Inspection on 19/09/05 for Westhaven

This inspection was carried out on 19th September 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

Westhaven 10/04/07

Westhaven 03/05/05

Westhaven 08/12/04

Westhaven 07/08/04

Westhaven 26/02/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

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 Westhaven Westhaven 68 Blackborough Road Reigate Surrey RH2 7BX Lead Inspector Susan McBriarty Unannounced Inspection 19th September 2005 10:00 Westhaven DS0000013822.V251357.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Westhaven DS0000013822.V251357.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westhaven DS0000013822.V251357.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Westhaven Address Westhaven 68 Blackborough Road Reigate Surrey RH2 7BX 01737 221503 01999 999999 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) Millsted Care Limited Amanda Vivienne Finch Care Home 6 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (2) of places Westhaven DS0000013822.V251357.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 41-65 YEARS & TWO OVER 65 YEARS 3rd May 2005 Date of last inspection Brief Description of the Service: Westhaven care home is owned and managed by Millstead Care Limited and is registered for six(6) people with a learning disability. The home has a fully equipped kitchen, dining room, living room and six single bedrooms. The property is located in a pleasant residential area in close proximity to two local towns, Reigate and Redhill. The home has its own transport which is accessible for current service users. Westhaven DS0000013822.V251357.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the second for 2005 – 2006. The inspection focussed on those Standards not assessed during the inspection of the 3rd May 2005 and confirmation that the requirements made on the 3rd May had been completed. During the inspection four (4) residents and two (2) staff were spoken to. The residents have complex needs and most have limited verbal skills and were therefore not able to discuss their needs fully and how they were being met. A number of documents were sampled during the inspection including staff personnel files, previous financial and business plans, staff training documents and residents finances. 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 contacting your local CSCI office. Westhaven DS0000013822.V251357.R01.S.doc Version 5.0 Page 6 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 Westhaven DS0000013822.V251357.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2,3,4 and 5 were assessed during the inspection of the 3rd May 2005. EVIDENCE: Westhaven DS0000013822.V251357.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8 Standards 6,7,9 and 10 were assessed during the inspection of the 3rd May 2005. Residents are encouraged to attend house meetings during which issues regarding the home are discussed. EVIDENCE: Not all the residents have good verbal skills and written information may be confusing or not accessible to them. Information regarding the home is therefore provided verbally during house meetings. The meetings are held regularly and minutes taken by staff. The hand written minutes are sent to head office for typing and on occasion may take some time to return in completed format to the home. The meetings offer the residents the opportunity to talk about what is happening in the home and/or any changes that are being planned. The requirements made at the inspection on the 3rd May had been met. Westhaven DS0000013822.V251357.R01.S.doc Version 5.0 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14,15,16 and 17 were assessed during the inspection of the 3rd May 2005. EVIDENCE: Although Standard 17 was not assessed during the inspection of the 19th September the Inspector observed that resident’s were provided with fresh fruit as a snack mid morning. The assistant manager advised that this was to encourage healthy eating throughout the day. The requirement regarding resident’s finances had been met. See also Standard 23 of this report. Westhaven DS0000013822.V251357.R01.S.doc Version 5.0 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19,20 and 21 were assessed during the inspection of the 3rd May 2005. EVIDENCE: Westhaven DS0000013822.V251357.R01.S.doc Version 5.0 Page 11 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Standard 22 was assessed during the inspection of the 3rd May 2005. Standard 23 was partially assessed during the same inspection. The care staff at the home had not received training in the protection of vulnerable adults. EVIDENCE: The organisation enables managers to attend training on the protection of vulnerable adults, however none of the care staff have attended. A requirement is made that all staff attend training regarding the local guidelines for the protection of vulnerable adults. Requirements were made at the last inspection that the protection of vulnerable adults policy be updated. The previous policy noted only that staff must inform the manager of any concerns. This has been completed. The complaint procedure has also been updated to ensure that there is no confusion between a complaint and a protection of vulnerable adults concern. The organisation acts as appointee for the majority of residents. The home receives an amount of money each week in the form of petty cash, the residents personal allowance is taken from these funds and separated to ensure that each person has the correct amount recorded against their name. Further clarity is required to ensure that there is a record for each person of their entitlement and the procedures in place regarding the appointeeship and management of resident’s monies. Westhaven DS0000013822.V251357.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24,25,26,27,28,29 and 30 were assessed during the inspection of the 3rd May 2005. EVIDENCE: The requirements made at the last inspection had been completed. The downstairs toilet has had a lock fitted and the debris in the garden had been removed. The fence at the side of the house requires replacement following near by building work. The organisation is aware of this and the Inspector was informed that negotiations are taking place. Westhaven DS0000013822.V251357.R01.S.doc Version 5.0 Page 13 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36 The home follows clear recruitment practice guidelines, however further work is required to ensure all the staff records are held at the home and that staff receive all the training required by the National Minimum Standards – Young Adults age 18-65 years. EVIDENCE: There have been changes to the needs of a specified person since the inspection on the 3rd May 2005. The staff team have received specialist training to ensure that the person’s needs continue to be met. The resident group is also ageing and the home needs to consider a variation of their registration during the course of the next few months. The staff team consist of male and female staff from various ethnic backgrounds; the resident group consist of four females and one male all of whom are white. The staff team were observed to have a good relationship with the residents who appeared confident enough to request openly that staff meet their needs in a way that they wished. The majority of staff files sampled by the Inspector contained job descriptions and contracts, however the manager and/or proprietor of the home had not signed a number of the contracts. Some of the files sampled did not evidence a Criminal Record Bureau (CRB) check although the Inspector was advised that all staff had been CRB checked and not all contained a job description. A Westhaven DS0000013822.V251357.R01.S.doc Version 5.0 Page 14 requirement was made that the home review the staff files to ensure that all the information required by The Care Homes Regulations 2001 (as amended) are kept at the home. In discussion with the assistant manager the Inspector was informed that staff members had not been given a copy of the General Social Care Council (GSCC) Code of Conduct for Social Care staff. A requirement has been made that the organisation provides staff with a copy of the Code of Conduct. A staff team of nine, including the manager work at the home; of the eight care staff three have completed the National Vocational Qualification (NVQ) Level 3 and two are undertaking the training. Those staff files seen by the Inspector indicated a low turnover of staff thereby providing a stable staff team for the residents. As stated previously the Inspector was informed that specialist training had been provided regarding one specified persons needs. A number of the staff provide social nail cutting for a some of the residents, none of the staff have received training from a specialist for this service. A requirement was made to ensure that where social nail care is provided that staff members have received appropriate training from a specialist. Those who have been assessed as requiring the service are supported to attend a chiropodist on a regular basis. The Inspector viewed evidence of staff and house meetings taking place, the Inspector was informed that the most recent records of those meetings have not yet been sent to the home for their records. Each new staff member receives a twelve week induction into the home that includes policies and procedures and training in specified areas. There was no evidence of training in health and safety or equal opportunities. A requirement is made that the organisation review its current training options to ensure that all necessary training is provided to each member of staff. In the staff files sampled evidence was found that a training record is kept documenting the training undertaking and the date completed. The Inspector evidenced staff supervision records; the supervision year runs from April to April, some work is required to ensure that each staff member received the minimum of six supervision sessions per year. A recommendation has been made that the home reviews the level of supervision to date in order to assist planning. Westhaven DS0000013822.V251357.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 43 Standards 40,41 and 42 were assessed during the inspection of the 3rd May 2005. Further work is required to ensure the home is able to evidence that up to date financial and business plans are in place informing of financial viability and any future plans the organisation may have. The CSCI have not been informed of all those accidents or incidents required within Regulation 37 of The Care Homes Regulations 2001 (as amended) EVIDENCE: The requirements made at the inspection of the 3rd May 2005 had been met. In discussion with the assistant manager the Inspector was informed that the manager is currently undertaking the Registered Managers Award. It was not possible for the Inspector to evidence that the home’s budget was being managed, as a copy was not available. The inspector was able to evidence the budget for 2004 and view the financial and business plan for 2004. Westhaven DS0000013822.V251357.R01.S.doc Version 5.0 Page 16 As stated previously the home enables regular house meetings to include the residents and to keep them advised of any changes that may be taking place within the home. The Inspector was informed that the proprietors visit the home regularly and residents are encouraged to voice their views. The organisation does not have a formal quality assurance process the outcomes of which could be published. A recommendation is made that the home reviews this informal process and consider alternatives that would enable the publishing of outcomes. Standard 42 was not assessed in full during the inspection. The inspector did view the accident and incident forms completed by staff and noted that not all the incidents had been notified to the CSCI. A requirement is made to ensure that incidents involving aggression by residents to others are reported, as are any incidents or accidents resulting in any injury. Westhaven DS0000013822.V251357.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score N/A X 3 X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 2 3 3 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Westhaven Score X X X X Standard No 37 38 39 40 41 42 43 Score 2 X 3 X X X 2 DS0000013822.V251357.R01.S.doc Version 5.0 Page 18 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 23 Regulation 17(2) Sch’4 (9)(a)(b) Requirement Timescale for action 30/10/05 2 31 3 34 4 35 5 35 The registered person must ensure that the service users records clearly identify the appointee, method of payment, income and any and all payments including the reason, made into their accounts. 18(4) The registered person must ensure that all staff members are provided with a copy of the General Social Care Council Code of Conduct for Social Care Staff. 19(4)(a)(b) The registered person must Sch’ 2 review the staff files to ensure they contain the information required in Schedule 2 of The Care Homes Regulations 2001 (as amended). 18(1)(c)(i) The registered person must ensure that staff members receive appropriate training from a specialist in order to provide social nail care. 18(1)(a)(c)(i) The registered person must ensure that a review of all staff training provision take place in order to ensure that all staff members receive DS0000013822.V251357.R01.S.doc 30/10/05 30/10/05 30/10/03 30/10/05 Westhaven Version 5.0 Page 19 6 37,42 37(1)(2) 7 43 25(1) appropriate training including the protection of vulnerable adults and health and safety. The registered person must review the scope of the Regulation 37 Notifications to be made to the CSCI. The registered person must forward a copy of the home’s financial and business plan to the CSCI. 30/10/05 30/10/05 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 36 Good Practice Recommendations It is recommended that the registered manager review the current levels of supervision provided in order that the minimum six sessions per year for each staff member is documented and recorded. Westhaven DS0000013822.V251357.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Surrey Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Westhaven DS0000013822.V251357.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!