Inspection on 23/06/04 for Whitwood Hall

Care Homes For Adults (18 ­ 65)Whitwood HallWhitwood Lane Castleford West Yorks WF10 5QDUnannounced Inspection23rd June 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 30th July 2002 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 21/01/04 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 323rd June 2004 11:00 am Tony Railton Not Applicable Not Applicable Not ApplicableID Code073592Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionNone Present Wayne Barker (Acting Manager) Emma Wheatley (Owners Representative)Whitwood HallPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings 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: D.1. D.2. D.3. Compliance with Conditions ( if 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 Commission for Social Care Inspection (CSCI) 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 CSCI in respect of Whitwood Hall. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) 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 CSCI 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 · 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. 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 residential and personal care for 16 people who have a learning disability. The home is situated on a country road on the outskirts of Castleford between Whitwood and Altofts. Set back in its own grounds the home is split into three separate units each having its own entrance, lounge, dining room, kitchen and bathing facilities. All accommodation offered is single and the ethos and philosophy of the home is based on ordinary living principles. Service users are encouraged and assisted to do as much for themselves as possible. There is also an expectation that service users take full advantage of local ordinary community based leisure and healthcare services. Whitwood Hall offers care to those who may have behaviours which challenge ordinary residential provision and the staffing ratios provided reflect this. The home is on a main bus route and very close to the M62 and M1/A1 link roads.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 unannounced inspection the inspector was pleased to note that the home continues to meet all of the statutory requirements and nearly all the minimum standards. The care management systems in the home are maintained to a good standard and in particular the behavioral assessments daily recording systems. However, on the day of the inspection it was established that there are some aspects of the physical environment which require attention. The inspector would like to thank the acting manager, support workers and service users for their patience and co-operation throughout this very enjoyable and positive inspection. Choice of Home (Standards 1-5) 4 of these 5 standards were met and 1 almost met. The home continues to provide a Statement of Purpose and Service users Guide and provides all of the information required for prospective service users and their families to make an informed choice about the home. There are no unplanned admissions to the home and all service users personal support and care needs are fully assessed before a placement is offered. All service users have a contract / terms and conditions, however, these are maintained centrally. To meet minimum standards fully a copy of the service users contracts should be maintained in their personal files. On the day of the inspection the inspector was impressed with the good quality of the daily recording systems in the home which are full of descriptive words to indicate and reflect service users choices, preferences activities undertaken and medical health and appointments. Individual Needs and Choices(Standards 6-10) 4 of these 5 standards were met and 1 almost met. All service users have a comprehensive assessment of their personal care and support needs. Service users care plans are reviewed on a monthly basis and there is also a si monthly multidisciplinary review. The day to day recording systems are good and indicate service users choices, preferences, likes, dislikes and also reflect any decisions they make regarding how they live their daily lives. Some service users are able to participate in the day to day running of the home and recently service users have been involved with staff recruitment and selection process. To comply with minimum standards fully the inspector recommends making a record of service Whitwood Hall Page 6 users involvement with staff selection and or any comments they may make regarding prospective employees. The ethos and philosophy of the home is based on ordinary living principles and there is an expectation that service users do as much for themselves as possible. Risk assessments are operated to identify any risks to service users who pursue the living of an ordinary lifestyle. Lifestyle (Standards 11-17) 7 out of these 7 standards continue to be met. The inspector was impressed with the daily recording systems within the home which give a good account of the lifestyles of service users. All service users are encouraged and supported to take full advantage of the services and facilities provided in the local community. A few service users are able to take advantage of sheltered employment and live as independently as possible. Ordinary living principles ensure that service users participate in and have a real and positive community presence. The inspector acknowledges the difficulties encountered by support workers in fulfilling the homes aims and objectives given the challenging behavior displayed by some service users. Personal and healthcare Support (Standards 18-21) 4 of these 4 standards continue to be met Service users have as much say and control over their own lives as is practicable. Individual care plans ensure that there is continuity and consistency of approach when meeting service users assessed personal care and support needs. Service users are encouraged and supported to take full advantage of local community based healthcare facilities and services. However, specialist support is available from other healthcare professionals such as Community Learning Disability Nurses and Specialist Social Workers. Some service users also have the support of hospital based consultants who monitor service users physical, emotional healthcare needs. The home has recently changed the method of ordering, storage, administration and recording of medicines which appears to be more efficient. Concerns, Complaints and Protection (Standards 22-23) Both of these 2 standards continue to be met. The home has an Adult Abuse and Protection Policy and Procedure which includes WhistleBlowing and forms pat of the induction training for new staff. The complaints procedure has recently been updated to reflect the launch of the Commission for Social Care Inspection in April this year. Environment (Standards 24- 30) 4of these 7 standards were not met 1 almost met, 1 not applicable and 1 was met. It is acknowledged that the aggressive and often destructive nature of the behavior displayed by most service users is continuous and can often be relentless. The effect on the physical Whitwood Hall Page 7 appearance of the home can be detrimental and accumulative. However, the inspector was disappointed to see that some minor damage to the home has not been dealt with quickly and has been left effecting some of the environment. The home cannot be complacent or underestimate the effect that disrepair has on service users and other visitors to the home. There is a need to provide a written plan of maintenance to the fabric and decoration of the home which is reviewed annually and records kept for inspection. The areas requiring remedial work include bedrooms, lounges, and bathrooms. There is also a need to review the use of curtains and blinds in two service users bedrooms and consider alternatives to ensure their privacy and dignity. The registered person is required to provide an action pan indicating how and when the remedial work identified in this report will be addressed. Staffing (Standards 31-36 ) 5 of these 6 standards were met and 1 almost met. The staff recruitment policies, procedures and practices are good. Staff receive a job description and induction training which reflects National Training Organization workforce targets. Staff training has a high profile and currently half the workforce is undertaking National Vocational Qualifying training. Four senior support workers are undertaking NVQ Level 3 and five Level 2. The acting manager said that the home is well on target for having a ratio of 50 of support staff qualified by January 2005. There was evidence that other specialist learning disability training is also offered and provided to staff. All staff receive a minimum of six line manager supervision sessions and an one appraisal per year. The inspector was impressed with the background information held on support workers training, supervision and appraisals by the acting manager. Conduct and Management of the Home (Standards 37-43) 4 of these 7 standards were met, 1 not met and 2 almost met. The management systems in the home appear to work well. Despite not having a registered manager the acting manager is ensuring that support workers are suitably supervised and care systems within the home are maintained. The owners are currently advertising for a new manager but without success. The inspector was impressed with the amount of service user, family and friends and other stakeholders quality assurance questionnaires that were available for inspection. This good practice is to be commended. However, the information gathered should be collated and a report provided which indicates service users and others views on the quality of care provided by the home. The registered person also needs to provide a business and financial plan for the home which is renewed annually and also available for inspection.Whitwood HallPage 8 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY 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. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action Not Applicable Action is being taken by the Commission for Social Care Inspection 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 2 YA8 YA37 A record should be made of service users participation and any contributions they make to the staff selection and recruitment processes. The home should have a registered manager.CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). Not Applicable.MET (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 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, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 2 3 23 (2) (d) 23 (2) (c) 23 (2) (c) YA26 YA26 YA27 The two bedroom carpets identified as having stains need to be cleaned or replaced. The wardrobe door identified needs to be repaired or replaced. The floor covering in the bathrooms identified need to be repaired or replaced. The torn sofa covering in the lounge identified needs to be repaired or replaced. The registered person is required to provide an action plan indicating how and when these four requireme nts will be met.423 (2) (h) (i)YA28RECOMMENDATIONS 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). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 2 YA5 YA8 A copy of the service users contract should be maintained in their personal files. A record should be made of service users involvement and contributions to staff selection and recruitment process.Whitwood HallPage 10 3YA24There should be a planned programme of renewal and maintenance for the fabric and decoration of the premises with records kept for inspection. The registered person should plan to have a minimum ratio of 50 of support workers trained to NVQ Level 2 or above by January 2005. The home should have a Registered manager. The information gathered as part of quality assurance monitoring should be collated and a report provided which reflects the views and outcomes for service users. The registered person should provide a annually reviewed financial and business plan which available for inspection.4 5 6YA32 YA37 YA397YA43* 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 NO YES YES YES YES YES YES YES YES YES NO YES 7 0 0 NO NO YES YES 26 0 23/06/04 11.00 3.45Whitwood HallPage 12 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) 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 and 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. 1,700.00 2,100.00 Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are 3 Key findings/Evidence Standard met? The home continues to provide a Statement of Purpose which includes all the relevant information required for prospective service users their family and friends to make an informed decision regarding the home. The information pack also includes other policies and procedures providing information about the running of the home. Standard 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? Service users are only admitted to the home following a comprehensive assessment of their supervision and care needs. Most service users are admitted with a great amount of assessment information as they are usually admitted from specialist services. On the day of the inspection it was noted that service users assessments are reviewed regularly placing authority professionals.Whitwood HallPage 14 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? On the day of the inspection examination of service users assessment, care plans, reviews and daily records indicate that the home is good at demonstrating its capacity to meet service users assessed care and support needs. The inspector was particularly impressed with the daily recording systems which have descriptive words to indicate service users choices and preferences. The daily records also demonstrate service users involvement with the local community including leisure and healthcare activities. This good practice is to be commended. 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 invited into the home to test drive the facilities and services provided before admission. The home works closely with service users, their relations and other healthcare professionals before any admission is agreed. There are no unplanned admissions to the home. 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. 2 Key findings/Evidence Standard met? Each service user is provided with a contract and statement of terms and conditions. However, service users contracts are kept in the central office. To comply fully with this standard and in particular standard 5.5, a copy of service users contracts/terms and conditions should be maintained in their personal case files.Whitwood HallPage 15 Individual 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? Service users have care plans which are developed following a comprehensive assessment of their care and support needs. These are reviewed on a monthly basis by their keyworker and with a multidisciplinary meeting held every six months. Some care plans have been signed by those service users who are able to do so. 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 daily recording systems in the home are very good. They are written to include descriptive words indicating service users choices, preferences, likes and dislikes. They also reflect the decisions service users make on a day to day basis regarding what they do and how they live their lives. The daily records also indicate service users healthcare appointments, day and night time activities, visits from family, friends and other stakeholders. The quality of the daily records is impressive. The acting manager and support workers are to be commended for their efforts in maintaining such a good standard of recording.Whitwood HallPage 16 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 examination of the daily records the inspector acknowledges that service users do have a say in the day to day running of the home. However, to comply fully with this standard and in particular standard 8.3 a record should be maintained of service users involvement in the staff selection and recruitment process, and of any contributions they make. 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? All service users have risk assessments implemented following comprehensive assessments including behavioural assessments. The ethos and philosophy of the home is based on ordinary living principles and service users are supported to take risks as part of living an independent lifestyle. All risk assessments are reviewed on a regular basis and are agreed as part of a multidisciplinary approach to care provision. 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 is included as part of the induction training for new staff. All support workers sign an individual statement on confidentiality which is maintained in their personal files. Information about service users is handled appropriately and their confidences are kept.Whitwood HallPage 17 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 ethos and philosophy of the home is based on ordinary living principles and all service users are encouraged to do as much for themselves as possible. There are daily opportunities provided for service users to develop their personal skills. On the day of the inspection there was evidence of Speech Therapists working with service users to increase and improve their communication skills. This good practice is to be commended. 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 currently has two service users who are able to benefit from sheltered employment. A local supermarket and Rugby Club offer opportunities to service users who are perceived as part of the local community and have a positive community presence. The manager and support staff are to be commended for their efforts in enabling and supporting service users to be part of the local community.Whitwood HallPage 18 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? Service users are encouraged and supported to take full advantage of local community based facilities and services. Some service users behaviour is very challenging but nevertheless support workers endeavour to ensure that adequate support is given to enable all service users to be part of the wider local community. The manager and support workers are to be commended for their efforts in promoting service users rights and giving them opportunities to develop a positive community presence. 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 are encouraged and supported to take full advantage of local community based leisure services and facilities. The acting manager and support workers are to be commended for their efforts in promoting ordinary living principles and trying to promote a positive community presence for service users.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? There was evidence in the daily records and service users reviews that positive relationships are encouraged with service users family and friends. Most service users families are involved with assessments and developing/ reviewing care plans. Some service users have friends outside the home. 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). 3 Key findings/Evidence Standard met? Examination of the daily records and service users risk assessments it was established that service users do have a say in the day to day running of the home. Some service users are very able and can give a good account of their daily lives. Others are less able , however, decisions regarding how the live their lives are reflected in the daily recoding systems.Whitwood HallPage 19 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? The ethos and philosophy of the home is based on ordinary living principles and there is an expectation that service users participate in food shopping, the preparation and serving of meals. Service users are asked what menu they would prefer and choices and preferences are taken into account and alternatives offered.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 procedures 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? Through examination of the daily records and service users care plans it was established that personal care and support is provided which is sensitive and flexible to meet service users needs. Service users have as much autonomy and control over their lives as is practicable. Care plans ensure that there is consistency and continuity of support offered to service users.Whitwood HallPage 20 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) 003 Key findings/Evidence Standard met? Through examination of the daily records and service users medical records it was established that service users are encouraged and supported to take advantage of ordinary community based healthcare services. However, most service users have the support of specialist Learning Disability Nurses and Social Workers. Some service users also receive support from hospital based consultants. 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. 3 Key findings/Evidence Standard met? The home currently does not have any service users who self medicate. The inspector was pleased to see that the medication systems in the home have been changed and improved. The home now uses the Boots Medication System. The acting manager and support workers said that the system is much better and easier to administer. 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. Service users family and other stakeholders are involved in the assessment and care planning process for service users in the home.Whitwood HallPage 21 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 timescales 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 CSCI 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 reflects the role of the Commission for Social Care Inspection. Relatives and visitors are given the opportunity as part of Quality Assurance Monitoring to comment on the running and quality of care provided by the home. The home, however, has not received any complaints over the past twelve months.Whitwood HallPage 22 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. These policies and processes form part of the induction training for all staff.Whitwood HallPage 23 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. 2 Key findings/Evidence Standard met? The inspector acknowledges that some service users display aggressive and destructive behaviour. The destructive nature of some of the behaviours has led to a deterioration in the physical operation and presentation of the home. The main areas of need are in some service users bedrooms, although there is one lounge and two bathrooms which also require attention. All of the repairs and issues outlined in this report have been recorded in the homes repair book. However, to comply with this standard fully and in particular standard 24.12 the registered person should provide an annual planned maintenance and renewal programme for the fabric and decoration of the premises , with records kept for inspection. The inspector acknowledges the difficulties experienced by the home in `keeping up appearances within the home given the nature of the service user group. However, this makes the need to have a planned programme of maintenance more important .Whitwood HallPage 24 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 YES NO NO 16 0 0 0 16 00 0 0 03 Key findings/Evidence Standard met? Though inspection of the bedrooms it was established that service users have the individual space they require.Whitwood HallPage 25 Standard 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. 1 Key findings/Evidence Standard met? On the day of the inspection two service users bedroom carpets were observed to have red stains on them from an unknown source. To comply with the Care Homes Regulations 2001, Regulation 23 (2)(d) these two carpets need to be cleaned or replaced. The wardrobe door in another bedroom was broken and needs to be repaired Regulation 23 (2)(c). One bedroom had no curtains or blinds at the window. The acting manager said that this particular service user is experiencing problems of a destructive nature involving personal passions and bedroom furniture. The inspector recommends that an alternative to blinds or curtains is found to preserve the privacy and dignity of the service user. 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. 1 Key findings/Evidence Standard met? On the day of the inspection the acting manager said that the bathrooms in the home have been replaced as the others were broken. However, the floor covering in both bathrooms has not been replaced. The acting manager said that the owners are aware of this and that the builders/ maintenance workers are currently busy at another home but will be coming to address this problem. To comply with the Care Homes Regulations 2001, Regulation 23 (2) (c) for the benefit and comfort of service users the bathroom floors need to be provided with suitable floor covering. 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. 1 Key findings/Evidence Standard met? On the day of the inspection it was noted that the sofa covering in the lounge was torn and needed to be repaired or replaced. The Care Homes Regulations 2001, Regulation 23 (2) (h) (i). 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? The home does not provide any disability equipment.Whitwood HallPage 26 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 infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? On the day of the inspection all areas of the home appeared to clean and were free from offensive odours. The acting manager and support workers are to be commended for their efforts in maintaining the standards of hygiene within the home.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. 3 Key findings/Evidence Standard met? Through examination of staff files it was established that all staff are provided with a job description and service users benefit from clarity of roles and responsibilities. All staff are also issued with a copy of the codes of conduct and practice issued by the General Social Care Council. 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. 2 Key findings/Evidence Standard met? Through examination of the staff training matrix, staff files, and service user, families and other stakeholders quality assurance surveys it was established that support workers have the skills and competencies and experience necessary for the tasks they are expected to do. On the day of the inspection the inspector was impressed with the background knowledge held by support workers and the positive relationships fostered with service users. There are currently 5 support workers undertaking NVQ Level 2 and 4 taking Level 3. The registered person should plan to have 50 of support workers qualified to NVQ Level 2 or above by January 2005.Whitwood HallPage 27 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. 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 9 3 4 0 6 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 1250 Nursing 0 0 0203 Key findings/Evidence Standard met? The home has a particularly high support worker service user ratio. This is because most service users require 1 to one or 2 to one care and support. There are regular staff meetings held and the numbers and skill mix of staff on duty day or night reflect and ensure that service users assessed and planned support needs are met. 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. 3 Key findings/Evidence Standard met? The home provides a staff recruitment and selection policy and procedure which is based on equal opportunities and which supports and protects service users.Whitwood HallPage 28 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 continues to provide induction training which reflects Sector Skill Council workforce training targets. There is also specialist training provided specific to the needs of service users. The Training Matrix ensures that mandatory training is planned for and provided. 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? Examination of the staff supervision lists and notes it was established that staff receive a minimum of six line manager supervision sessions per year. Staff also receive an annual appraisal and a record is maintained in their personal files.Whitwood HallPage 29 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 [by 2005]. NO2 Key findings/Evidence Standard met? Discussion with the home owner indicates that they are currently advertising in nationally for a qualified manager for the home but with little success. The acting manager is a very experienced senior and has worked at Whitwood House and Whitwood Hall for a number of years. The inspector reminded that the owners need to provide a Registered Manager for the home. A period of three months is the usual timescale allowed by CSCI for the home to be without a registered manager. Despite the difficulty with recruitment the situation should be reviewed after three months and a manager application/ nomination put forward. 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? Through discussion with service users, support workers , acting manager and owner it was established that service users benefit from the ethos, leadership and management approach of the home. There is relaxed, homely and comfortable environment created.Whitwood HallPage 30 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. 2 Key findings/Evidence Standard met? Through examination of the quality assurance monitoring questionnaires it was established that the views of service users, their relatives and friends and other stakeholders are sought by the home. However, to comply fully with this standard and in particular standard 39.4 the information gathered as part of quality assurance monitoring should be collated and a report provided which reflects the findings and outcomes for service users. 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 Adults (18-65). 3 Key findings/Evidence Standard met? Service users rights and best interests are safeguarded by the homes policies and procedures. 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 by the home 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, safety and welfare of service users and support workers are promoted and protected. 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. 2 Key findings/Evidence Standard met ? Service users benefit from competent and accountable management of the service. However, to comply fully with this standard and in particular standard 43.2 the home should provide a financial and business plan for the service which is reviewed annually and open to inspection.Whitwood HallPage 31 PART C(where applicable) Condition CommentsCOMPLIANCE WITH CONDITIONSComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateTony Railton Ruth Rainey 22 July 2004Signature Signature SignaturePublic reports It should be noted that all CSCI inspection reports are public documents. Whitwood Hall Page 32 PART DD.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 23 June 2004 Whitwood Hall and any factual inaccuracies: Please limit your comments to one side of A4 if possibleWhitwood HallPage 33 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary YESComments 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 accurateYESYESNote: 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. D.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 34 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.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 D.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 35 - 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. 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