Inspection on 13/12/07 for Whiteheather

This inspection was carried out on 13th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Whiteheather 19/02/07

Whiteheather 14/02/06

Whiteheather 21/10/05

Whiteheather 17/11/04

Whiteheather 11/06/04

Whiteheather 29/01/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Whiteheather Clacton Road Weeley Essex CO16 9DN Lead Inspector Pauline Dean Unannounced Inspection 13th December 2007 09:15 Whiteheather DS0000048917.V356585.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 Whiteheather DS0000048917.V356585.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. Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whiteheather Address Clacton Road Weeley Essex CO16 9DN 01255 830502 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) white.heather@btconnect.com Consensus – Caring Homes Miss Elizabeth Ikeolumwa El-Schaeddhaei Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 5 persons) 19th February 2007 Date of last inspection Brief Description of the Service: Whiteheather is a detached bungalow offering care for five younger adults with learning disabilities. The property is situated on the Clacton Road, in the village of Weeley, Essex. Within the village there are local shops, a post office and schools. Public transport is available and the home has their own transport. In the last year the home has had a change in registration. It is now registered with Consensus Support Services, part of Caring Homes who had brought out the previous company. The registered manager is Miss Elizabeth El-schaeddhaei. The property is set back off the road, with parking areas. At the rear of the property there is a large enclosed garden with decking and a BBQ area. There is a garden shed for storage. The front garden has an ‘in and out’ driveway with trees and lawn. Bedroom accommodation comprises of five single bedrooms, all with en-suite facilities of a toilet and wash hand basin. In addition there is a bathroom with bath, overhead shower, wash hand basin and toilet, there is also a separate shower room and separate toilet. Communal accommodation comprises of a lounge/dining room offering access to the back garden. The kitchen and laundry are comparable with those found in a normal household. Current fees are from £1,400 per week. These fees are negotiated and they will depend on staffing levels required, the service user’s dependency and the individual assessment. Hairdressing, toiletries and personal equipment are purchased at cost. Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of Whiteheather took place on 13th December 2007 over an eight-hour period. The inspection involved checking information received by Commission for Social Care Inspection (CSCI) since the last inspection in February 2007, looking at records and documents at the care home and talking to the registered manager, care staff and the people living at the home. In addition the Annual Quality Assurance Assessment (AQAA) completed in October 2007 was considered as part of the inspection process and a tour of the premises was completed at the site inspection. Surveys were sent to the home prior to the site visit and they had been distributed to the people living at Whiteheather. All had required assistance with completing these forms. Furthermore staff surveys were sent, as were relative surveys. At the time of writing this report, four surveys had been received from residents, five staff surveys and two relative surveys had been completed and returned to the Commission for Social Care Inspection (CSCI). What the service does well: What has improved since the last inspection? The use of pictorial symbols and easy read documents is seen as an improvement. This is particularly relevant for communication with the residents and in some documents such as the service user guide and the complaints procedure. The general decoration and appearance of the home particularly in the lounge/diner is noticeable. Two bedrooms have also been decorated and new carpets fitted in the hallway. Since the last inspection there has been an increase in the leisure and social activities on offer to the residents. Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Detailed information is found in the Service users’ Guide and the Statement of Purpose to ensure that a prospective resident can make an informed choice. A comprehensive admissions process ensures that people who come to live at White Heather are assured that their needs are met. EVIDENCE: The Service User’s Guide was revised and adopted in April 2007 when there was a change to the registration of the care home. It is now presented in a pictorial form and in easy read language, which is appropriate for the people living at Whiteheather. The registered manager said that these documents were used as part of the most recent admission in May 2007 and had been commented on as being very informative. The Statement of Purpose was also developed and adopted in April 2007. This was in consultation with Consensus Support Services. This was a detail document, which met requirements. Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 9 As stated above a new resident was admitted to the home as an emergency placement in May 2007. Whilst it was an emergency placement, all the initial assessments, referral procedures and background information were gathered from health professionals, care manager and family. These records were seen and inspected at the site visit and are referred to in the Annual Quality Assurance Assessment (AQAA). This document clearly detailed the processes followed, highlighting the need to ensure that the home has a person-centred admission to the care home. The registered manager said that this placement had proved successful and they had now been offered a permanent placement at the home. Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care planning documents were comprehensive detailing health, personal and social care needs. Regular reviews were in place to ensure that the people who use the service receive the care they wish and require. Risk assessments enable the people living at Whiteheather to take manageable risks. EVIDENCE: Care plans were sampled and inspected for two of the people living at the home. One of these was the most recent admission to the home. This was found to be both detailed and informative, giving all carers a good idea of the support and care needed by that individual. Some use of pictorial symbols was seen in this care plan and the registered manager said this form of communication is to be developed in the home. Initially the care plan for the new admission was reviewed after three months, with a planned reviewed every six months or as needed. Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 11 The second care plan sampled and inspected was in a format as found at the last inspection. Approximately fifty care planning goals are considered with the importance of person-centred care highlighted. Care planning goals covered all aspects of personal and social support and healthcare needs. Changes are being made to this person’s medication and this was noted in the care plan and was under review. The records clearly detailed the changes and the action to be taken. Risk Assessment and Management Tools are in place. Whilst there were some variants in the paperwork used, it met requirements. Risks, factors and triggers with a management plan were in place. An example of risk assessments was seen with regard to cigarette smoking. This was linked into a care-planning goal and reviews were in place as needed. The registered manager recognised the importance of using the service of an advocacy group for each of the individuals living at Whiteheather. They said the most recent admission had had the use of an advocacy service in their area and they had found it very useful as they had come to Whiteheather. This service had continued until September 2007 when their out of county placement had become permanent. The registered manager said she was looking into whether such a service was available in the area. Unfortunately she had been told that the advocacy service in the area is only able to offer a service in an emergency. Records and reports relating to health care were seen on individual files. A carer on duty confirmed a recent dentist appointment when there had been an episode of challenging behaviour. They were able to tell us how this had been managed and the planning for future appointments. All of the residents at Whiteheather are registered with a local GP surgery. GPs visit the home as requested. Referrals are made to consultants as required and an occupational therapy assessment has been requested following a review of care for one resident. Within care planning records, care planning strategies were seen to enable residents to make choices. Picture symbol cards have been introduced and these are used in conversation with the individual to identify choices available. Within the Annual Quality Assurance Assessment it was stated that all of the people living at Whiteheather have person centred plans and their individual needs are recorded. This was evidenced in the sampled file. The registered manager said that should staff have a difficulty in meeting specific needs, and then the home will look to offering training to support them. As Five staff surveys produced by Commission for Social Care Inspection (CSCI) had been completed and all five said that they felt they were Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 12 given staff training, which was relevant to their role. One detailed the basic training courses they received confirming that they are required to attend annual refresher training courses on these topics e.g. Fire Safety, Abuse and Medication. Whiteheather DS0000048917.V356585.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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use this service are able make choices with regard to their daily routine and leisure activites and contact with their family. People who use this service are provided with a varied and healthy diet to promote good health. EVIDENCE: It is recognised and acknowledged by the home that the present resident group present very challenging behaviours and opportunities for both training and social activities are limited. This was especially so during the winter. However residents continue to go out and about in the mini-bus, go for walks, enjoy pub visits, feed the ducks at local lakes and attend weekly discos. In the summer outings to local attractions had been arranged e.g. the zoo and Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 14 the seaside and three residents had enjoyed a weeks holiday at Butlins Holiday Centre in Skegness. All of the residents at Whiteheather possess televisions and music systems in their rooms and staff organise special disco parties to celebrate birthdays. Evidence was seen jigsaws, Lego and art and craft materials which individually the residents enjoy doing. Within the AQAA it was stated that it was there intention in 2007-08 to ensure that all four residents of the home access more day centre facilities in the Tendring, Colchester and Ipswich area. The registered manager stated that it is anticipated that the residents will participate in the Service User Form, which is conducted by Consensus. This would enable them to make new friends and have their voice heard. In May 2007, staff completed a course entitled ‘Training in Communication’ and the home has introduced picture symbols, some of which detail social and leisure activities. Evidence of this was seen in both individual’s rooms and in the office. A carer spoken to on the inspection visit demonstrated how these symbols worked with a resident. Two of the people living at Whiteheather have regular contact with their relatives. Relatives had completed two surveys and both were very positive regarding the care of their relative. One said ‘Their activities are very good’. Both said that they felt their relative got the support and care they needed. Evidence was seen of the home ensuring that the rights and responsibilities are respected. Within care planning there was reference to the management of keys. All four residents are unable to use a key to lock their bedroom doors and therefore do not hold keys. A 4-week rotation menu plan is in place at Whiteheather with both hot and cold choices. The registered manager said that the residents usually select hot dishes for both lunch and dinner. Each week a different resident is encouraged to select a meal. Pictorial food pictures are used to assist with selecting the food. These cover main courses, fruit and desserts. Records are kept on each individual’s file of the food eaten and refreshments offered and taken during the day. It was seen from the planning and records of the food eaten that the residents enjoy a varied and healthy diet. Weight charts are also kept on file. These were in use and the registered manager said that they were in place for monitoring purposes. Within the home there was ample food supplies, tinned, dried, fresh and frozen. The registered manager said that shopping at local supermarkets is completed twice a week and whilst changes are envisaged to the present Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 15 shopping arrangements, the present frequency is likely to continue. Records of temperatures of the two freezers and two fridges were seen in the home. Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 16 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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home’s arrangements for supporting the healthcare of the people living at the home was detailed to enable staff to know what action is required and what action is to be taken. EVIDENCE: Within the care plans and daily records sampled and seen at the inspection, there was evidence of the people living at Whiteheather receiving their personal support in the way they prefer and require. Examples were seen in the record keeping of nighttime sleeping patterns and arrangements and the planned action to elevate current problems. As stated earlier in this report, evidence was seen of visits to GP, opticians and dentist. The registered manager and staff confirmed that they escort residents to healthcare appointments. Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 17 Following the last inspection the registered manager had conducted a thorough investigation of medication practices and record keeping in the home. Inhouse guidance and training had been given and all staff who give medicines have attended a training course The home has used the Boots The Chemist medication training course – ‘Care of Medicines’ a foundation module for all staff. In addition one carer is completing a long distance training course in medicines. All of the people living at Whiteheather have a Health Action Plan in their care plans. Within the AQAA this was stated to be formulated in consultation with their key worker, community nurse and GP. The document looks at daily and life long health needs. The registered manager said in the AQAA that the home would be looking to review and develop these documents further in the future to enable easy access to information on these files. Medication administration and record keeping was sampled and inspected for the two people living at the home who are part of the case tracking. The storage and record keeping was found to be in good order, with individual storage boxes used. Medicines were in good supply and the home was not holding excessive medication supplies. Records were seen of medicines entering the home. These were detailed on the Medication Administration Record (MAR) sheet and a return book is used for returning and disposing of medication. The registered manager said that no Controlled Drugs are held in the home. The practice of decanting medication had ceased and staff had a greater understanding of medicines. Overall the printed Medication Administration Record (MAR) sheets gave clear instructions. One exception was found however. This was discussed with the registered manager and a senior staff member and whilst the written instructions were not clear, it was clear that the carer had a clear understanding of the application of a solution and an ointment. The registered manager said that they would speak to their pharmacist to request clear instructions for both items. Within survey work conducted by the Commission a relative said that their relative had ‘put on some weight and looks well.’ Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 18 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 & 23. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at Whiteheather were well treated and listened to, with complaints and adult protection procedures in place. EVIDENCE: A complaints procedure entitled ‘ Making a Complaint or Speaking Out’ was found at the home. It was both pictorial and in easy read language. This document detailed how you make a complaint and it gave the procedure for raising a complaint to management and with the Commission. In addition in the office there was a poster, which gave the details of the Clinical Director of the company where complaints can be directed. This made reference to the complaints may be anonymous. All four people living at Whiteheather had completed a Commission for Social Care Inspection (CSCI) survey and all said that knew how to make a complaint. Keyworkers and the registered manager were detailed as being appropriate to raise a complaint with. Consensus, the registered providers have central policies, which the home has adopted. A policy entitled ‘Protection of Vulnerable Adults Policy and Abuse’ was found on the Care Policy and Procedure. The registered manager said that all staff are to read these policies. Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 19 Records are kept of complaints raised and since the last inspection there has been one complaint, which related to a problem when the washing machine had broken down and the length of time for a repair or replacement. The records seen detailed the problem and the action taken. The home now has new washing machine. Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 20 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 & 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at Whiteheather have homely, comfortable and safe surroundings, which are kept clean and tidy. EVIDENCE: A tour of the premises took place at the site inspection and all four occupied bedrooms were seen. Since the last inspection two bedrooms had been decorated and new heavy-duty flooring fitted in one room. Three out of four of the bedrooms had evidence of the individual whose room it was. Open shelving and hanging space had been created when there were problems with wardrobe doors being broken and opaque film has been fitted on to a bedroom window in one of the rooms. We were told that several attempts had been made to fit curtaining and blinds to these windows and they had been pulled Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 21 down. Having considered this within the individual’s care plan, this option had been adopted. The registered manager said that this solution is being considered for a second resident. They too had no curtains and whilst the bedroom was not overlooked or at the front of the building, some form of dressing at the windows would make the room more cosy and less stark. Three of the resident’s bedrooms had Christmas decorations in, as did the lounge area. Since the last inspection the extended lounge and dining room have been redecorated and new carpet has been laid in the hallway. Christmas decorations were in evidence in this communal area. On the day of the site inspection, repair work was required to the kitchen sink tap. It continually dripped and staff had taken to turning it off under the sink. The registered manager said that she had notified Consensus and they were awaiting a repair. She said that currently they received regular maintenance support, but sometimes because of the challenging behaviour of the residents this is difficult to keep up. However, if required local tradesman can be called to complete a repair. The home was experiencing problems with the central heating system on the day of site inspection. It had failed to come on. A heating engineer was called and a temporary repair made, with new parts to be fitted the following day. Within the AQAA it was said that in line with the home’s five-year business plan further decoration and repairs are planned for the kitchen and corridors. Whilst the kitchen is fully operational, some of the cupboards are looking worn and tired and could do with replacing. A new cooker has been fitted however. As internally the exterior of the property was in good repair. The rear garden with lawn and decking was secure and tidy and the front driveway and lawn was tidy. An Environmental Health Inspection had take place in July 2007 and there were no contraventions. The homes laundry is situated at the front of the bungalow and has one industrial washer and one domestic dryer. The laundry was completed by the care staff during the day, with ironing completed at night. Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 22 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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff were roistered in sufficient numbers to ensure the people who live at the care home are safe and their individual needs are addressed. The care home has a permanent staff team to provide consistency and security for the people living at the home. EVIDENCE: It was evident that Whiteheather has an established staff team. The registered manager said that a core of the staff had been with the home since 2004. Opportunities for staff training were said to have enlarged since Consensus took over the home. Three staff surveys said that they felt their induction training had covered the skills they needed to know and two said that it had partly covered the information they needed to know. However, they had gone on to say that they had more training as they were working in the home. Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 23 The registered manager said that staffing levels in the home continue to be monitored and reviewed, particularly since the most recent placement in May 2007. Four staff who completed the survey work commented on staffing levels. Two staff said that they always had enough staff and two said they usually had enough staff. One care worker had commented on the reduction to three care staff in the afternoon. The registered manager said this was because it was a quiet time after lunch, when several residents have a rest. She did say however, that she continually monitors this to ensure that the needs of the residents are met at all times. There had been some staff recruitment in the past year and two new female staff have been employed. The staff recruitment files of two care workers were sampled and inspected. Overall they had been completed well, although further employment history details were required and the ‘Reason for Leaving’ needs to be added to one file. Later we were able to speak with the care staff member and they were able to clarify these entries. The registered manager said that she would get them to add more detail to their application form. Evidence was seen of previous social care training on file and two references were seen for each person. For the most recent employee there was no evidence of a Protection of Vulnerable Adults (POVA) 1st check. The registered manager acknowledged this omission and said that normally she received this conformation via an email from head office. Whilst at the site inspection, she set about chasing this up. Paperwork relating to the second member of staff seen had evidence of training under the previous training company. Since Consensus had taken over the home they had attended a – Physical Interventions course valid for 1 year until October 2008, 2 day workshop in ‘Understanding & Responding to Behaviours that Challenge’ – April/May 2007 & Fire Safety Training – July 2007. A Staff Induction, Development & Training record check sheet was in evidence for both care workers and Induction Training was planned for 16th January 2008, with the company’s trainer for the most recent member of staff. At the site inspection one member of staff was spoken to. They had started work at Whiteheather in early December 2007. They said that they found the staff extremely supportive and were willing to help and advice as they required. They said that they were getting to know the residents and had some understanding of the care planning and records kept for each person. They confirmed that they were currently going through their induction training and they were shadowing care staff. The majority of their duties were catering at present until they had full Criminal Record Bureau (CRB) clearance. They informed us that they were due to have further Induction Training early January 2008. Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 24 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 & 42. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use this service benefit from good management, a well run home and a developed quality assurance and quality monitoring system. People who use this service can expect their health, safety and welfare to be promoted and protected. EVIDENCE: Whiteheather has an established staff team and a competent and qualified manager to run the home. Alongside the registered manager, there is a deputy manager. Training opportunities are available and Miss Elizabeth Elschaeddhaei said that she is planning to attend a twelve month Professional Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 25 Development Programme for Managers one day a week. In addition she plans to update her training qualification in March 2008 and has a Fire Marshall training course booked for January 2008. Whiteheather has an ongoing quality assurance and quality monitoring system in place. Regular visits and reports as required under the Care Homes Regulations 2001 – Regulation 26 are conducted and copies of these reports are sent to the via email. Furthermore the registered manager receives regular supervision from her line manager and detailed discussion records are kept. The registered manager said that quality assurance questionnaires had recently been sent out to relatives of residents in the home and they had been very positive. In addition survey work had been completed by the residents of the home. These were in a pictorial and easy read format. Alongside this care staff have been surveyed and seven had been returned. Issues around the maintenance and the outdoor activities in the home in the winter had been raised and the registered manager said that the home was looking to feedback the results through staff supervision and staff meetings and feedback to residents and their families. As stated earlier in this report a staff training and development programme has been developed. Training courses completed in October/December 2007 were Epilepsy Awareness, Manual Handling, First Aid, Food Hygiene, Fire Marshall and Protection of Vulnerable Adults (POVA). Safety certifications were sampled and inspected. Inspected at the site inspection was the servicing record - Gas Safety Record completed August 2007, the Electrical Installation Certificate – completed December 2005 valid for five years and a risk assessment had been completed for Legionella in May 2007. Hot water temperature checks are completed each month and some variance from 43 °C i.e. 35.8°C was noted. Some adjustment may be necessary to ensure that the temperature remains as close to 43° as possible. Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 26 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X 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 3 3 X 3 X 3 X X 3 X Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Whiteheather DS0000048917.V356585.R01.S.doc Version 5.2 Page 29 - 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. 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