Inspection on 21/01/04 for Whitwood Hall

Care Homes For Adults (18 ­ 65)Whitwood HallWhitwood Lane Castleford West Yorks WF10 5QDUnannounced Inspection21st January 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Whitwood Hall Address Whitwood Lane, Castleford, West Yorks, WF10 5QD Email Address Tel No: 01977 667200 Fax No:Name of registered provider(s)/Company (if applicable) Mr Michael Wheatley Name of registered manager (if applicable) Miss Diane Palmer Type of registration Care Home No. of places registered (if applicable) 16Category(ies) of registration, with (number of places) Learning disability (16) Registration number J010000068 Date First registered 21 March 2000 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 11th September 2003 YES NO 13/06/03 If Yes Refer to Part CWhitwood HallPage 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector 1 2 321st January 2004 11 am Tony Railton Not Applicable Not Applicable Not ApplicableID Code073592Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at the time of inspectionNone Present Not Applicable John Baldwin (Senior Support Worker) Simon Howson (Senior Support Worker)Whitwood HallPage 2 CONTENTSIntroduction to Report and Inspection Inspection visits Description of service Part A: Summary of Inspection Findings Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods Used & Findings The Standards. National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration ( if applicable) Lay Assessors summary (where applicable) Providers Response Providers comments Action Plan Providers agreementWhitwood HallPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the NCSC in respect of Whitwood Hall. The inspection findings relate to the National Minimum Standards (NMS) for Care Home published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000 and the Children Act 1989 as amended. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Whitwood HallPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Whitwood Hall provides personal care for 16 adults who have a learning disability. The home is situated on the outskirts of Castleford between Whitwood and Altofts. Set back in its own grounds the Whitwood Hall provides three self contained units. There is a large drive with parking to the front and two large walled gardens to the rear. Each unit has its own lounges, kitchen, dining room and conservatory and the home provides single private accommodation for all 16 service users. The home does not provide any aids or adaptations and does not provide care for those with physical disabilities. The care provided by the home is based on ordinary living principles and there is an expectation that service users do as much for themselves as possible. Service users are supported and encouraged to take full advantage of local community based amenities and facilities. The home is on a main bus route and is close to the M62 & M1/A1 motorway system.Whitwood HallPage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) On the day of the inspection it was noted that the registered manager has resigned. The providers have identified a senior support worker to manage the home on a temporary basis until a replacement can be found. Despite the absence of the registered manager the care management and staff support systems are been maintained. The senior support workers appeared confident, capable and comfortable throughout the inspection. The inspector was pleased to see that the home had complied with the majority of the recommendations made following the previous announced inspection. However, there are still a number of outstanding requirements. This was an enjoyable and positive inspection and the inspector would like to thank service users, care staff and senior support workers for their hospitality and co-operation throughout the inspection. Choice of Home (Standards 1-5) 4 of these 5 standards were met and 1 not inspected on this occasion. Service users personal care needs are assessed before admission. However, the home provides a comprehensive assessment system which includes behavioral and risk assessments. Service users are invited to `test drive the home before admission and all are provided with a written and `costed contract. Individual Needs and Choices(Standards 6-10) 4 of these 5 standards were met and 1 almost met. All service users have care plans that reflect their assessed care needs. All care plans are reviewed and updated on a regular basis. The inspector observed the interaction between service users and care staff and the positive relationships being fostered. Service users are continually asked their opinion about what they want to do The care provided by the home is based on ordinary living principles and there is an expectation that service users do as much for themselves as possible within a risk management framework. Senior support staff said that service users are part of the staff selection and recruitment processes, however, the home should consider ways of recording service users involvement and in particular any contributions or comments they may make.Whitwood HallPage 6 Lifestyle (Standards 11-17) 6 of these 7 standards were met and 1 almost met Care staff are to be commended for their efforts in ensuring that service users are part of the local community. Service users are encouraged and enabled to take full advantage of ordinary community based leisure facilities. Some service users work on a voluntary basis in local charity shops and one service user is currently in paid employment. The inspector is convinced that service users are given opportunities to decide what they want to do on a regular basis, indeed this is part of the philosophy of care provided by the home. However, there remains very little documented evidence of this. The daily records would benefit from the use of descriptive words to reflect service users choices and preferences on a day to day basis. Personal and healthcare Support (Standards 18-21) 3 of these 4 standards were met and 1 almost met. Service users are encouraged and supported to use ordinary community based healthcare services. Having said this, a number of service users health is monitored by hospital based consultants. The home has a good working relationship with specialist Learning Disability Teams and there is specialist advice and support available if required. To comply fully with minimum standards and as a matter of good practice a key coding system should be developed to indicate when service users have missed or refused to take prescribed medication. Concerns, Complaints and Protection (Standards 22-23) 2 of these 2 standards were met The home continues to provide a Complaints Policy and Procedure which forms part of the induction training for mew staff and includes the name address and telephone number of the National Care Standards Commission. The home also provides an Adult Abuse and Protection Policy and Procedure which includes `Whistle Blowing. Environment (Standards 24- 30) 7 of these 7 standards were not inspected on this occasion. Staffing (Standards 31-36 ) 4of these 6 standards were met and 2 almost met. All staff with the exception of the manager have a job description. To comply fully with minimum standards a job description should be provided for the manager to reflect their role and responsibilities outlined in the Care Homes Regulation 2001. Senior support workers said that they know a job description has been provided for the manager , however, it was unavailable for inspection. Staff training has a high profile in the home and a training Matrix indicates what training staff need and what they have received. Despite the absence of the registered manager staff still receive regular line management Whitwood Hall Page 7 supervision, and there are regular staff meetings. To comply with minimum standards fully the home should ensure that all staff have copies and are familiar with the codes of conduct and practice set out by the General Social Care Council. Conduct and Management of the Home (Standards 37-43) 4 of these 7 standards were met, 1 almost met and 2 not met The registered manager has resigned and the providers are currently advertising for a replacement. The providers have identified a senior support worker to manage the home as a temporary measure. Despite the absence of the registered manager senior support workers have done well to maintain the care management and staff systems in the home. Staff are receiving regular line management supervision and the providers are supervising senior support workers. The management systems continue to provide an open and inclusive atmosphere and on the day of the inspection staff appeared confident and service users were relaxed and comfortable. The providers need to provide a report as part of the quality assurance monitoring system which reflects the views of service users, their families and other stakeholders. The information gathered as part of quality assurance monitoring needs to be collated and a report provided indicating any changes to the way the home runs as a result of service users surveys. A business and financial plan also needs to be provided and available for inspection by the National Care Standards Commission.Whitwood HallPage 8 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for action 1 24 (1)(2) YA39 Collate the information gathered as part of quality assurance monitoring and provide a report indicating any changes to the running of the home and to reflect service users views. The providers need to send a copy of the monthly report about the running of the home to the National Care Standards Commission. 1 Sept 03226 (1)(2)(3)& (4)YA361 Sept 03Action is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 YA16 Service users choices and preferences should be reflected in the daily records.CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). Not ApplicableMET (YES/NO)Whitwood HallPage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, the National Minimum Standards and the relevant sections of the Childrens Act. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action 1 26 (1)(2)(3)(4) YA36 The home needs to send a copy of the Regulation 26 meetings between the provider and the manager of the home to the National Care Standards Commission. 1 March 04224 (1)(2)YA39A report needs to be provided which reflects the views of service users, their relatives, other stakeholders and any changes to the 1 April 04 running of the home as a result of quality assurance monitoring. There needs to be an annual business and financial plan available for inspection. 1 April 04325 (2)(3)YA43RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard * 1 2 YA16 YA8 Service users choices and preferences should be reflected in the daily recording systems. A record should be made of service users participation and any contributions they make to the recruitment and selection process. A `key should be provided to indicate the coding system to be used on the medicine record sheets when service users refuse or miss their medication. Page 103YA20Whitwood Hall 4YA31A job description should be provided for the manager of the home which reflects their role and responsibilities outlined by the Care Homes Regulations 2001. Care staff should be familiar with the codes of practice and conduct issued by the General Social Care Council. The home should have a registered manager.5 6YA34YA31 YA37* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.Whitwood HallPage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs) YES YES NO YES YES NO NO NO YES YES YES NO YES NO YES NO NO YES NO YES 7 0 0 NO NO YES NO 25 0 21/01/04 11.00 4Whitwood HallPage 12 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Whitwood HallPage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives, philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. X X Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are Key findings/Evidence Not inspected on this occasion.Standard met?0Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user using an appropriate communication method, and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? All service users have a comprehensive assessment. All service users are admitted following an assessment by the placing authority. The home however, has a very good and comprehensive assessment system which complements and builds on existing service users assessments. Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? Examination of service users case notes, assessments, care plans, reviews and daily records the home can demonstrate its capacity to meet service users care needs.Whitwood HallPage 14 Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis, before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? Service users are encouraged and supported to visit and `test drive the home before admission. Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 3 Key findings/Evidence Standard met? Each service user has written and `costed contract with the homeIndividual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? All service users have care plans developed following a comprehensive assessment of their personal, emotional, behavioural and healthcare needs. All service users have a key worker who provide a progress report once a month and attend regular six monthly multidisciplinary reviews.Whitwood HallPage 15 Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions and that right is limited only through the assessment process, involving the service user and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? The care provided by the home is based on ordinary living principles and there is an expectation that service users make decisions about their day to day lives. However, service users do so within a risk assessment framework and any restrictions are agreed and appropriately recorded. Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day-to-day running of the home and to contribute to the development and review of policies, procedures and services. 2 Key findings/Evidence Standard met? Through discussion with the senior support workers it was established that service users have recently been involved in the staff selection and recruitment process which is to be commended. However, to comply fully with standard 8.3 a way of providing evidence and a method of recording service users participation along with any comments they may make should be considered. Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? Service users are supported to take risks as part of an independent lifestyle Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998 and in the best interests of the service user. 3 Key findings/Evidence Standard met? The home has a confidentiality policy and procedure which forms part of the induction training for new staff. All staff sign as part of their employment contract a confidentiality statement. Information about service users is handled appropriately and their confidences kept.Whitwood HallPage 16 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? The care provided by the home is based on ordinary living principles which includes providing opportunities to learn and develop practical life skills. Service users care plans and activity programmes reflect the opportunities for personal development. Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities 3 Key findings/Evidence Standard met? The home has one service user who is currently employed by a local supermarket. There are others who work on a voluntary basis at local charity shops. Service users are encouraged and supported to take part in age, peer and culturally appropriate activities.Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? The philosophy of the home is one of inclusion and service users are encouraged and supported to participate in ordinary community based amenities and facilities. Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to and choose from a range of appropriate leisure activities. 3 Key findings/Evidence Standard met? Service users have the opportunity to participate in appropriate, ordinary, community based leisure activities.Whitwood HallPage 17 Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Service users are encouraged and supported to maintain family links and develop new personal relationships. Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 2 Key findings/Evidence Standard met? Service users rights are respected and responsibilities recognised in their daily lives. However, there appears to be limited, documented evidence of this. To comply fully with this and in particular standard 16.7 service users individual choices and preferences should be reflected in the daily records.Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Service users are encouraged and actively supported to help plan, prepare and serve meals as part of living an ordinary lifestyle.Whitwood HallPage 18 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes policies and procedure for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? Personal support is provided in private and intimate care by a person of the same gender. Service users have guidance and support regarding personal health and hygiene and there are opportunities for additional specialist support for example from Community Learning Disability Nurses or Specialist Social Workers. Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No of service users with pressure sores at the time of inspection (from information taken from care notes) 103 Key findings/Evidence Standard met? Service user are supported to take full advantage of ordinary community based healthcare services. There are also other specialist healthcare professionals available and accessed if the need arises.Whitwood HallPage 19 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 2 Key findings/Evidence Standard met? To comply fully with this standard and in particular standard 20.6,the home should develop the medicine record sheets to include a `key to the coding system used for when service users refuse or miss medication. Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 3 Key findings/Evidence Standard met? The aging, illness and death of a service user are handled with respect and as the individual would wish.Whitwood HallPage 20 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure which includes the stages of and times-scales for the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days 0 0 0 0 0 0 0 3 Key findings/Evidence Standard met? The home provides a complaints policy and procedure which forms part of the induction of new staff and includes the name, address and telephone number of the National Care Standards Commission.Whitwood HallPage 21 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence, or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES03 Key findings/Evidence Standard met? The home provides an adult abuse and protection policy and procedure which includes `whistle blowing and forms part of the induction training for new staff.EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Whitwood HallPage 22 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence Not inspected on this occasion. YES NO NO 0 0 0 0 Standard met? 0 0 00 0 0 0Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Key findings/Evidence Not inspected on this occasion. Standard met? 0Whitwood HallPage 23 Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 0 Key findings/Evidence Standard met? Not inspected on this occasion. Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 0 Key findings/Evidence Standard met? Not inspected on this occasion. Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 9 Key findings/Evidence Standard met? Not applicable. The home does not provide care for service users who require any aids or adaptations.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of inspection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Whitwood HallPage 24 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 2 Key findings/Evidence Standard met? On the day of the inspection it was established that there are job descriptions provided for all staff with the exception of the manager. To comply with minimum standards fully and in particular 31.1 a job description should be provided for the manager which reflects their role and responsibilities outlined in the Care Homes Regulations 2001. To comply with standard 31 care staff should be familiar with the codes of practice and conduct issued by The General Social Care CouncilWhitwood HallPage 25 Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 15 0 0 0 7 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided 0 0 0 1,050 Nursing 0 0 0503 Key findings/Evidence Standard met? Staff training has a high profile in the home. The induction of new staff reflects National Training Organisation specification most staff have National Vocational Qualification Level two or above. There is other relevant training provided and there is also a small library provided for staff which includes NVQ Handbooks and information about caring for adults with learning disabilities. Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. 3 Key findings/Evidence Standard met? Regular staff meetings are held and all staff receive six line management supervision sessions per year. Senior support workers are to be commended for their efforts in maintaining staff supervision in the absence of the registered manager.Whitwood HallPage 26 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? The staff selection and recruitment processes remain good, however , to comply fully with minimum standards and in particular standard 34.5 all staff should be given copies of the codes of conduct and practices. Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? The home provides a staff training Matrix which identifies the training undertaken by care staff. It also identifies future training needs and in particular mandatory training. Each staff member has a training profile which is reviewed at supervision. Induction training reflects Sector Skills Council workforce training targets and is currently under review and may be amended to include Learning Disability Award Framework material.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? Despite the absence of the registered manager the senior support staff continue to provide line management supervision for care staff. The home has procedures for dealing with aggression and staff receive regular training and update training which is recorded in staff training files.Whitwood HallPage 27 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care or equivalent. NO2 Key findings/Evidence Standard met? The registered manager has recently resigned. A senior support worker has been identified as a temporary measure and the owners are currently advertising for a qualified manager for the home. On the day of the inspection it was noted that there are support systems in place for the supervision of care staff and senior care workers are supported by the providers.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? On the day of the unannounced inspection it was noted that there was a relaxed and comfortable atmosphere created in the home. Senior support workers appeared confident and along with care workers clear about their roles and responsibilities. Service users also appeared happy, relaxed and comfortable. Service users appeared to be benefiting from the ethos, leadership and management of the home.Whitwood HallPage 28 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems based on seeking the views of service users are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 1 Key findings/Evidence Standard met? A report still needs to be provided which reflects the views of service users, their relatives and other stakeholders. The report should also indicate any changes made to the way the home runs as a result of any comments made. This recommendation is outstanding from previous inspections. The inspector acknowledges that the home currently does not have a registered manager. Nevertheless, efforts should be made to `complete the quality assurance `cycle by collating the information already gathered through quality assurance surveys. To comply with the Care Homes Regulations, Regulation 24 (1)(2) a report needs to be produced and published. Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Younger Adults. 3 Key findings/Evidence Standard met? Service users rights and best interests are safeguarded by the homes policies, procedures and practices. Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained up to date and accurate. 3 Key findings/Evidence Standard met ? Service users rights and best interests are safeguarded b the homes record keeping policies, procedures and practices. Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? The health and welfare of service users and staff are promoted and protected by the homes health and safety policies, procedures and practices. Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 1 Key findings/Evidence Standard met ? On the day of the unannounced inspection service users finances were been appropriately administered. However to comply with minimum standards , standard 43.2 and the Care Homes Regulations 2001, and in particular Regulation 25 (2) (3) there needs to be a business and financial plan available for inspection.Whitwood HallPage 29 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateTony Railton Ruth Rainey 13 April 2004Signature Signature SignatureWhitwood HallPage 30 PART D(where applicable) N/aLAY ASSESSORS SUMMARYLay Assessor Date Public reportsNA NASignatureNAIt should be noted that all NCSC inspection reports are public documents.Whitwood HallPage 31 PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 21 January 2004 of Whitwood Hall and any factual inaccuracies: Please limit your comments to one side of A4 if possibleWhitwood HallPage 32 Action taken by the NCSC in response to provider comments: Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. E.2 Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther:Whitwood HallPage 33 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I of Whitwood Hall confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I of Whitwood Hall am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Whitwood HallPage 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!