Care Home: Whitehatch

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What the care home does well The home operates a structured admission procedure when a vacancy becomes available. Only after the completion of a detailed needs assessment will consideration be given to acceptance of a service user on a trial basis. This ensures that all assessed needs can be met and that the service user is compatible with the other service users in the home. Good arrangements are in place to meet the health care needs of service users and support is in place to access health care facilities in the locality. Service users are supported to take part in meaningful activities. A service user state “I am starting a new college tomorrow” and “I have been shopping for pens”, another said “I have been to the library this morning”, someone else Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 said “I ma going out for a meal this evening and looking forward to it”. Individual activity programmes are varied and interesting. Dietary needs are being met. A service user said “I can choose what I want for lunch which is different every day”. The home is clean comfortable and well maintained. It benefits from spacious communal areas enabling service users to choose where they sit depending on their moods. One service user said “I like purple in my bedroom”. And another said “I like to spend time alone in my room making models”. The staff team have the qualifications and skills necessary to meet the assessed needs of the service users in their care. The home is well managed by a recently appointed manager, with the support of a deputy manager and four senior support workers. The health, safety, and welfare of the service users and the staff are promoted and protected. What has improved since the last inspection? The recommendation from the last inspection that the manager attends local authority in safeguarding procedures was undertaken. However she has now left the organisation. The self contained flat on the top floor has now been registered and the home is now registered to accommodate eleven service users. Policies and procedures continue to be reviewed and updated. Induction training has been revised and now includes a workbook handout for staff to work with. A “sentry safe” monitoring system has been installed in the office for the monitoring of epileptic seizures with complex needs. What the care home could do better: The home continues to provide a good service for people living there. Since the last inspection a new manager has been appointed. She is currently in the process of collating her application pack for submission to The CareWhitehatchDS0000072268.V377829.R01.S.docVersion 5.3Quality Commission to become the registered manager of the home. A requirement has not been made as this is in progress. Arrangements for the collection of clinical waste must be reviewed as mentioned in the report to minimise the risk of infection. Key inspection report CARE HOME ADULTS 18-65 Whitehatch Oldfield Road Horley Surrey RH6 7EP Lead Inspector Mary Williamson Key Unannounced Inspection 24th September 2009 10:30 Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Whitehatch Address Oldfield Road Horley Surrey RH6 7EP 01293 782123 01293 823231 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.achuk.com Aitch Care Homes (London) Ltd Post Vacant Care Home 11 Category(ies) of Learning disability (0) registration, with number of places Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD) The maximum number of service users to be accommodated is 11. Date of last inspection 14th October 2008 Brief Description of the Service: Whitehatch has been registered to provide residential care and support for eleven service users with a learning disability. The home has been adapted to provide single en-suite bedrooms for service users arranged over two floors. The first floor is accessible by a shaft lift. There is ample communal accommodation including a large lounge, conservatory and dining room. There is also a log cabin in the back garden which is used as a sensory room or as a quiet area. The home is located on the outskirts of Horley Town in a residential road, and accessible to local shops, train station, and local buses. There is a well maintained garden to the rear with decking and a ramp. The front of the home has been adapted to provide ample car parking space. The fees charged in this home range from £1,195 to £2124 per week. Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is a TWO STAR rating. This means that people who use the service experience GOOD quality outcomes. This was a key inspection and was unannounced. The inspection was undertaken by Mary Williamson Regulation Inspector over six hours. The recently appointed home manager was present for the duration of the inspection. It was possible to meet and talk with most of the residents who were going about their daily activities and were present in the home at some point during this visit. It was also possible to meet with some relatives who were attending a meeting regarding a review of care. The inspector was invited to view some service user’s rooms and gain some feedback about their experience of life in the home. Records relating to the care of the residents and the management of the home were examined. Some examples include needs assessments, care plans, medication records, risk assessments, menus, staff training files, and staff employment documents. Health and safety policies and procedures were also explored. Staff on duty were spoken to and they confirmed some of the training they had undertaken, the support they receive, and their experiences of working in the home. What the service does well: The home operates a structured admission procedure when a vacancy becomes available. Only after the completion of a detailed needs assessment will consideration be given to acceptance of a service user on a trial basis. This ensures that all assessed needs can be met and that the service user is compatible with the other service users in the home. Good arrangements are in place to meet the health care needs of service users and support is in place to access health care facilities in the locality. Service users are supported to take part in meaningful activities. A service user state “I am starting a new college tomorrow” and “I have been shopping for pens”, another said “I have been to the library this morning”, someone else Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 6 said “I ma going out for a meal this evening and looking forward to it”. Individual activity programmes are varied and interesting. Dietary needs are being met. A service user said “I can choose what I want for lunch which is different every day”. The home is clean comfortable and well maintained. It benefits from spacious communal areas enabling service users to choose where they sit depending on their moods. One service user said “I like purple in my bedroom”. And another said “I like to spend time alone in my room making models”. The staff team have the qualifications and skills necessary to meet the assessed needs of the service users in their care. The home is well managed by a recently appointed manager, with the support of a deputy manager and four senior support workers. The health, safety, and welfare of the service users and the staff are promoted and protected. What has improved since the last inspection? What they could do better: The home continues to provide a good service for people living there. Since the last inspection a new manager has been appointed. She is currently in the process of collating her application pack for submission to The Care Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 7 Quality Commission to become the registered manager of the home. A requirement has not been made as this is in progress. Arrangements for the collection of clinical waste must be reviewed as mentioned in the report to minimise the risk of infection. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, and 5. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective service users and their family have access to sufficient information to help them in their choice of service. Detailed pre admission needs assessments are carried out to ensure the home can meet individual needs and expectations. EVIDENCE: The home has a statement of purpose and service user guide in place. This is available to all prospective service users and their relatives to provide them with the necessary information to help them in their choice of home. A picture format of this document is also provided when appropriate. A parent stated that she had all this information prior the admission. Detailed needs assessments are in place for all service users. These are undertaken by the clinical team within the organisation, and the manager’s input prior to a service user being admitted. These assessments portray a good analysis of needs and establish the suitability of the placement. Three needs assessments were seen and give a good overall account of individual needs and goals. These are reviewed and updated on a regular to reflect changing needs. A service user stated “I was able to come and visit the home Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 10 before I moved in”. The managed stated that trial visits are part of the assessment and admission process. The manager also stated that specific training is provided for staff to meet individual needs as highlighted in the pre admission assessment. For example training was taking place the following week regarding the maintenance, and management of a hearing aid and audio equipment to enhance communication skills for one service user. Individual contracts of occupancy are in place. These outline the care provided, the accommodation offered and the fees paid. Contracts are signed by a designated representative on behalf of service users and retained on file for information. Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service user’s needs and goals are outlined in well maintained care plans that are person centred. Staff support service users to make choices in all aspects of their care enabling them to be as independent as possible. Good risk assessments promote independence at home and in the community. EVIDENCE: Individual care plans are in place for all service users. These are person centred and include all aspects of daily living. Care plans are well written based on information gathered at the pre admission needs assessment, participation from service users as much as possible, information obtained from relatives and advocates, and input from other health care professionals, and education establishments. Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 12 Care plans reflect the agreed care to be provided, and describes how this care is to be undertaken and the outcomes expected. Care plans are reviewed according to needs and range from weekly for one service user, to six monthly for others, with formal reviews of care being undertaken annually. Staff respect service users rights to make decisions and support them choose when they get up, what time they go to bed, how they like their daily routines of care to be carried out, what time they like to take meals, what activities they partake in, how they like to spend their leisure time, where they go on holiday and their choice of food. Service users told the inspector that they had chosen a new name plate for the home due to be delivered next week. A service user said “I can get up and go to bed when I want to”, another said “I have just been shopping for new pens for college tomorrow”. Service users are supported to take risks as part of their independent lifestyle. Risk assessments are in place and are included in individual care plane. These risk assessments do not restrict independence, but promote safety. An example of this is the introduction of a programme allowing someone to attend college on public transport. Risk assessments are reviewed regularly and updated accordingly. Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12, 13, 15, 16, and 17. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are able to take part in appropriate activities that meet their individual and collective needs. Family and community links are maintained, and the diverse needs of service users are supported. Dietary needs are being met and service users choose a menu that is nutritious, and flexible to meet their individual lifestyles. EVIDENCE: Individual activity programmes are in place which form part of the care plan. Some service users attend college at various locations and days. Two service users stated that they enjoyed this and one said “it is good to see my friends and teachers”. Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 14 On arrival at the home some service users were in the dining room having coffee, some were planning a shopping trip to buy items for college the following day, one was planning a trip to the library to exchange his books, and one had gone to the park. Four service users have funding in place to facilitate a one to one support to help with individual activities at various times throughout the day. A service user stated that he was going to Spain next month with two staff on holiday, another service user had just returned from a break in Selsey, and three service users are going to Blackpool to see the illuminations soon. All service users spoken to stated that they enjoyed going on holiday and one service user said “I like going home”. The home has its own transport and can be used to take service users shopping, bowling, and trips to the coast, cinema outings, and to the pub. Family and friendship groups are maintained and supported. Relatives and friends are welcome in the home at any time and the manager stated that the staff team had started to plan home events over the coming months for example Halloween, and Christmas. Families are encouraged to take an active part in home events and a relative stated that she was kept informed. Relatives are also consulted for their views as part of the quality assurance process. Menus are planned at service user meetings with the support of the staff, and knowledge of individual likes, dislikes, and dietary needs. Staff support service users to choose food that is fresh and in season. The choice of food offered is nutritious, wholesome, and appetising. Lunch was served during the inspection and four service users had four different choices. The main meal is served in the evening and some service users are involved in the preparation of this, others help to clear away after. Special diets are catered for and there is also access to a dietician if required. A service user said “I like to eat healthy food, and others commented that the food was good. All staff working in the home undertake training in food hygiene and safety. Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, and 20. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users receive personal care as agreed and outlined in care plans, in a way they prefer. Appropriate arrangements are in place to meet their health care needs. The medication policy in place protects service users living in the home. EVIDENCE: Staff provide flexible personal support for service users as agreed and outlined in individual care plans. A service user said “I like my shower”. All the service users looked well cared for and well groomed. During the inspection three service users were provided with professional and sensitive support during epileptic seizures. The staff team have received training to manage emergency situations in a calm and collective manner. Privacy and dignity are observed and staff were seen to interact with service users in a polite and respectful manner. They communicate well and explain Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 16 procedures to service users, sign language and gestures are also used if required. All the service users are registered with local GP’s and are well supported by the surgery. Staff arrange appointments when necessary and home visits will also be facilitated. There is also good support from the district nursing team when required. Service users also have access to dental care at the local hospital, audiologist, chiropodist, physiotherapist, speech and language therapist, diabetic nurse, and psychiatrist who oversees medication. It was possible to talk with a therapist who was visiting a service user to assess him for an arm chair in order that he may have an alternative form of seating to his wheelchair for comfort. Specialist equipment is provided for example a monitor to can record epileptic seizures in an individual bedroom. The home has a medication policy in place and all staff that administer medication have undertaken training in medication safety awareness. Boots the Chemist in Crawley provide the medication for the home mainly in blister pack format. They can also undertake occasional audits of medication. The medication recording charts (MAR) were seen and are well maintained. Medication is stored safely in a medication room. Currently there are no service users in the home that self medicate. Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22, and 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The complaints procedure and the safeguarding adult’s procedure protect service users living in the home. EVIDENCE: The home has a complaints procedure in place. This is available to all service users and their relatives on admission to the home. It is also included in the service user guide and in picture format if required. A service user said “I would tell staff if there was anything wrong”. The home maintains a complaints log and there were four complaints logged since the last inspection. These were all resolved using the complaints procedure. The home has a safeguarding vulnerable people policy in place and all staff undertake training in this during their induction. The home also has a copy of Surrey’s Multi-Agencies policies and procedures on Safeguarding Vulnerable Adults in place. A complaint was referred to the local authority recently and investigated using Surrey’s policies with a satisfactory outcome. Staff confirmed during conversation that they were aware of the safeguarding procedures and would not hesitate to report an incident of suspected abuse if necessary. Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, and 30. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is suitable for its stated purpose. Service users live in a safe, clean and comfortable environment. Communal facilities are good providing service users with ample space to meet assessed needs. Bedrooms are personalised and suit individual needs and choice. EVIDENCE: The manager showed the inspector around the communal areas of the home. It was possible to meet with most of the service users in various parts of the home and talk about the facilities provided. A service user stated that he liked to play cards in the dining room while another liked the peaceful conservatory area. Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 19 The home is well maintained and decorated to a good standard providing service users with a comfortable and safe environment to live. Some service users invited the inspector to view their bedrooms. These are tastefully decorated and personalised to reflect individual personalities, hobbies, and choice. All rooms have en-suite facilities. Communal facilities include a comfortable lounge equipped with furniture and items appropriate to the age of the service users. A spacious dining room designed to create a relaxed atmosphere at meat times and a well equipped kitchen that is accessible to service users. The home has a log cabin situated in the back garden that can be user for relaxation therapy and leisure activities. This can also be used to accommodate meeting, and a staff interview was also undertaken there during the inspection. The home has been adapted to meet the mobility needs of residents and includes assisted bathing facilities, shower room, grab rails, a hoist, and ramp access to the garden, a call bell system and a shaft lift to access the first floor. The laundry is located in a building to the side of the home and has sufficient facilities to meet the needs of the home. Infection control policies and procedures are adhered to and staff receive training in these policies. The clinical waste bin located at the front of the home was overflowing. Arrangements for the collection of clinical waste need to be reviewed to minimise the risk of infection and odour. The manager stated that this was “in hand”. Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, and 35. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are supported by a competent and skilled team in sufficient numbers to meet their assessed needs. The staff recruitment procedures protect the service users living in the home, who also benefit from a well supervised staff team. EVIDENCE: The staff duty rota was seen and indicated that sufficient staff are employed in the home throughout the day at night to meet the assessed needs of the service users. This also includes the one to one support agreed in individual contracts. There are currently four staff vacancies covered by regular agency staff. The manager explained that one post had been recruited to depending on background checks, and another interview was taking place during the inspection. Staff training and development is ongoing and all staff have development profiles in place. Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 21 The manager stated that all staff undertake induction and she is currently restructuring this training and providing written work sheets for staff. Mandatory training is in place and specific training to met assessed service user needs for example challenging behaviour, epilepsy awareness and communication skills are constantly been updated. NVQ is ongoing at various levels. Some staff have NVQ level 3 while five staff are currently undertaking NVQ level 2. Staff recruitment procedures are in place, which protect the service users in the home. Three staff employment files were seen. These are well maintained and contain the required employment documentation to include two written references, an employment history, and a Criminal Record Bureau (CRB) disclosure. Formal staff supervision takes place at least six times a year and recorded on file. Annual staff appraisal is also in place. Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, and 42 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed by an appointed manager in the best interests of the service users. The health, safety and welfare of the service users and staff are promoted to protect the people living in the home and promote a safe working environment. EVIDENCE: The service has appointed a home manager who has been in post since July 2009. She has been a registered manager within other organisations and manages the home well. She has considerable experience in caring for people Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 23 and managing care homes, she has an NVQ level 4, and her Registered Managers Award (RMA). The manager is mindful of her obligation to become registered with The Care Quality Commission and stated that she has begun to complete her application process. The home also benefits from the experience and competence of the deputy manager who has worked in the home for several years. There are also four senior support workers that make up the management team, who are all accountable to the Regional Operations Manager. Systems are in place to monitor quality assurance. Regulation 26 visits are undertaken unannounced every month, and reports retained in the home for inspection. These are detailed and any shortfalls noted are acted upon and reviewed the following month. Residents meetings are facilitated with more frequent meetings planned for the next three months. Staff meetings also take place. Questionnaires are distributed to relatives for comment, and the manager stated that she hopes to develop this practice further to stakeholders. The health safety and welfare of the service users and the staff are observed. All staff undertake mandatory health and safety training, which is updated annually. This includes manual handling, food hygiene, first aid, and infection control. Risk assessments are in place for all identified risks within the home and community participation, and to promote safe working practice. Fire safety awareness training is also provided for staff and the home has a contract in place for the maintenance of fire fighting equipment and emergency lighting. Accidents and incidents are reported and recorded appropriately. Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 4 26 X 27 3 28 4 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Version 5.3 Page 25 Whitehatch DS0000072268.V377829.R01.S.doc NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA23 Good Practice Recommendations It is recommended that the Registered Manager attends the Surrey Multi Agency Safeguarding Vulnerable Adults training when a place becomes available. Whitehatch DS0000072268.V377829.R01.S.doc Version 5.3 Page 26 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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