Inspection on 06/07/07 for Whiteley Bank House

This inspection was carried out on 6th July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Whiteley Bank House 14/11/06

Whiteley Bank House 12/01/06

Whiteley Bank House 20/09/05

Whiteley Bank House 24/02/05

Whiteley Bank House 09/09/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Whiteley Bank House Whiteley Bank Newchurch Isle Of Wight PO38 3AF Lead Inspector Mark Sims Unannounced Inspection 12:30 06th June 2007 X10015.doc Version 1.40 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 Whiteley Bank House DS0000012556.V336192.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 Older People. 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. Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whiteley Bank House Address Whiteley Bank Newchurch Isle Of Wight PO38 3AF 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) 01983 867541 01983 863378 Mrs Daphne Zosha Hayles Mrs Daphne Zosha Hayles Care Home 12 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (12), of places Physical disability over 65 years of age (2) Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th November 2006 Brief Description of the Service: Whiteley Bank House is a home providing care for up to twelve older people. The home is privately owned and managed by Mrs Daphne Hayles. It is situated in the village of Whiteley Bank between Godshill and Shanklin. All amenities are available in Shanklin, approximately one mile away. The home is a two storey detached former coach house set in substantial grounds. There is off road parking to the front and level access into the building. The home has a mixture of single and double bedrooms, one with en-suite facilities. There is a passenger lift to access the upstairs. The current scale of charges is £50.73 £60.00 per day with additional charges for chiropody (£7.50) and hairdressing and newspapers (prices vary). Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the Second ‘Key Inspection’ of Whitley Bank House, a ‘Key Inspection’ being part of the inspection programme, which measures the service against core National Minimum Standards. The fieldwork visit, the actual visit to the site of the home, was conducted over four and half hours, where in addition to any paperwork that required reviewing the inspector met with service users and staff and undertook a tour of the premises to gauge its fitness for purpose, several issues outstanding from the last inspection were also considered during the fieldwork. The inspection process involves far more pre fieldwork visit activity, with the inspectors gathering information from a variety of professional sources, the Commission’s database, pre-inspection information provided by the service and linking with previous inspectors who have visited the home. What the service does well: Choice of Home: The home has an effective, if not somewhat basic admission tool, which is used to gauge whether or not the needs presented by a potential resident can be met at the home. Pre-admission literature is available, although this is a little dated and basic. Daily Life and Social Contacts: During the visit, several visitors were welcomed into the home to visit their relatives, mealtimes were also observed, when a choice of evening fare was provided to the service users. The home’s extensive grounds were also popular with the service users, who commented on being able to sit outside when the weather was more welcoming. Complaints and Protection: Whilst the home’s ‘service user guide’ should be updated to reflect the change in the title of the regulatory body, the home’s general approach to the management of complaints appears satisfactory a view shared by visitors and residents. Environment: The environment is generally well presented and maintained, with many bedrooms clearly having been personalised by the occupant. The grounds are extensive and accessible to the service users and their relatives when visiting. Parking is however, a problem, although one beyond the control of the proprietor. Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 6 Staffing: The staff were found to be friendly and co-operative during the fieldwork visit. They have a clear understanding of the needs and wishes of the client group and were noted to have developed good relationships and a rapport with both the residents and their relatives. Management: The home appears well managed, with the residents, their relatives and the staff team supportive of the management team. 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. The summary of this inspection report can be made available in other formats on request. Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 3 and 6: Prospective residents and their representatives have the information needed when choosing the home and have their needs assessed. EVIDENCE: Pre-admission Assessment: The evidence indicates that residents are having their needs assessed prior to admission and that they are provided with sufficient information prior to deciding to move into the home. The evidence used to make this judgement includes: o The availability within the main entrance hallway of small leaflet style brochures, which provide a basic introduction to the home and is general services, a copy was provided to the inspector for reference purposes. Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 9 o The availability of a ‘service users guide’, which whilst basic and truly incorporating all of the information set out within the National Minimum Standards, does provide an informative document that compliments the brochure. The three care plans scrutinised as part of the commissions case tracking process, both of which contained assessments cared out be a member of the home’s management team, as well as a professional assessment completed by the clients care manager. Details of the home’s policy on emergency admissions, which was included within the ‘Annual Quality Assessment Audit’, which is a tool used by the Commission and dispatched prior to the fieldwork visits occurring. Comments from both relatives and service users, who clearly felt the home meet their needs and wishes, as it provided a quiet homely atmosphere, which larger establishments could not mirror. o o o Standard 6: The home does not provide and intermediate care facility. Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards 7, 8, 9 and 10: The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Service user plans: The evidence indicates that the home’s care planning system has improved since the last inspection, when it was required that: ‘Care plans must contain more detail as to how identified needs will be met, be reviewed at least monthly and be signed by the resident or their representative’. The evidence used to make this judgement includes: o The review of three service user plans, as part of the case tracking process, which established that each plan contained: 1. Risk assessments, although these could still be expanded upon. Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 11 2. Care plans, which had been agreed with the resident and included details of personal choices, evidence of regular monthly review and updating. 3. Moving and handling assessments, which provided basic instructions and guidance to staff on equipment and personnel to be involved in the moving process. 4. Running records, which provided a summary of the day-to-day events in a person’s life, although could include more social recording. 5. Medical, Health/Social Care contacts and/or professional visitors records. o Discussions with staff, who confirmed that the care plans were working tools and that people were trying to embrace the changes made since the last inspection and develop the service user plans accordingly. Meetings with the service users, when those subject to case tracking were observed to be receiving care in accordance with their wishes and in line with the plan prescribed within the care records. o Health Care: The evidence indicates that the health care needs of the service users are being appropriately met. The evidence used to make this judgement includes: o The ‘service users guide’, which states: ‘Medical care is available from your own Doctor (if in catchment area) or a General Practitioner from the local Health Centre. We also have arrangements with Dentist’s, Optician’s, hairdresser’s and Chiropodist’s who make regular visits to the home. As mentioned above the service user plans include details of all medical and/or health care contacts made on behalf of the service users, the records maintained providing details of the reason for the contact, the date of the visit, etc and the outcome of the visit and any follow-up treatments/visits. On reading through the plan of one service user it was noted that they had required emergency health care treatment during the night following the development of unexpected physical health problems. The attending paramedics had determined that this was not a life threatening illness and had request that the home contact the client’s General Practitioner (GP) the next morning, which the records indicated had been done. During the fieldwork visit the GP arrived to see the resident and was escorted by a senior staff member to see the resident, who had been much improved since the paramedic visit, notes of the GP’s visit and his diagnosis were written up. Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 12 o o o During meetings with service users no complaints were raised with regards to the support provided when accessing medical/health care bodies. It was also observed that the management team discussed with the relative of the person mentioned above, the details of their health scare and the actions/outcomes of the GP’s and paramedic’s visits. o Medication: The evidence indicates that improvements in way the home manages service users medications must be made. The evidence used to make this judgement includes: o A review of the medication administration records (mar) established that staff are not appropriately or effectively using the codes, which denote the reason for the non-administration or omission of a medication, when completing the mar sheets. This issue/problem leads to inaccurate maintenance of medication records, which when reviewed by a GP or Health care professional distorts the picture of the person’s medication habits/routine/compliance, etc. o A review of the medication storage/bulk medicines, etc, revealed that when changes are being made, by a GP, to a prescription that the staff are removing additional medicines when dispensed and replacing them within the ‘monitored dosage system’ (mds). These medications are not intended for re-dispensing or administration and are returned to the pharmacy at the end of the 28 day cycle, however, it would be more sensible for these medications to be placed within a secure container, where they can be accounted for and safely returned to the pharmacist without fear of loss. o Accounting for medications or monitoring/auditing their use was also an issue of concern, as a service user had their paracetamol changed to codydramol, a slightly stronger analgesic, which contains codeine and paracetamol. However, the original paracetamol prescription was never cancelled and it would appear that on one occasion the client might have been given four dosages of co-dydramol and one of paracetamol, which would exceed the recommended daily intake of paracetamol for an adult. It is most likely that this is a clerical error, the staff member routinely signing all of the boxes for medications due at that time, however, this Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 13 error was not picked up by the home and not challenged, neither has the confusion over the two prescribed analgesics been addressed, when it would be most sensible to ask for the paracetamol to be removed from the mar sheet and repeat prescriptions. Privacy and Respect: The evidence indicates that people’s rights to privacy and respect are appropriately promoted. The evidence used to make this judgement includes: o During the tour of the premises it was noted that not all of the accommodation is single occupancy, with several shared bedrooms in use around the home. On visiting these rooms it was noted that individual screens are accessible within each room and that people’s toiletries, etc are maintained on an individual basis within each bedroom. o o People’s rooms or areas of the room, etc, were also personalised, with pictures, posters and ornaments seen during the tour. The bathrooms and toilets were fitted with appropriate locks, which could be secured from the inside but released from the outside in the case of an emergency. The relationship between the residents and the staff was clearly a mutually respectful one, with people noticed to be very friendly and responsive to each other. The service user plans, contain details of the forms of address the people prefer to be known by, whilst the language used throughout the care plans reviewed, was respectful and appropriate. The home’s contract terms and conditions document also set outs people’s rights within the home and the service they should expect to receive whilst resident at the home. o o o Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 12, 13, 14 and 15: People who use services are able to make choices about their life style, and supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: Activities and Entertainments: The evidence indicates that the activities and entertainments provided meet the needs of the people residing at Whitley Bank. The evidence used to make this judgement includes: o Both the leaflet style brochure and the ‘service users guide’ make reference to the home’s efforts to support people on outings, maintain hobbies and interests. Whilst talking to the management team it became apparent that activities and/or outings for people are becoming less frequent due to the increasing dependency and frailty of the people living at the home. DS0000012556.V336192.R01.S.doc Version 5.2 Page 15 o Whiteley Bank House This statement given some weight during the tour of the premise when a number of the service users were found resting in their bedrooms and reliant on staff for their general safety and wellbeing, etc. o However, people were still able to discuss using the garden, during nice weather and a number of tables, chairs and umbrella’s were noticed outside during the tour of the premise and grounds. People also discussed a barbeque, which appears an annual event and the fact that chickens were being introduced to the grounds, which provided something additional to watch. Each bedroom and the lounge was noted to have a television, a payphone is accessible within the main hallway, although it is understood most people use the home’s phone for making calls, radio’s/music systems were in use by some clients during the visit and the home’s pet cat was observed keeping one resident company whilst she rested in her bedroom. o It was also noticed on the home’s white (notice) board that ‘NELLE’ a company that encourages exercise and fitness programmes for the elderly, visits the home weekly, which according to the manager people appreciate. The management team also discussed how some people go out with their family for drives or meals, etc and that the local priest visits weekly, on a Monday to visit the residents. Visiting and Family Contacts: The evidence indicates that people are able to maintain appropriate contact with their families and friends. The evidence used to make this judgement includes: o The home’s brochure leaflet and the ‘service user guide’ both make clear reference to the home’s visiting arrangements: ‘We are proud of the happy family atmosphere that prevails in our home and in this respect visitors are welcome at any time’. o During the fieldwork visit an number of visitors were noted around the home, the inspector able to speak to one person briefly and to establish their satisfaction with the service and the friendly staff. The person also added that they had visited other establishments in and around the Sandown/Shanklin area and that this home had the nicest, friendliest atmosphere. Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 16 o The visitor’s book, maintained within the entrance hallway, provides a good indicator to the numbers of people who visit the home, most people apparently happy to sign into and out of the home, when visiting. The managements comments earlier, about people/families taking their relatives out for drives, etc also suggests that people’s contacts with relatives and friends are appropriate, although improved documentation, within the service user plans, would be a useful way of reflecting the contacts made, etc. o Choice and Control: The evidence indicates that people are encouraged to make decisions for themselves, although this is constrained at time by their physical and mental frailties. The evidence used to make this judgement includes: o The improved care planning system, appears to encourage far more reflection of what the person wants, i.e. their term of address, their preferences for rising and retiring, their involvement in personal care, their leisure activities, etc. People are also being offered a range of choices on a day-to-day basis, meals they eat, where they spend their time (lounge, garden, bedroom, etc), clothes they wear, how their bedrooms are set out and personalised. However, as established earlier within the report people’s increasing dependency, both physically and mentally, does restrict their ability to go out independently (other than in the garden), as does the home’s location, which is not central, as mentioned within the brochure: ‘a truly rural setting’. o People are also provided with choices on entering the home, the contract making it clear that the first month is a trial and people can opt to move or stay after this period should they wish. Choice of GP, from within the local catchment area, geographic restrictions sometimes making it difficult for people to retain the services of their previous GP. Right to self medicate, although at the time of the visit no one was self medicating. Meals and Menus: The evidence indicates that people enjoy a varied diet and are provided with a range of meals. The evidence used to make this judgement includes: Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 17 o o During the fieldwork visit the inspector observed the staff going around to each individual service user and asking them what they wished to eat for tea. Whilst a menu exists, this is clearly only a rough guide, with the residents freely choosing what they wanted without reference to a menu, the teatime selection or range of meals including sandwiches, crumpets, cheese on toast, etc. o In conversation with two clients in the dining room it was quickly established that people often choose different meals at teatime and that the staff seemed happy to prepare what you wanted. People also praised the lunchtime and breakfast meals, although breakfast appeared for most people to be a routine mealtime, with the residents stating that they often stick to the same breakfast day after day, this despite a range of cooked breakfasts, toast and cereals being made available. o Food stocks seen during the fieldwork visit would appear to support the claims of the residents, that a wide choice and/or variety of meals are provided, as the catering materials are good. What is additionally pleasing to see is the inclusion of fresh, home grown vegetables and fruits within the home’s food stocks and area of the grounds set aside for the growing of home produce. Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 16 and 18: People who use the service are able to express their concerns and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. EVIDENCE: Complaints: The evidence indicates that people are both aware of their rights to make complaints and happy to raise issues with the management. The evidence used to make this judgement includes: o The ‘service users guide’ makes reference to peoples rights to make complaints and for any unresolved issues to be brought to the attention of the regulator for mediation. However, some of the copies of the ‘service user guide’, ‘statement of purpose’ and the complaints procedure, will need updating as they do not all contain accurate information in relation to the regulatory body. o The home’s complaints process and/or procedure appears to be reasonable well structured, with a log book available for recording the details of any complaints received and the outcomes following investigation. DS0000012556.V336192.R01.S.doc Version 5.2 Page 19 Whiteley Bank House On reading through the complaints record it was apparent that nothing has been documented since November 2005, whilst it is appreciated that no complaints have been received in that time, as stated by the management team, it could also be construed that the system put in place for the purposes of recording people’s concerns is not being effectively operated despite being well organised/structured. o However, given the feedback from the service users and the views expressed by visitors, it is possible that no complaints or concerns, that could not be immediately addressed, have been received. People praising the staff and the home for the service and expressing their happiness and satisfaction with life at Whitely Bank. Protection: The evidence indicates that people are appropriately protected from abuse and/or harm. The evidence used to make this judgement includes: o o The home’s statement via the Annual Quality Assurance Audit (AQAA) that policies for the protection of the service users are in place. A staff handbook, which is provided to all new staff/employees and includes details of the home’s policies on the safeguarding of vulnerable adults and whistle blowing, under the ‘Public Disclosure Act’. The views of the service users and their relatives, as indicated above. The lack of Adult Protection Investigations or referrals, as established via the ‘Dataset’ and a review of the Commission’s databases. o o Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 19 and 26: The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: Environment: The evidence indicates that the environment is well maintained and meeting the needs of the service users. The evidence used to make this judgement includes: o A tour of the premise was undertaken, which enabled the inspector to ascertain that the property is in a good state of repair, both internally and externally and that the decorative condition of the home is reasonably good, with several rooms recently refurbished and supplied with profiling beds. DS0000012556.V336192.R01.S.doc Version 5.2 Page 21 Whiteley Bank House o The views of the service users were clearly that the home was a pleasant place to live and that it was clean and tidy throughout. People also new the maintenance staff, one pair of residents watching the maintenance personnel building a new chicken run from their bedrooms and joking with the staff about how this was progressing. o Maintenance issues are generally identified by the staff, as they go about their day-to-day activities and are documented/recorded on the white (notice) board, where the maintenance personnel are able to see the jobs that require attention and delete the job once completed. During the tour a couple of items were noted to be recorded on the board, although these were none essential repairs, which according to the management would be addressed in due course. o The AQAA also makes clear that all major domestic services/appliances, gas, electric, etc, are appropriately serviced and maintained. Cleanliness and Hygiene: The evidence indicates that the home is clean and tidy throughout. The evidence used to make this judgement includes: o As mentioned, a tour of the premise was undertaken, when in addition to considering the decorative condition of the home the inspector also monitored the cleanliness of the property, which was good. Domestic staff are employed, with a member of the team available five mornings a week for a minimum of five hours per day. New sluicing facilities have been created on the ground floor, whilst the laundry is housed within a separate building. Infection control policies and procedures, are according to the information taken from the AQAA, made available to staff. o o o Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 27, 28, 29 and 30: Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: Staffing numbers: The evidence indicates that sufficient staff are employed to meet the needs of the service users. The evidence used to make this judgement includes: o The home’s duty roster indicate that a minimum of two staff are on duty across the twenty four hour period: AM. Two carers 08:00 hrs to 14:00 hrs PM. Two carers 14:00 hrs to 18:00 hrs Evening. Two Carers 18:00 hrs to 21:00 hrs Night. Two carers 21:00 hrs to 08:00 hrs, one of the two is a sleep-in carer. o The staff confirmed that they are a relatively new team, given one or two changes in personnel recently, however, they feel they have gelled well DS0000012556.V336192.R01.S.doc Version 5.2 Page 23 Whiteley Bank House and work together in the best interests of the service users, whom they have developed good relations with. Two newer staff, who were on duty during the inspection, also said that they enjoyed working at the home and had been supported in learning the role, routines and completing their induction programmes. o Observations during the visit supported the statement that the team works well together, people sharing roles, completing tasks without undue difficulty and seemingly available to meet the needs of the service users, or address questions raised by the service users relatives. At the time of the fieldwork visit, three care staff and two members of the management team were on duty or available. When the inspector queried the reason behind the additional staffing numbers, it transpired that a long-term resident was due to return from hospital and the additional staff member was a senior who had worked the early shift and who had stayed on to support the two junior staff with the extra work created by the re-admission. o Training and Development: The evidence indicates that the staff training opportunities are reasonably good. The evidence used to make this judgement includes: o 1. 2. 3. 4. 5. 6. o Information included within the AQAA identifies that staff have received training in the following areas: First aid Moving and handling Food hygiene Infection Control Managing Challenging Behaviour Dementia Awareness This declaration was supported by findings during the fieldwork visit, when it was noticed, whilst reviewing the staffing files, that a large number ‘BVS’ training video’s were available/accessible. The management team also described how, via training videos and questionnaires, the staff are kept updated on issues such as, food hygiene, moving and handling, etc. The inspector able to talk briefly with the home’s and/or companies training co-ordinator about the courses she runs/oversees and to the staff to confirm that they have attended sessions, as listed above. o Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 24 o The inspector also noted on the employment files reviewed, competed ‘Skills for Care’ induction booklets, ‘Skills for Care’ being the sector skills council for the social care field. Information taken from the AQAA and confirmed during the visit, also indicates` that currently all but one employee has completed a National Vocational Qualification (NVQ) at level 2 or equivalent qualification and that several staff having also completed level 3 NVQ. o Recruitment and Selection: The evidence indicates that the recruitment and selection process is now being appropriately operated. The evidence used to make this judgement includes: o At this visit the file of the last person (only person employed since the last inspection) was reviewed and found to contain the following information: 1. 2. 3. 4. 5. 6. 7. 8. 9. o An application form Two written references Dates of employment Protection Of Vulnerable Adults (POVA) clearance Criminal Records Bureau (CRB) check outcome Induction details Photo Identification Contract Interview questions and responses. In discussion with the staff it was confirmed that they had completed an induction, as mentioned above, and that they had undergone a reasonable recruitment process, the roles they had applied for being learnt about via the advertising and/or word of mouth and that each person had receive a copy of the home’s employment handbook. The dataset establishes that a recruitment and selection strategy/procedure exists to support the management staff when employing new staff. o Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 31, 33, 35 and 38: The management and administration of the home is based on openness and respect, and has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: Management: The evidence indicates that the home is currently being managed to a satisfactory standard. The evidence used to make this judgement includes: o Information taken from the last inspection report suggests: Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 26 ‘The proprietor/manager has proved herself a competent manager of the home with many years of experience in providing care for older people. She has been in her position since 1984. The manager/proprietor does not intend to gain the NVQ level 4 in care or the Registered Manager’s Award. The home has recently appointed a new member of care staff who has NVQ level 4 in care and is an NVQ assessor. Once settled in post the proprietor/manager stated she would consider future training needs of this person that may include the Registered Manager’s Award. The proprietor/manager maintains a hands on approach with residents and throughout the inspection it was evident that she had a good knowledge of individual residents, demonstrated when she assisted a resident to walk to the dining room for a private discussion with the inspector. Staff and residents all stated that they felt able to discuss any concerns with the proprietor/manager and were confident that any issues would be resolved. The manager provides an on call arrangement when not present in the home’. o The information contained within the last inspection report, would appear to mirror most of the findings of this visit and inspection process, with the management team, clearly maintaining an understanding of the service users needs and the day-to-day operation of the home. Quality Audit and Assurance: The evidence indicates that service users and/or their relatives are afforded the opportunity to comment on the service provided at the home. The evidence used to make this judgement includes: o Information already presented within this report, which indicates that people have their rights to comment on the service and influence the care and provision they receive include: 1. The improved care planning system, which appears far more focused on the persons’ individualised wishes. 2. Meals and menus, which are clearly influenced by the resident on a daily basis. 3. People had clearly been involved in the setting up or decorating and personalising their bedrooms. 4. The management teams rapport with the service users and their relatives, who clearly, from observations, find it easy to approach and discuss issues with the management. 5. Care plans that were reviewed and updated monthly. o It would however, be an idea to introduce a more formal feedback or auditing system for use with residents and/or their families, a questionnaire might be a useful tool. DS0000012556.V336192.R01.S.doc Version 5.2 Page 27 Whiteley Bank House o It is also worthwhile remembering that occasionally the management should audit documents such as the medication records, this might element errors, such as those found during the visit. Service users finances: The evidence indicates that the arrangements within the home promote independent when managing finances. The evidence used to make this judgement includes: o The home does not get involved with the residents’ finances. Fees are usually paid through direct debit from the residents’ bank. Personal allowances are held by the resident and spent how they wish, or by the relatives on their behalf. Health and Safety: The evidence indicates that the health and safety of the service users and staff is being reasonably well managed. o The AQAA and dataset information establishes that full health and safety policies/guidance documents are made available to the staff and that equipment is regularly maintained and serviced, gas, electrical installations, portable electrical appliances, hoists, baths, etc. Health and safety training is clearly made available to staff, with the AQAA evidencing that staff have completed moving and handling, infection control and first aid training recently. • Maintenance issues are also being appropriately identified and recorded by staff and responded to within a reasonable time period by the maintenance personnel, as demonstrated by the white board and well maintained premises. o Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 29 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 OP9 Regulation Requirement Timescale for action 01/08/07 Regulation The management take steps to 13 ensure that the medication administration records are accurately maintained. This will aid visit health professionals when assessing a persons’ medication habits and prevent errors when dispensing and administering medicines to residents. 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 OP33 Good Practice Recommendations The management should consider introducing more formalised auditing and quality assurance systems. Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Whiteley Bank House DS0000012556.V336192.R01.S.doc Version 5.2 Page 31 - 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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