in one place. Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 12 Many risks to the service user had been assessed in order to support the service user to maintain their independence. It was positive to note that the level of risk had been recorded, and whether or not that level of risk had been agreed as acceptable or manageable. The assessments had been reviewed to ensure they were up to date and reflected any changes in the level of risk. It was observed that assessments of risks to service users were all stored in a file together, divided into sections for each service user. This does not ensure or promote confidentiality and is not a person centred way of storing documents or information. As above it is recommended that all information relating to service users in contained in their individual plan. For the more recently admitted service user however, no individual plan had been drawn up and no risks had been assessed since their admission to the home. The manager stated that staff were providing support to the service user based on the support plan and risk assessments provided by the service user’s previous placement, as they were still assessing the service user’s needs. It was noted that the documentation provided by the service user’s previous placement was outdated, did not reflect their current needs or the current level of any risks and some identified risks had not been assessed at all. It is not clear how staff would know what support was required by the service user or how to protect the service user from risks to their health, safety or welfare. Staff advised that service users are supported to make choices in their daily lives, such as of clothes to wear or food to eat. Staff advised that they offer a selection of these items for service users to choose from and staff were seen using a communication book to assist service users to make their choice and decision. Requirements have been made regarding Standard 6, that an individual plan must be drawn up to guide staff to the support needs of service users; regarding Standard 9, that assessments of risks to service users must be carried out and must be kept up to date to reflect the current level of risk; and a recommendation has been made regarding Standard 10, that all information relating to service users should be stored in their individual plan to maintain confidentiality and to ensure it is person centred. Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are offered a range of activities to take part in and are supported to be active members of their community. Support is provided to enable service users to maintain contact with their family and friends and to take part in the daily life of the home. A well balanced diet is available to service users. EVIDENCE: Staff advised that service users attend local classes to develop or maintain their skills, such as cooking, gardening and woodwork, and other activities for leisure or pleasure, such as bowling and swimming. The home is well equipped with a range of games and puzzles and a sensory room is provided off the lounge. This is equipped with lights and music to relax or stimulate, as preferred, and is also equipped with a number of larger games such as table football. A local allotment is maintained by service users who enjoy gardening, staff advised. Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 14 Service users were seen coming and going to their planned and spontaneous activities during the course of the inspection, and another service user was helping in the kitchen to prepare lunch. An aromatherapist visits the home on a regular basis and was visiting on the day of inspection. Service users were seen enjoying the treatments which were carried out in the lounge. The aromatherapist advised that service users are only treated if they wish to be and their choice is always respected. It was positive to observe the number of photographs around the home and in service users’ individual files recording their varied interests and visits out, such as to the London Eye, to a football stadium and to a barbeque. The service has two vehicles, one of which is used to transport service users to their arranged activities such as classes and day services, and one which is used for spontaneous activities, as and when requested or needed by service users. From the information seen, it was clear that service users are supported to maintain contact with their families and friends. Visitors to the home are welcomed and these were seen recorded. Where they are able, service users also go out to visit their families, and families are invited to be involved in events in the service users life, such as birthdays and support reviews, staff advised. Service users are encouraged to be involved in the running of the home and any risks that may occur as a result had been assessed, although not for all service users. The risks involved in helping in the kitchen, in the laundry and with household chores had all been assessed for one service user, and these included measures to minimise the risks, the level of the risk and whether or not the risk was agreed as acceptable or manageable. Meals are served in the attractive and bright dining room which is next door to the kitchen, and the lunchtime meal was seen being served. Service users could have the planned meal or could ask for an alternative. Staff advised that service users are asked for their views when the menu is planned for the week, to enable the correct shopping to take place. The menu was seen on the notice board in the dining room in a written form, but staff stated that individual service users are asked what they would like to eat before each meal, using formats to suit their needs, such as in pictures. A service user was happy to show their communication book which related to food and meals, which contained pictures of a wide variety of meals, drinks and snacks. Staff advised that service users were encouraged to have their meals in the dining room so that they could enjoy the social aspects of meals, but that service users are supported to have their meal/s in their room if that was preferred. Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ receive personal support in the way they prefer and their healthcare needs are very well met. The administration of medication needs to be improved to ensure service users are safeguarded. EVIDENCE: To ensure consistency and continuity of personal support to service users, a key-worker system is in place and some service users were able to indicate who their key-worker was. The likes and dislikes of most service users were recorded in their individual plans and staff advised that they work to meet these. Where necessary, service users are supported in a referral to an occupational therapist (OT) or physiotherapist, to obtain any aids that will assist them in their independence. It was positive to note that service users are very well supported in maintaining their health and well being by their local general practitioner (GP) and by a community nurse who is trained to work with people who have learning disabilities. The community nurse was visiting a service user on the Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 16 day of inspection. Staff advised that both these healthcare professionals are regularly involved with service users, to promote good health and take action to prevent illness, such as with health checks, and to support service users if they become unwell. Detailed health action plans are being drawn up for service users the community nurse advised, and these are also developed into a format that suits the needs of each service user, it was advised. The community nurse stated that a member of staff was being trained to be a “champion” of the health action plans, to ensure that they are kept up to date and to provide guidance to staff in their use. From the information provided, it was clear that a number of healthcare professionals are involved in the support of service users in addition to those already mentioned, including chiropodist, optician, dentist, hospital specialists, psychiatrist, speech and language therapist and dietician. Staff stated that medication and printed medication administration record (MAR) charts are supplied to the home by a local pharmacy. Most medication is supplied in “blister” packs, with each blister containing an individual dose of each medication, for ease of monitoring. The administration of lunchtime medication was observed and it was noted that when medication was administered to service users, the member of staff did not refer to the MAR chart to check what should be administered, and only referred to the MAR chart to sign it after the medication had been given. It was also noted that there were a number of gaps in the recording of medication administered on the MAR chart, so it was not clear whether service users had received their medication as prescribed. The amounts of medication held were randomly sampled and checked against the records held. It was noted that for two medications belonging to one service user, the amounts held did not accurately match the record held. Although it was positive to observe that medication to be administered “as required” was stored in sealed bags for security, it was noted that the record of this type of medication for one service user was incorrectly calculated, so it was not possible to know how much medication should be present, or to follow an audit trail. A requirement has been made regarding Standard 20, that medication must be administered as prescribed and with reference to the medication administration record, the medication administration record must be maintained as an accurate record and gaps in the record must not occur, and records must be maintained to enable an audit trail to be followed. Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A complaints policy and procedure is in place and only one complaint has been received, but there is confusion in the home between complaints and incidents/accidents. Staff are aware of their responsibilities in the protection of service users, but senior staff need to receive local authority multi-agency Safeguarding Adults training, to ensure that correct actions are taken if abuse is ever alleged or suspected. EVIDENCE: Information supplied in the AQAA indicated that twelve complaints had been made in the last year, although the manager stated that this was not correct. The question had been misunderstood and had been thought to refer to accidents and incidents as well. Only one complaint has been received staff advised, and this was resolved within the timescale stated in the complaints procedure and was upheld. CSCI has not received any information regarding a complaint made about the service. The complaints procedure is made available to service users in formats to suit their needs, including a picture format. A requirement was made following the last inspection on 22nd June 2006, that a compliments and complaints record log must be kept in the home, and must record any outcomes and actions taken. A timescale of 31st August 2006 was given, and an improvement plan supplied by the service stated that this had been done. On the day of inspection however, the compliments and Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 18 complaints record could not be found. The timescale for this requirement has been extended. The service has its own policy and procedure in safeguarding adults from abuse and this was seen to link with other policies, including equality and diversity, challenging bad practice, management of aggression, bullying and harassment, whistle-blowing and restraint. The home’s safeguarding policy also linked with the local authority multiagency Safeguarding Adults procedure, which the manager said the home would follow in the event of a suspicion or allegation of abuse. An up to date copy of the local authority procedure was held in the home for staff to refer to if needed. From the staff training records seen, it was clear that most staff have undertaken training in the Safeguarding of Adults (formerly the Protection Of Vulnerable Adults). The manager stated that she had recently undertaken The Avenues Trust safeguarding adults training, although she has not received the local authority multi-agency training. It is recommended as good practice for managers and deputy managers to undertake this training so that they are fully aware of the correct action to take in the event of a suspicion or allegation of abuse, and are better equipped to support their staff. Staff who were spoken with all stated that they would report any concerns to the manager or person in charge, and would feel able to do so. Staff were also aware that they could report any concerns outside the home, if needed. Staff advised that monies are held for safekeeping on behalf of service users. The amounts of these were randomly checked with the records held and all accurately matched. It was noted that there is space on the record sheets for two staff to sign to show they have been involved in the transactions, but that only one member of staff had signed the record sheet. It is recommended that two staff handle and record all transactions, to protect service users and staff. The requirement previously made regarding Standard 22, that a compliments and complaints record is created, has been given an extended timescale. A recommendation has been made regarding Standard 23, that the manager and deputy manager should receive local authority, multi-agency safeguarding adults training. Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service was decorated and furnished in a homely style and was clean and freshly aired, but the rear garden needs attention to ensure that it is a safe and pleasant outdoor space for service users to enjoy. EVIDENCE: Improvements have been made to a number of areas of the home to meet requirements made at the last inspection, including decorating the lounge, dining room, the room that was vacant at the time and a service user’s bedroom. Repairs have been made to a service user’s bedroom door, a lock has been fitted, the service user has been supplied with a key and the hole in the lawn has been filled. All areas of the home were attractively decorated, were light and bright and communal rooms and bathrooms were seen to be spacious. Furnishings appeared to be comfortable and of a homely style, and photos and service users own artworks decorated the walls. Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 20 Three service users were happy to show their rooms and these had been made personal with their own belongings, including photos, televisions, pictures and music facilities. It was observed that the garden did not present as an attractive or safe outdoor space for the service users to use, as it was unkempt with very long grass. Staff advised that contractors visit to maintain the lawn and it is recommended that the frequency of this is reviewed. A number of items of unwanted furniture were seen stored in the garden and in and around the garden shed. These included a bed and an upholstered chair and looked unsightly. Staff stated that these were scheduled to be disposed of and it is recommended that these are removed as soon as possible. The home was very clean, tidy and appeared hygienic. Personal protective equipment is provided and used by staff to prevent infection and the spread of infection, including gloves and aprons. A separate laundry room is provided and this was equipped with a washing machine and tumble dryer, with appropriate settings. Staff advised that colour coded cleaning materials are used in different areas of the home to maintain hygiene and prevent the spread of infection. It was positive to note that rooms in the home which may present hazards to service user were kept locked when not in use. Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A team of suitably recruited and trained staff are employed to meet the needs of service users, although the specified recruitment and induction records must be kept in the home for inspection. EVIDENCE: From information supplied and records and documents seen, it was clear that a full team of support staff are employed to meet service users’ needs. Staff advised that they carry out all roles in the home, including personal support, shopping, cooking, housekeeping and laundry. Staff also support and transport service users to their educational and leisure activities. Information in the AQAA stated that six staff have achieved a National Vocational Qualification (NVQ) to level 2 or above, and a further ten staff are working towards this. It is recommended that 50 of support staff should have an NVQ to this level, and when all staff working towards this have completed the course, the home will have met the recommended standard. Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 22 The required information and documents relating to staff recruitment are not held in the home, but at the head office of The Avenues Trust, the manager stated. As these were not available for inspection, the manager offered to bring the required documents to a CSCI office and the documents were presented before this report was written. The recruitment files of two recently recruited staff were sampled and were found to hold all the required information and documents. The required checks had been carried out to ensure the applicants were suitable to work in the home, including two written references and a Criminal Records Bureau (CRB) disclosure. Individual staff training records are maintained and from these and speaking to staff, it was clear that training is undertaken as required by law, such as fire safety, first aid and food hygiene. Other training has also been undertaken to develop knowledge and skills such as valuing diversity, understanding challenging behaviour and techniques to deal with challenging and aggressive behaviours. It was noted that no record was held of the induction of the two recently recruited staff. This is required to ensure that staff are fully aware of their role, responsibilities and of the home’s policies and procedures. Requirements have been made regarding Standard 34, that the records specified in Schedule 4 of the Care Homes Regulations, must be maintained and held in the home, and regarding Standard 35, that a record of the induction of staff must be maintained and kept in the home. Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A manager has been appointed, but has yet to be registered by CSCI. The quality of the service provided is monitored and some aspects of the health and safety of service users and staff is promoted, but improvements need to be made to ensure good outcomes for the people living at the home. EVIDENCE: The manager stated that she was appointed to her role in May 2007 and has submitted an application to be registered as the manager of the service, although the CSCI registration team advised that no application has yet been received. The manager advised that she has completed the NVQ Registered Manager’s Award (RMA), is waiting to receive her certificate for this and has plans to undertake NVQ level 4 in Care. Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 24 Support to the manager is provided in the home by a recently appointed deputy manager, who had previously worked in the home as a senior support worker. Further management support is provided by a service manager, who is employed by The Avenues Trust to oversee a number of services in the area. As noted above, the majority of the outcome groups in this report have been assessed as adequate, based on the information provided in the AQAA, at the service during the site visit, and observations made during the visit to the home. These have a direct bearing on the quality of life for people who live at the home. Improvements need to be made to meet the shortfalls identified in the required standards, to ensure better outcomes for the people living at the home. Aspects of the quality of the service provided were being assessed on the day of inspection, by a quality assurance audit assistant from The Avenues Trust. It was advised that an audit consists of two visits, one to look at the whole service and another to assess specific issues. These are linked to the National Minimum Standards (NMS). On the day of inspection, service users’ individual plans were being reviewed and it was identified, as at Standard 6, that these were not being used in a person centred way and there was a risk that service user’s confidentiality could be breached. The information supplied in the AQAA addressed the areas under each standard that asked “what we do well” and “our evidence to show that we do it well”, but most of the areas asking “what we could do better”, “how we have improved in the last twelve months” and “our plans for improvement in the next twelve months” were not completed. Further information supplied in the AQAA stated that electrical, gas, heating and fire safety equipment in the home has been services or tested as recommended, to ensure the health and safety of service users and staff. Staff stated that a number of household health and safety checks are carried out each week, such as testing of the fire alarm and each month, such as the checking of safety equipment and the home’s vehicles. During the tour of the premises, it was noted that a number of doors in the home which are designed to close automatically in the event of the fire alarm being activated, were being wedged or propped open. The dining room door was propped open with a chair and the lounge door was held open with a wedge. These would prevent the doors closing and would not safeguard service users from the spread of fire or smoke. It was observed that other doors in the home which were designed to close automatically were held open by devices which were fitted, which would release when the fire alarm was activated. A requirement has been made regarding Standard 42, that doors designed to close automatically must not be propped or wedged open. Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 25 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 Standard No Score 1 X 2 2 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 1 X 2 X 3 X X 2 X Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 YA2 Regulation 14 Timescale for action The needs of service users must 22/10/07 be assessed before they move into the home, to ensure that any identified needs can be met. An individual plan must be drawn up to guide staff to the support and care needs of each service user, to ensure that service users receive the support and care they require. Risks to service users must be assessed, to ensure they are safeguarded and enabled to take risks as part of an independent lifestyle. Medication must be administered as prescribed and with reference to the medication administration record. The medication administration record must be maintained as an accurate record and gaps in the record must not occur. Records must be maintained to enable an audit trail to be followed. DS0000052104.V344731.R01.S.doc Requirement 2 YA6 15 22/10/07 3 YA9 13 (4) (c) 22/10/07 4 YA20 13 (2) 08/10/07 Westhall Park Version 5.2 Page 27 5 YA22 22 A complaints and compliments record log must be kept at the home detailing the outcomes and any actions taken, to ensure that service users’ views are listened to and acted on. Timescale of 31/08/06 not met. The information and documents specified in Schedule 4 of The Care Homes Regulations in regard to persons employed at the home must be maintained and kept in the home. This is to ensure that service users are (a) safeguarded from persons who are unfit to work in a care home and (b) are supported by staff who have received an induction to their role and responsibilities. Doors which are designed to close automatically must not be wedged or propped open. 08/10/07 6 YA34 YA35 17 (2) Schedule 4 08/10/07 7 YA42 13 (4) (a) 08/10/07 Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA10 Good Practice Recommendations It is recommended that all information relating to individual service users is maintained within their individual plan, to ensure confidentiality is maintained and to ensure the information is person centred. It is recommended that the manager and deputy manager receive local authority multi-agency safeguarding adults training, to ensure they are fully aware of the procedure and are able to effectively support the staff working in the home if needed. It is recommended that the unwanted furniture stored in the garden and in and around the garden shed, is disposed of. The recently appointed manager should submit her application for registration by CSCI without delay. 2 YA23 3 YA24 4 YA37 Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: 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 © 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 Westhall Park DS0000052104.V344731.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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