Inspection on 07/03/05 for Whitwood Hall

Care Homes For Adults (18 ­ 65)Whitwood HallWhitwood Lane Castleford West Yorks WF10 5QDAnnounced Inspection7th and 14th March 2005 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 5.5.04 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 37th and 14th March 2005 10:00 am Tony Brindle Not Applicable Not Applicable Not ApplicableID Code131382Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionNone Present Jeff Barlow (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. The residents are encouraged and assisted to do as much for them selves as possible. There is also an expectation that residents take full advantage of local ordinary community based leisure and healthcare services. Whitwood Hall offers care and support to those who may have behaviours which may 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.)Choice of Home (Standards 1-5) 2 of these 5 standards were assessed. Both were met.All the residents have a comprehensive assessment carried out before they are admitted to the home, and there are no unplanned admissions. The homes assessments are also very comprehensive andinclude behavioural and risk assessments. Each resident is provided with a contract and statement of terms and conditions.Individual Needs and Choices (Standards 6-10) 4 of these 5 standards were assessed, 3 were fully met. 1 was over the above the standard.The residents have behavioural assessments, which identify risks and there are agreed management strategies developed to minimise risks to the residents. These are reviewed on a regular basis. The residents are involved in the staff recruitment and selection process and are given opportunity to meet and comment on prospective employees. In-house assessments and care plans show that wherever possible, residents are involved in the homes decision-making processes.Whitwood Hall Page 6 Although this can be more difficult for some residents who have communication difficulties, the registered manager explained that despite this, residents are consulted about aspects of their daily lives at all times. All the residents have care plans that are reviewed and updated on a monthly basis. The care plans were found to focus on positive behaviours and outcomes for each individual resident, taking account of changing needs, aspirations and achieving personal goals. The care plans were seen to be very good examples of the way it should be done. Lifestyle (Standards 11-17) 5 of these 7 standards were assessed, all 5 were met.Individual Resident Plan details how the persons assessed needs; preferences and goals are to be met by the home. Opportunities for personal development, appropriate education and training, meaningful occupation and for integration into community life and leisure activities are created by the home. Personal and healthcare Support (Standards 18-21) 2 of these 4 standards were assessed, both were met.The management team of the home pointed out, the residents have the right to good quality physical and mental health care wherever they are living. The home supports the residents to manage their own healthcare where appropriate (including visual, hearing, oral and continence care) and to access NHS community facilities, whilst ensuring that individuals health is reviewed and maintained.Whitwood Hall Page 7 Concerns, Complaints and Protection (Standards 22-23) 2 of these 2 standards were assessed, both were met.These standards require care home managers to have clear procedures that enable residents to make their views known, and reassurance that appropriate action will be taken. This was found to be satisfactory. The homes policies and procedures for dealing with suspicion or evidence of abuse were found to in place and were found to satisfactory. Environment (Standards 24- 30) 1 of these 7 standards were assessed, this was met.The environmental aspects of this service are of a high standard. The residents have their own personalised bedrooms The lounges, dining areas, conservatories and kitchens and the various houses on the site are all tasteful decorated, and contain domestic style, quality furniture. A monthly check of the building takes place. Repairs are quickly reported and completed. Staffing (Standards 31-36 ) 4 of these 6 standards were assessed 3 were met, 1 was partially met.Whitwood Hall50 NVQPage 8Examination of documents held within the home and through discussion with some staff it is clear that that the staff understand the purpose of the home and the key values that underpin the work they do. Emphasis is placed on developing staff training to meet, and on supporting staff to gain qualifications. Staff benefit from regular supervision. The registered person should plan to have a minimum of 50 of care staff trained to National Vocational Qualification Level 2 or above by the end of 2005. Conduct and Management of the Home (Standards 37-43) 2 of these 8 standards were assessed, both were met.MANAGER The home has satisfactory systems in place that protect the health and safety of the staff and resident group.The inspector would like to thank all the residents, staffand members of the management team for their time and co-operation throughout the inspection process.Whitwood HallPage 9 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 na 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 na CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). Not Applicable.MET (YES/NO)Whitwood HallPage 10 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 13 YA42 The use of door wedges to prop open doors, must cease. The home must find alternatives to this in consultation with the local fire service and fire detection system provider. On going from the date of this inspectionRECOMMENDATIONS 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 * CARRIED OVER FROM THE LAST 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 2005.1YA32* 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 Resident survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of residents 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 07/03/05 10.00 5Whitwood 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 residents have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective residents know that the home they choose will meet their needs and aspirations. Prospective residents have an opportunity to visit and to `test drive the home. Each resident 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 resident with a residents 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 0 Key findings/Evidence Standard met? On this occasion, this standard was not fully assessed. A full assessment may take place at the next inspection. Standard 2 (2.1 ­ 2.8) New residents 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. 4 Key findings/Evidence Standard met? Residents are only admitted to the home following a comprehensive assessment of their supervision and care needs. Most residents were 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 residents assessments and care plans 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. 0 Key findings/Evidence Standard met? On this occasion, this standard was not fully assessed. A full assessment may take place at the next inspection. Standard 4 (4.1 - 4.5) The registered manager invites prospective residents to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met? On this occasion, this standard was not fully assessed. A full assessment may take place at the next inspection. Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective resident written and costed contract/statement of terms and conditions between the home and the service user. 3 Key findings/Evidence Standard met? Each resident is provided with a contract and statement of terms and conditions. These are now kept in their personal files.Whitwood HallPage 15 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · Residents know their assessed and changing needs and personal goals are reflected in their individual Plan. Residents make decisions about their lives with assistance as needed. Residents are consulted on, and participate in, all aspects of life in the home. Residents are supported to take risks as part of an independent lifestyle. Residents 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 resident 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. 4 Key findings/Evidence Standard met? Residents 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 residents who are able to do so. The care plans were found to focus on positive behaviours and outcomes for each individual resident, taking account of changing needs, aspirations and achieving personal goals. The care plans were seen to be very good examples of the way it should be done. 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 Resident 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 residents choices, preferences, likes and dislikes. They reflect the decisions residents make on a day to day basis regarding what they do and how they live their lives. The daily records indicate residents healthcare appointments, day and night time activities, and visits from family, friends and other stakeholders. The standard of the daily records is high. The staff team 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 residents 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. 3 Key findings/Evidence Standard met? Through examination of the daily records the inspector acknowledges that residents do have a say in the day-to-day running of the home. A record is maintained of the residents involvement in the staff selection and recruitment process, and of any contributions they make. Standard 9 (9.1 ­ 9.4) Staff enable residents 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 residents have risk assessments implemented following comprehensive assessments including behavioural assessments. The ethos and philosophy of the home is based on ordinary living principles and residents 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 the provision of care and support. Standard 10 (10.1 ­ 10.6). Staff respect information given by residents in confidence, and handle information about residents in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 0 Key findings/Evidence Standard met? On this occasion, this standard was not fully assessed. A full assessment may take place at the next inspection.Whitwood HallPage 17 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · Residents have opportunities for personal development. Residents are able to take part in age, peer and culturally appropriate activities. Residents are part of the local community. Residents engage in appropriate leisure activities. Residents have appropriate, personal, family and sexual relationships. Service users rights are respected and responsibilities recognised in their daily lives. Residents are offered a healthy diet and enjoy their meals and mealtimes.Standard 11 (11.1 ­ 11.4) Staff enable residents to have opportunities to maintain and develop social, emotional, communication and independent living skills. 0 Key findings/Evidence Standard met? On this occasion, this standard was not fully assessed. A full assessment may take place at the next inspection. Standard 12 (12.1 ­ 12.6) Staff help residents 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? Some of the residents are involved in sheltered employment schemes. A local supermarket and Rugby Club offer opportunities to residents, allowing them to be part of the wider local community and establishing a positive community presence. The staff are to be commended for their efforts in enabling and supporting residents to be part of the local community.Whitwood HallPage 18 Standard 13 (13.1 ­ 13.5) Staff support residents 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? Residents are encouraged and supported to take full advantage of local community based facilities and services. Some residents behaviour is seen to be challenging but nevertheless support workers endeavour to ensure that adequate support is given to enable all residents to be part of the wider local community. Once again, the support workers and extended staff team are to be commended for their efforts in ensuring that the residents live full and active community based lives. The staff strive and ensure that the residents maintaining a positive community presence. Efforts to provide support for integrated recreational experiences are based on the belief that integration is possible for all. The home and staff team along with the residents find the how best to promote participation and interaction, and how to help make this possible. Standard 14 (14.1 ­ 14.6) Staff ensure that residents have access to, and choose from a range of, appropriate leisure activities. 0 Key findings/Evidence Standard met? On this occasion, this standard was not fully assessed. A full assessment may take place at the next inspection. Standard 15 (15.1 ­ 15.5) Staff support residents 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 residents reviews that positive relationships are encouraged with residents family and friends. Most residents families are involved with assessments and developing / reviewing care plans. Some residents have friends outside the home. Family and friends are welcomed, and their involvement in daily routines and activities is encouraged, with the residents agreement.Whitwood HallPage 19 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 residents risk assessments it was established that residents do have a say in the day to day running of the home. Some residents 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. Any restrictions imposed on the residents form part of their agreed care plan. 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 residents are actively supported to help plan, prepare and serve meals. Residents are asked on a day to day basis what menu they would prefer. There are appropriate and satisfactory risk assessments and approaches in place for some residents in relation to the use of the kitchen and various appliances within that area of the home. The ethos and philosophy of the home is based on ordinary living principles and there is an expectation that residents participate in food shopping, the preparation and the serving of meals.Whitwood HallPage 20 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · Residents receive personal support in the way they prefer and require. Service users physical and emotional health needs are met. Residents 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 resident 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 in line with the wishes of each resident. Times for getting up/going to bed, baths, meals and other activities are flexible (including evening and weekends), subject to restrictions agreed in each individual care plan. Where needed, guidance and support regarding personal hygiene (e.g. to wash, shave) is provided. Service users choose their own clothes, hairstyle and makeup and their appearance reflects their personality. Residents are supported to make some choices about which staff that work with them. Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of residents are assessed and recognised and that procedures are in place to address them. No. of incidents where residents have been taken to Accident & Emergency during last 12 months No. of residents with pressure sores at the time of inspection (from information taken from care notes) 0 03 Key findings/Evidence Standard met? The residents are encouraged and supported to take full advantage of ordinary community based healthcare services. In addition to this, advice and help is given from specialist Social Workers and Community Learning Disability Teams. Some of the residents have links with hospital based consultants. All incidents affecting the wellbeing of the residents are reported to the CSCI within 24 hours of the incident occurring.Whitwood HallPage 21 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support residents 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. 0 Key findings/Evidence Standard met? On this occasion, this standard was not fully assessed. A full assessment may take place at the next inspection. Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a resident with sensitivity and respect. 0 Key findings/Evidence Standard met? On this occasion, this standard was not fully assessed. A full assessment may take place at the next inspection.Whitwood HallPage 22 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Residents feel their views are listened to and acted on. Residents 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 residents 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 has an appropriate complaints policy and procedure. It 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.Whitwood HallPage 23 Standard 23 (23.1 ­ 23. 6) The registered person ensures that residents 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 has an appropriate Adult Abuse and Protection Policy and Procedure in place, including a Whistle Blowing procedure which forms part of the induction of new workers.Whitwood HallPage 24 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · Residents 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. Residents 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. 3 Key findings/Evidence Standard met? As highlighted at the last inspection, the Commission acknowledges that some residents can display aggressive and destructive behaviour. This can led to deterioration into some aspects of the physical presentation of the home. However, the home has access to its own building and maintenance team who act promptly and effectively to ensure any deterioration is dealt with, and dealt with sympathetically taking account of the needs, desires and personalities of the resident group. The home has a monthly environmental visit and active renewal programme. The requirements made at the last inspection relating to the renewal of various items of furniture and flooring coverings has taken place.Whitwood HallPage 25 Standard 25 (25.1 ­ 25. 11) The registered person provides each resident 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 00 Key findings/Evidence Standard met? On this occasion, this standard was not fully assessed. A full assessment may take place at the next inspection.Standard 26 (26.1 ­ 26.4) The registered person provides each resident with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 0 Key findings/Evidence Standard met? On this occasion, this standard was not fully assessed. A full assessment may take place at the next inspection.Whitwood HallPage 26 Standard 27 (27.1 ­ 27.6) The registered person provides residents with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 0 Key findings/Evidence Standard met? On this occasion, this standard was not fully assessed. A full assessment may take place at the next inspection. 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? On this occasion, this standard was not fully assessed. A full assessment may take place at the next inspection. 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. 0 Key findings/Evidence Standard met? On this occasion, this standard was not fully assessed. A full assessment may take place at the next inspection.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.Whitwood HallPage 27 StaffingThe intended outcomes for the following set of standards are: · · · · · · Residents benefit from clarity of staff roles and responsibilities. Residents are supported by competent and qualified staff. Residents are supported by an effective staff team. Residents are supported and protected by the homes recruitment policy and practices. Residents individual and joint needs are met by appropriately trained staff. Residents 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. 0 Key findings/Evidence Standard met? On this occasion, this standard was not fully assessed. A full assessment may take place at the next inspection. 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 information, staff files, and the surveys return to the Commission from various stakeholders it was accepted that the staff team have the skills and competencies and experience necessary for the tasks they are expected to do. To support this, the home should ensure that the registered person should plan to have a minimum of 50 of care staff trained to National Vocational Qualification Level 2 or above by the end of 2005. Once the home have achieved the 50 target, then this standard will be seen as being fully met. The staff team who are currently undertaking an NVQ award are on line to complete it within the above timescale.Whitwood HallPage 28 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 residents are based on guidance recommended by the Department of Health. Personal Care No. residentsHigh needs No. residentsMedium needs No. residentsLow 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 X 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 0XX3 Key findings/Evidence Standard met? The home has a particularly high support worker resident ratio. This is system is in place to fully support individual residents. There are regular staff meetings held and the numbers and skill mix of staff on duty (day or night) reflect the support needed to meet the assessed needs of the residents. The staff group have recently been put into Core Teams, allowing for even more personalised support to individual residents. 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 29 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 programme run by the home ensures that mandatory, essential 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. 0 Key findings/Evidence Standard met? Although some of the details of this standard were discussed with the registered manager, on this occasion, this standard was not fully assessed. A full assessment may take place at the next inspection.Whitwood HallPage 30 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · Residents benefit from a well run home. Residents benefit from the ethos, leadership and management approach of the home. Residents 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 residents are promoted and protected. Residents 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]. YES0 Key findings/Evidence Standard met? On this occasion, this standard was not fully assessed. A full assessment may take place at the next inspection. However, the home now has a manager who is registered with the Commission. Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? On this occasion, this standard was not fully assessed. A full assessment may take place at the next inspection.Whitwood HallPage 31 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. 3 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. The information gathered as part of quality assurance monitoring is collated and a report is provided which reflects the findings and outcomes for service users. It would be of benefit to the effective management of the home, for the registered person to consider ways of recording effective their monthly management visits as detailed within Regulation 26. 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). 0 Key findings/Evidence Standard met? On this occasion, this standard was not fully assessed. A full assessment may take place at the next inspection. Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of residents and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met ? On this occasion, this standard was not fully assessed. A full assessment may take place at the next inspection. Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of residents and staff. 3 Key findings/Evidence Standard met? The health, safety and welfare of residents and support workers are promoted and protected. However, during the tour of the building, a door wedge was found within a residents bedrooms. The use of door wedges in this context is not permitted. As detailed within the requirements of this report, an alternative to door wedges must be found. 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. 0 Key findings/Evidence Standard met ? On this occasion, this standard was not fully assessed. A full assessment may take place at the next inspection.Whitwood HallPage 32 PART C(where applicable) Condition CommentsCOMPLIANCE WITH CONDITIONSComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateTony Brindle Ruth Rainey 6 April 2005Signature Signature SignaturePublic reports It should be noted that all CSCI inspection reports are public documents. Whitwood Hall Page 33 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 7th and 14th March 2005 Whitwood Hall and any factual inaccuracies: Please limit your comments to one side of A4 if possible We are working on the best way to include provider responses in the published report. In the meantime responses received are available on request.Whitwood HallPage 34 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 35 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 36 Whitwood Hall / 7th and 14th March 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000006213.V205580.R02© This report may only be used in its entirety. 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