Inspection on 14/02/06 for Whiteheather

This inspection was carried out on 14th February 2006.

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 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Whiteheather 13/12/07

Whiteheather 19/02/07

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 14 February 2006 09:00 th Whiteheather DS0000048917.V279979.R01.S.doc Version 5.1 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.V279979.R01.S.doc Version 5.1 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.V279979.R01.S.doc Version 5.1 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) talk2gam@btinternet.com Whiteheather Care Ltd Mr Shashi Dhanatunge Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Whiteheather DS0000048917.V279979.R01.S.doc Version 5.1 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) 21st October 2005 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. This home was opened and registered in 2003 by the present proprietors, Whiteheather Care Ltd. Mr Gamika Rasal Gunasene is the Responsible Individual and Mr Shashi Dhanatunge is the Registered Manager. The property is set back off the road, with parking areas. At the rear of the property there is a large enclosed garden with a patio area, a paved area, lawns and flowerbeds. 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. Whiteheather DS0000048917.V279979.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over one day in February 2006. This was the second inspection of the inspection year 2005 – 2006. Mr Shashi Dhanatunge, the Registered Manager was present and three care staff were spoken with during the inspection. All three residents were met during this inspection. No visitors or relatives were present during this inspection. Records relating to both service users and staff were sampled and inspected, as were some of the policies and procedures. Twelve of the forty-three standards were inspected; of these nine were met and three were nearly met. All key standards were inspected over the two inspections of the inspection year 2005 – 2006, with some key standards inspected on both occasions. As at the last inspection, there has been a gradual improvement in meeting the requirements and, although the remaining requirements are repeat requirements, it can be seen that action has been taken. Also, whilst there continue to be some shortfalls, improvements have been made. Shortfalls noted were the frequency of staff supervision, an analysis of the quality assurance survey and the completion of a Gas Maintenance/Service Check. These are all requirements, which should be easily overcome. What the service does well: What has improved since the last inspection? Both care planning documentation and risk assessment and management have been reviewed and revised to meet requirements. Staff recruitment paperwork was inspected and was now found to meet requirements and staff training now includes the underpinning knowledge and understanding from Learning Disabilities Award Framework (LDAF) accredited training. Whiteheather DS0000048917.V279979.R01.S.doc Version 5.1 Page 6 A relative’s comment card, completed and returned following this inspection, spoke of the home offering “Excellent” care for their relative with staff undertaking personal care tasks, which only they were able to complete. With their assistance their relative had also completed a comment card in which they had confirmed that they were well cared for, that staff treated them well and they like living at Whiteheather. 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. Whiteheather DS0000048917.V279979.R01.S.doc Version 5.1 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.V279979.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5. Residents have individual contracts/statements of terms and conditions that clarify services offered. EVIDENCE: Copies of the ‘General Terms and Conditions Agreement and Costed Contract of the Provision of Residential Care Services’ were seen on the files for each resident. The content of this document detailed requirements as stated in the National Minimum Standards – Standard 5.2. Whiteheather DS0000048917.V279979.R01.S.doc Version 5.1 Page 9 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): 6, 7 & 9. Residents’ assessed and changing needs and personal goals are detailed in their individual care plans to ensure that their personal needs are met. Care planning records detail residents’ rights to make decisions about what they wish to do and staff enable them to take responsible risks with both risk assessments and risk management strategies in place. EVIDENCE: All three care plans and risk assessments for each resident were sampled and inspected. Alterations and improvements were noted in the care planning documentation and these were found to meet requirements. A detailed risk assessment format has been introduced and on completion this is linked into the resident’s care plan. An example of this was seen with measures put in place and detailed in a care plan to minimise the risk. Mr Dhanatunge said that this is to be introduced into the care planning documentation, as applicable for the remaining two residents. Mr Dhanatunge said that alongside the ‘normal’ care plan the home is planning to introduce a Health Action Plan, as implemented by the local Primary Care Trusts (PCT). He said that he had attended an informative workshop on the implementation of this process. Whiteheather DS0000048917.V279979.R01.S.doc Version 5.1 Page 10 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): None of these standards were inspected at this inspection. EVIDENCE: None of these standards were inspected in detail at this inspection. As at the last inspection, only one resident is able to access college courses. Residents continue to access the community enjoying car trips out to the local countryside and surroundings. Family links and contacts are progressed, as the home is able. One relative completed a comment card following this inspection – see Summary. Nutrition records and menu planning were not considered in detail at this inspection. Residents were seen enjoying the lunchtime, light lunch and consideration had been given to the preferences of the residents. Kitchen cupboards, fridges and freezers were seen to be full of a wide variety of fresh, tinned and frozen foods. Mr Dhanatunge said that the shopping continues to be completed at least three times a week. Whiteheather DS0000048917.V279979.R01.S.doc Version 5.1 Page 11 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): None of these standards were inspected at this inspection. EVIDENCE: None of these standards were inspected in detail at this inspection. Care planning records evidenced that consideration is given to ensuring that residents receive personal support and care in the way they prefer and require. Healthcare records, sampled and seen, detailed evidence of recent consultation with a GP, psychiatrist and Community Nurse regarding the introduction of non-smoking campaign for a resident. Other entries were found relating to GP and Community Nurse visits. Whiteheather DS0000048917.V279979.R01.S.doc Version 5.1 Page 12 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): None of these standards were inspected at this inspection. EVIDENCE: None of these standards were inspected in detail at this inspection. At the time of the inspection there were no ongoing complaint investigations or Protection of Vulnerable Adults (POVA) investigations. Whiteheather DS0000048917.V279979.R01.S.doc Version 5.1 Page 13 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): 26. Whiteheather provides a safe, homely and pleasant environment, which was clean and comfortable. EVIDENCE: A tour of the premises was conducted at this inspection. All of the accommodation was viewed. As at the last inspection, the property is subject to considerable wear and tear, often through episodes of challenging behaviour. The home continues to overcome this by adding fixtures and fittings to the home to ensure that appropriate facilities are available for use by residents. An example of this was the installation of a CD player, fitted cupboards and wardrobes in a second bedroom and a new floor covering in a resident’s room. Mr Dhanatunge said that the home has been granted planning permission to extend the lounge/dining room. They are looking to commence this building work in May 2006. Mr Dhanatunge was advised of the need to notify Commission for Social Care Inspection (CSCI) and to seek advice from both the Fire Service and Environmental Health Service. Whiteheather DS0000048917.V279979.R01.S.doc Version 5.1 Page 14 Since the last inspection, Whiteheather have introduced large lettered signs around the home. In addition, photographs of residents have been added to the resident’s room. The signage has been used to identify bedrooms, bathrooms, toilets etc. Whilst it is acknowledged that this has been introduced to enhance the home and inform residents and their carers of the location of the rooms, it does appear to make the home feel institutional; this is possibly because of the large lettering used. On consideration, management should give some thought to this practice, reviewing the use of the large lettering on all doors and considering smaller, more discreet lettering in its place. Whiteheather DS0000048917.V279979.R01.S.doc Version 5.1 Page 15 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): 34, 35 & 36. Staffing levels and skills are appropriate to the needs of the residents and there are appropriate recruitment procedures in place. LDAF training is in place to ensure that there are appropriately trained staff. There is a need to introduce the frequency of recorded supervision sessions to help ensure that staff are appropriately trained and supervised to meet residents’ individual needs. EVIDENCE: The files of two care staff were sampled and inspected. References, checks and Criminal Record Bureau (CRB) disclosures were found to be in place, as was an application form detailing employment history and training. Mr Dhanatunge clarified the recruitment and employment processes, confirming that staff are not employed until the return of a satisfactory Criminal Record Bureau (CRB) disclosure. Learning Disabilities Award Framework (LDAF) training has now been introduced into the home. With the most recent members of staff having completed the LDAF Induction/Foundation training. Both annual appraisals and regular recorded supervision records were sampled and seen. Mr Dhanatunge was advised of the need to review the completion of these records to ensure that they fully detail requirements as stated in the Whiteheather DS0000048917.V279979.R01.S.doc Version 5.1 Page 16 National Minimum Standards – Standard 36.4. Furthermore, it was acknowledged that the frequency has to be increased to meet requirements of at least six times a year. Whiteheather DS0000048917.V279979.R01.S.doc Version 5.1 Page 17 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): 27, 39, 41 & 42. Staff and residents are well supported by the home’s manager, who is handson and part of the care team in the home. An effective quality assurance and quality monitoring system has been introduced. There is still a need to review, analyse and reflect on the service offered. Overall, records and basic training needs are in place to protect residents. EVIDENCE: Mr Shashi Dhanatunge confirmed that he had completed the National Vocational Qualification (NVQ) Level 4 in Care in January 2006. The certificate of the units completed was seen. Mr Dhanatunge said that he is hoping to complete the Registered Manager’s Award by March 2006. Following the last inspection, a quality assurance survey was completed in December 2006. A relative, a trainer and a NVQ Assessor have completed questionnaires. Whilst it was acknowledged this was a small sample, the need to undertake an analysis of the results and review and reflect how these can be introduced into an annual development plan is needed. Whiteheather DS0000048917.V279979.R01.S.doc Version 5.1 Page 18 Records to ensure the protection of residents and the effective and efficient running of the business were sampled and inspected at this inspection and found to be in place. Training records evidenced that Fire Safety Training, Moving & Handling, Infection Control, Health & Safety at Work, Basic First Aid, Basic Food Hygiene, Training in Physical Intervention, Boots the Chemist Monitored Dosage System and the Protection of Vulnerable Adults (POVA) training have taken place since the last inspection. The most recent member of staff had attended these basic training courses as part of their induction and other care staff had attended these courses as refresher training. In addition four staff have completed the ASET Health & Safety modules with three staff being successful at the examination. The maintenance of electrical systems and equipment was seen to be up-todate with both an Electrical Installation certificate seen and Portable Appliance Testing (PAT) records in place. As at the last inspection, the Gas Safety Record was seen, but the home did not have a Gas Maintenance/Service Check Record. Clarification was given to Mr Dhanatunge, who agreed to pursue this. Whiteheather DS0000048917.V279979.R01.S.doc Version 5.1 Page 19 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 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 3 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 2 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 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 3 X 2 X 3 2 X Whiteheather DS0000048917.V279979.R01.S.doc Version 5.1 Page 20 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 YA36 Timescale for action 17, 18, 24 The registered manager must 18/04/06 ensure that all staff receive the support and supervision they need to carry out their job. (This a repeat requirement. Previous timescale of 18/12/05 not met.) 24 The registered person must 18/04/06 ensure that there is an effective quality assurance and quality monitoring system in place to measure success in achieving the aims, objectives and statement of purpose of the home. (This a repeat requirement. Previous timescales of 09/01/05 and 18/12/05 were not met.) Regulation Requirement 2. YA39 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.V279979.R01.S.doc Version 5.1 Page 21 Whiteheather DS0000048917.V279979.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Whiteheather DS0000048917.V279979.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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