Inspection on 28/03/07 for Whitewater Road

This inspection was carried out on 28th March 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Whitewater Road 17/09/07

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Whitewater Road 1A - 1B Whitewater Road Ollerton Newark Nottinghamshire NG22 9XF Lead Inspector Stuart Hannay Key Unannounced Inspection 28th March 2007 09:30 Whitewater Road DS0000068818.V333866.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 Whitewater Road DS0000068818.V333866.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. Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitewater Road Address 1A - 1B Whitewater Road Ollerton Newark Nottinghamshire NG22 9XF 0115 969 1300 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) www.mencap.org.uk Royal Mencap Society Post Vacant Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Royal Mencap Society is registered to provide accommodation and personal care at 1a/1b Whitewater Road, Ollerton, Newark, Nottinghamshire NG22 9XF for a maximum of 12 people whose primary care needs fall within the following numbers and categories: Learning Disabilities (LD) 12 Date of last inspection Brief Description of the Service: Whitewater Road is located in a residential area close to shops and other amenities. It provides personal care to 12 people with learning disabilities between the ages of 18 and 65. The home consists of two bungalows with 12 single bedrooms and is fully equipped to care for a number of people with physical disabilities. The home has been registered with its new owners since November 2006. Charges range from £343.00 to £388.00 per week. Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection started at 9.30 a.m. and lasted for six hours. The main methodology of inspection is called case tracking, which means selecting a number of service users, spending time with them, looking at records and talking to staff and relatives about the experiences of support offered by the home. In addition, other information supplied to the commission is also used to evidence compliance with the Care Home Regulations. The service users were not able to verbally describe how they felt about the service. Time was spent in the home’s lounges observing care practices with two service users in their bungalow but formal interviews were not conducted. Most of the service users were attending day services away from the home. One care officer and one care assistant were interviewed: the home’s manager, who is not yet registered with the Commission For Social Care Inspection, assisted the inspector throughout the day. A range of records was checked: three service users’ plans, staff training records, fire safety records and the recruitment records of two staff members. The medication storage and administration records were checked. A partial tour was made of the premises to check the environment and décor in the communal areas and in the service users’ private rooms. What the service does well: There was a relaxed atmosphere in the two bungalows; staff spoke with the service users in a friendly but non-patronising manner; they were clearly aware of the service users’ needs and wishes and how they expressed themselves. All of the service users have lived at the home for many years, the most recent admission being around 10 years before the current inspection. Most of the service users took part in structured activities throughout the week. Written information about the service users was comprehensive and their changing needs were regularly reviewed. Staff interviewed displayed a very good understanding of the service users’ needs and had received a range of training relating to the needs of the service users. They had had most of the required statutory training. They said that they found the managers to be approachable and supportive. Comprehensive checks had been made on staff when they were recruited and there is a detailed induction programme for new starters. The home was clean and tidy. Effort had been taken to ensure that there is a ‘homely’ feel to the building, including the bedrooms, which were pleasantly decorated and furnished. Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 6 Medication was securely stored, staff could only administer it after they had been fully assessed. The records of its administration had been wellmaintained. 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. Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 7 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. Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A full assessment is made of potential service users prior to them coming to the home to ensure that the service is suitable and their needs could be met. Information for potential and existing service users needs to be updated to ensure that they have full information about the home. EVIDENCE: There have been no new admissions to the home for several years. Full assessments of service users’ needs had been made in the three service users’ plans that were checked. Staff interviews indicated that the staff had good knowledge of the service users needs. MENCAP have created a new Statement of Purpose for the home but the Service User’s Guide has not yet been changed and some of the information in the documents was contradictory, such as the complaints procedures. A review of the dependency levels of the service users is being undertaken as most of the service users have been at the home for many years and their needs have changed. Whitewater Road DS0000068818.V333866.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 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All the service users have a care plan, which identifies levels of support and how to reduce the risk of harm to the service users. Service users have choice of how they spend their time and are based around their preferences. The plans are reviewed to ensure information is up to date. EVIDENCE: Three service users plans were checked in detail. The care plans identified what assistance the service users needed and what staff needed to do to meet these needs. The risk assessments were comprehensive and reviewed up-todate and focused on service users being able to participate in normal daily life as much as possible. Their health and personal care needs had been assessed and any contacts with health professionals were recorded, including any prescribed treatments. Whilst none of the service users whose plans were checked had been able to fully contribute to the plan, their wishes and needs appear to have been Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 11 ascertained from them and other people important to them. The home is in the process of implementing a new care planning system to make them more accessible to service users and to create more ‘person centred plans’. Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff members support the service users in attending social and occupational activities outside of the home. Families and friends can visit the home at any time. There was information about service users dietary needs and preferences. Staff felt that there was not enough time to do as many social activities with service users as they would wish. EVIDENCE: On the day of the inspection ten of the twelve service users were attending a day centre. Social activities take place mostly in the evenings and weekends and include trips to the cinema, the pub and bowling. Service users’ care plans contained information about their preferred activities and what support they needed to be able to do them. Three staff members interviewed felt that the increasing dependency of the service users meant that they could not always provide social activities in line with the service users’ wishes. They also felt that the amount of cleaning and Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 13 cooking tasks that they were required to do prevented them from doing more activities with service users. Staff said that they sometimes had to postpone events, for example one service user was not able to do an activity on his birthday. Staff said that the service users have relaxed routines whilst at the home and can generally choose when to go to bed and when to get up, although they said that they are encouraged to go to bed at a reasonable time if they have to attend their day services on the following day. This was also recorded in the care plans checked. The two service users at home on the day of the inspection appeared relaxed and ‘at home’. They were using the communal areas of the home, sitting with staff. Staff communicated with them in a friendly way and they clearly felt comfortable in their presence. The service users’ plans checked contained information about their preferred foods and any special dietary needs. Meals were prepared by the staff and two staff interviewed said that they had up-to-date food hygiene training. There were printed menus in the kitchen and these offered a variety of home cooked meals, as well as giving the service users the opportunity to have a takeaway meal once a week if they wanted it. The manager said that whilst the staff felt that they knew the service users’ food preferences extremely well, they were looking at ways of increasing their involvement in the choice of meals, for example by providing photographs of different foods. Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ plans identified what personal care and healthcare they needed and how it should be provided. The care plans included information on the service users’ physical and emotional needs and described how staff could ensure these needs were met. Medication was safely stored and administered but the home’s pharmacist needs to check the system regularly. EVIDENCE: Three service users’ plans described clearly what personal care they needed and how they would want it to be delivered. The plans had been regularly reviewed by the key workers and the senior staff to ensure that health and personal care needs are being met. Service users’ health care needs had been clearly identified and monitored. All contacts with other professionals had been documented and prescribed treatments adhered to. Service users had been assessed as to whether they can look after their own medication but it was felt that there were no service users at present who could safely do this. The medication storage system was checked in both bungalows and medication was securely stored. All the prescription information was clearly visible on Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 15 bottles and boxes and the records of administration were fully completed with no gaps on the recording sheets. The home’s system had not been checked by the supplying pharmacist in the previous 6 months. Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a clear complaints policy, which service users or their relatives could use to raise any concerns about the service. Staff interviewed had undertaken training on the recognition and reporting of abuse and there were procedures in place to protect vulnerable adults. EVIDENCE: MENCAP has a complaints procedure, which includes timescales for the resolution of complaints and identifies other avenues of complaint for service users and their families. There is a pictorial format for service users who cannot use the written documentation. No complaints had been received about the service since the previous inspection. Copies of the complaints format had been sent to each relative involved with the care of the service users. Two care workers were interviewed, one had worked at the home for over 10 years and one had started within the previous two months. The experienced staff member had undertaken adult protection training and the new staff member was undertaking an induction course, which included the promotion of dignity and respect towards service users and the need to report any concerns. The home has adult protection procedures in place; there had been no allegations at the home since the previous inspection. A recent incident between service users had been appropriately reported to the adult protection team. Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 17 Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 18 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, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well-maintained and well-decorated, ensuring a pleasant and homely environment for the service users. Their bedrooms were highly personalised, decorated and furnished to a good standard. Specialist equipment was provided in bathrooms and bedrooms. EVIDENCE: Twelve bedrooms were checked during the inspection. Each of these was decorated differently, in line with the service users’ preferences. There were pictures and ornamentation in line with their personal taste. Carpets and flooring in the bedrooms were in good condition. The care workers are responsible for cleaning the home and both houses were clean and tidy in the private and communal areas. There was a pleasant, wellmaintained garden area, accessible to the service users. The communal areas were very ‘homely’ and non-institutional in appearance. Hoists and other Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 19 moving and handling equipment was provided in bathrooms and bedrooms for service users who needed assistance. Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 20 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, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team were experienced with a good knowledge of the service users’ needs and had undertaken a range of training related to the care of people with learning disabilities. Checks had been made on the staff to ensure that vulnerable service users were protected. EVIDENCE: The staffing rotas and the staff team were flexible in order to ensure that the needs of the service users could be met. Staff members interviewed said that levels of staff were maintained at four on each day shift and two at night. Staff members interviewed felt that the increased levels of dependency of the service users was affecting their ability to involve them in as many activities outside of the home as in previous years. Staff had undertaken a range of courses related to understanding the needs of the people they worked with. One new staff member was undergoing a thorough induction programme and felt well supported through this. Most staff had received a range of statutory training including manual handling training, first aid and food hygiene. An overview of staff training had been made and had identified that some mandatory training had not been provided for some Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 21 staff members. Training sessions had been booked to ensure that the identified training would be provided for these staff in the forthcoming months. Checks were made on staff when they were recruited in order to protect the service users; records showed that Criminal Records Bureau checks and POVA checks had been made on all the staff at the home. The recruitment records of two new staff members were checked. All the required information was now kept on site, including application forms, proof of identity and written references from previous employers. A system for the formal supervision of staff had been established but had not yet been fully implemented. Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The acting manager is currently carrying on the day to day running of the home without being registered, therefore service users do not benefit from the ethos, leadership and appropriate management of the home. Some staff required updated fire training and the home was storing some equipment inappropriately in the boiler room. EVIDENCE: The acting manager is currently carrying on the day to day management of this service without registration and this is an offence againstWhilst it was difficult to verbally ascertain the views of the service users on the day of the inspection, the interaction between the service users and the staff seemed mutually friendly and respectful. Staff clearly understood the service users when they made requests or expressed their feelings using non-verbal communication. The care plans had been created and reviewed using information obtained from family members and other professionals. Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 23 Staff interviewed felt that the managers of the service were approachable and supportive. They said that they would have no hesitations in raising concerns about the service with them. Fire safety records were completed to a good standard and staff interviewed were able to clearly describe the action to be taken in the event of a fire. One person who had recently started at the home said that she had been instructed in what to do in the event of a fire and could describe the procedures. An outside contractor had checked the fire system within the previous 12 months. The fire training records indicated that there were three staff members who had not had training in the previous 12 months. Regular monthly visits had been made by the company to the home to ensure standards were being maintained. In February 2007 a detailed quality audit was made at the home by MENCAP which identified areas of good practice and areas for improvement. The building was generally safe, however items such as a wheelchair and a quilt were being stored in the boiler room in ‘Conifers’ bungalow, which may constitute a fire risk. Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 24 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 2 2 3 3 2 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 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 1 3 X X 2 X Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA1 YA3 Regulation Schedule 1 Requirement Timescale for action 01/08/07 01/08/07 3. YA14 4. 5. 6. YA20 YA35 YA37 7. YA42 The Service User’s Guide must be updated to include all new information about the home. 12 (a) A review of of the dependency and (b) levels of service users must be completed to ensure that the and 18 needs of the service users can be met with the existing staffing levels. 18 and 12 A calculation of staffing levels (b) must be completed in relation to the dependency levels of service users needs to faciltate activities of their choice. 13 (2) The medication system and storage must be checked by the home’s pharmacist. 18 (1) (c) All staff must undertake updated training in moving and handling, first aid and fire safety. Part II ‘Any person who carries on or CSA 2000, manages an establishment 11 without being registered under this Part(of the Act) shall be guilty of an offence’ 13 (4) (c) The boiler rooms at the home must not be used as storage areas. 01/09/07 01/08/07 01/09/07 01/05/07 01/05/07 Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 26 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 YA36 Good Practice Recommendations The home should ensure that the new staff supervision system is fully implemented. Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Whitewater Road DS0000068818.V333866.R01.S.doc Version 5.2 Page 28 - 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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