Care Home: Whitmore Vale House

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What the care home does well The home has a Statement of Purpose that had been reviewed in October 2007. This includes information in regard to the aims and objectives, accommodation, contracts, privacy and dignity and the staffing at the home. Assessment documentation is in place and care plans and risk assessments have been produced to ensure individual needs are met. Service users are supported to lead active and fulfilling lives. Staff respect service users` religious beliefs, and support service users to attend the church of their choosing. Physical and health care is offered in such a way as to ensure service users` personal, physical and health care needs are met. Staff having knowledge, training and an understanding of adult protection issues protect the people using the service. People who use the service are protected by the organisation`s recruitment policy and procedures. The arrangements for management and administration ensure the home is run in the best interests of service users, and their safety is promoted and safeguarded. What has improved since the last inspection? No requirements were made at the last inspection. CARE HOME ADULTS 18-65 Whitmore Vale House Whitmore Vale House Churt Road Hindhead Surrey GU26 6NL Lead Inspector Joseph Croft Unannounced Inspection 28th February 2008 10:30 Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitmore Vale House Address Whitmore Vale House Churt Road Hindhead Surrey GU26 6NL 01428 604477 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) felicia@whitmorevale.co.uk Whitmore Vale Housing Association Ms Felicia H Yarborough Care Home 20 Category(ies) of Learning disability (20), Learning disability over registration, with number 65 years of age (12), Mental disorder, excluding of places learning disability or dementia (4) Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Up to four of the residents may be within category LD/MD (Learning Disability/Mental Disorder). The age range of the persons to be accommodated will be: Up to twelve service users may be LD(E) Seven residents will be accommodated in `Treetops`, six in `Rose Flat` and seven in `Wishing Well Cottage`. 31st October 2006 Date of last inspection Brief Description of the Service: Whitmore Vale House is owned and managed by Whitmore Vale Housing Association. Their main office is situated on one floor of the original building. Whitmore Vale House is a care home divided into three self-contained living areas. These are Rose Flat, Wishing Well Cottage and Treetops and together, provide living areas for twenty people with learning disabilities. Rose flat has six bedrooms. Wishing Well and Treetops have seven bedrooms each. Each living area has a kitchen, laundry, lounge and dining room. Rose Flat and Treetops are located in the original building and Wishing Well Cottage is a detached bungalow built in the grounds, at the side of the original house, and linked by a service corridor. The weekly fees range from £730 to £850. Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 Star. This means the people who use this service experience good quality outcomes. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit on the 28th February 2008, using the ‘Inspecting for Better Lives’ (IBL) process. This visit was undertaken by Regulation Inspector Mr Joe Croft and took over six hours, commencing at 10:30 and concluding at 17:00. The registered manager assisted the Inspector throughout the site visit. The Inspector was informed that people using the service prefer to be known as service users, therefore this reference is used throughout this report. The inspection process included a tour of the premises and sampling of residents’ care plans and risk assessments. Other documents sampled included policies and procedures, records of medication, training records, staff recruitment files and health and safety records. The Inspector had discussions with the manager, two members of staff who were on duty, and six service users. Service users were observed to be appropriately cared for, and staff were attending to and supporting individuals as and when required. Service users were able choose how they spent their time. During the site visit some were in their bedrooms watching their televisions, others were in the lounge. During discussions service users informed the Inspector that they were happy living at the home, they do lots of activities, have annual holidays and attend the day centre. Two service users told the Inspector about their jobs, one in particular was very proud of their job. The Annual Quality Assurance Assessment (AQAA) completed by the home, and returned to the Commission For Social Care Inspection, has been used as a source of evidence in this report. The Inspector did not receive completed surveys at the time of writing this report. Feedback was provided to the Manager before the end of this site visit. The inspector would like to thank the manager, staff and service users for their cooperation during the inspection. Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: No requirements have been made at this inspection. One good practice recommendation has been made. The manager should produce a development plan for the refurbishment of the home. Please contact the provider for advice of actions taken in response to this Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are provided with the written information they need to enable them to make a choice about living at the home. Assessment documentation is in place to ensure the individual needs of service users can be met. EVIDENCE: The home has a Statement of Purpose that had been reviewed in October 2007. This includes information in regard to the aims and objectives, accommodation, contracts, privacy and dignity and the staffing at the home. Each service user has a copy of the Statement of Purpose and Service Users Guide, which use the widget symbols and key words that make the documents more users friendly for the service users. There are currently fifteen service users living at the home. The Inspector viewed the pre-admission assessment for the most recently admitted service user. This included a copy of the Community Care Assessment. The manager also undertakes an assessment of needs that includes information in regard to personal, social and health care needs. Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 10 The home follows the organisation’s Admissions Policies and Procedures that was last reviewed in 2003. This provides the procedures to be followed when admitting a new service user to the home, and includes requesting an assessment of need from the placing authority. Prospective service users are encouraged to make various visits to the home for a meal and to meet the staff and other service users. During discussions the most recently admitted service user to the home informed the Inspector that they did visit the home before moving in, and the manager visited them where they were staying at that time. Evidence found during the site visit supported the information provided in the Annual Quality Assurance Assessment (AQAA). Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have care plans and risk assessments in place that ensure their needs are met. Service users are supported by staff to lead active and fulfilling lives. EVIDENCE: Three care plans were sampled as part of the case tracking process. Care plans included information in regard to physical, personal and health care needs, social skills, religion, communication and activities. Statutory reviews of care plans had been conducted, and key workers had undertaken six monthly reviews. Care plans have a specific section for the recording of likes, dislikes, hobbies and interests. One service user had not signed their care plan. There was a valid reason for this, however, if service users or their relatives are not able to sign their care plans then the reasons for this should be recorded. This was discussed with the manager who stated that this would be attended to. Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 12 During discussions some service users were aware that they have a care plan, others could not remember. Staff were knowledgeable of the contents of the care plans for the service users who they key work with, and were aware of the need to review them on a six-monthly basis. Staff stated that care plans are also reviewed as and when changes occur. Staff stated they support service users to make choices for themselves, the clothes they wish to wear, food they would like to eat and daily activities. During discussions service users informed the Inspector that they make choices every day, choose what they want to do during the evenings and can have a lay in at the weekends if they so wish. Risk assessments were observed in the care plans sampled and included assessments in regard to every day life skills pertaining to the individual service user. Evidence found during the site visit supported the information provided in the Annual Quality Assurance Assessment (AQAA). Under “plans for improvement” in the AQAA it states that training in regard to risk assessment is to be provided to every member of staff. Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 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): Standards 12, 13, 15, 16 and 17 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are encouraged by staff to participate in a range of activities. A balanced diet is provided for service users. EVIDENCE: Service users living at the home continue to attend the day services that are situated in the grounds of Whitmore Vale House. Two service users informed the Inspector that they undertake paid employed, one has a paper round, and the other attends to the maintenance of the garden and grounds of a house in the local community. The manager informed the Inspector that some service users have chosen not to follow their religion, however, staff respect service users religious beliefs, and support service users to attend the church of their choosing. It was observed in one bedroom that the service user had a Crucifix on their wall. The service user informed the Inspector that they attend the local church every Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 14 week. Care plans include information in regard to service users’ spiritual orientation. During discussions staff informed the Inspector that they continually engage service users in activities inside and outside of the home that includes trips to the cinema, discos, pubs and shopping. This was confirmed during discussions with service users. Service users informed the Inspector that they enjoy doing the food shopping, going to the seaside and having their annual holidays. One service user stated that they were planning to have a holiday in Morecambe this year. As well as attending the day centres, service users partake in different activities during the evenings and weekends, and including cooking, domestic chores and cleaning their bedrooms. One member of staff stated that service users go to football matches to watch their local team. This was confirmed during discussions with one service user, who was also able to give an accurate description of other football grounds he has visited to support his football team. The manager informed the Inspector that residents are provided with opportunities to meet with other people who do not have a Learning Disability through attending external activities. Staff stated they respect service users’ privacy and dignity through knocking on bedroom doors, calling service users by their preferred names and providing personal care in the privacy of their bedrooms and bathrooms. Service users have their own keys to their bedrooms. The home follows the organisation’s Policies and Procedures in regard to Equality and Diversity, and the sampling of training records provided evidence that staff had received training in this area. During the site visit staff were observed interacting with service users, supporting them as and when required, and allowing them to have time on their own. Staff stated that they encourage service users to be as independent as they are able. The manager informed the Inspector that there are no restrictions on visitors to the home. This was confirmed during discussions with service users, who also stated that they could make and receive telephone calls in private and they receive their own mail. Staff and service users were actively involved in recycling, saving different materials in appropriate containers. The manager informed the Inspector that service users choose the weekly menu, and then partake in the shopping. Menus include meat, fish and fresh vegetables. Fresh fruit was noted to be available for service users during the site visit. Records of menus were recorded in the diary. This was viewed Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 15 during the site visit. Due to attending day centres throughout the week, service users have their main meal in the evening. Breakfast is a choice of cereals, juices, toast, tea and coffee. A cooked breakfast is provided at weekends. Staff informed the Inspector that service users could have a different meal from the day’s menu if they wish. Records of these are also maintained in the daily diary. Evidence found during the site visit supported the information provided in the Annual Quality Assurance Assessment (AQAA). Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Physical and health care is offered in such a way as to ensure service users’ personal, physical and health care needs are met. People who use the service are protected by the home’s storage and administration of medication procedures. EVIDENCE: During discussions, the manager and staff informed the Inspector that personal support takes place in the privacy of residents’ bedrooms and/or bathrooms. Information in regard to the personal support of service users was clearly recorded in the care plans sampled. Care plans sampled evidenced service users are registered with the local GP practice, and have access to a Dentist, Optician, and Chiropodist, and all National Health Services as required. Records of all medical appointments were maintained in care files. Service users informed the Inspector that they attend the various surgeries when they need to. The home follows the organisation’s Medication Policy and Procedure. Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 17 The manager informed the Inspector that two service users self medicate, for which risk assessments were in place, and no current service user was taking a Controlled Drug. The home uses the Medical Administration Record sheets (MARs) provided by the local pharmacy for the recording of medicines. During discussions staff stated that only those who have received the appropriate training administer the medication. The sampling of training files provided evidence that staff had received training in regard to medication. Medicines were appropriately stored in locked metal medicine cabinets. Records of medicines received and returned to the Pharmacist are maintained, although these were not viewed during this sight visit. The manager informed the Inspector that she undertakes monthly audits of the medication. Medication is also audited at the staff handover time. Service users informed the Inspector that they always receive their medication on time. Evidence found during the site visit supported the information provided in the Annual Quality Assurance Assessment (AQAA). Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have access to a satisfactory complaints system that enables service users and their families to raise concerns. Staff having knowledge, training and an understanding of adult protection issues protect the people using the service. EVIDENCE: The Commission For Social Care Inspection has not received any complaints in regard to the care home. The home follows the organisation’s Complaints Policy and Procedure that was last reviewed in August 2005, however, it was noted that the most recent change of address for the Commission For Social Care Inspection had been added to this document. This document included the timescale for responding to complainants and informed that the Commission For Social Care Inspection can be contacted. Each service user has a copy of this document that also includes the widget symbols and key words. Copies of the complaints procedures were on display on the notice boards. The home has a complaints/compliments book. One complaint had been received by the home since the previous inspection and was appropriately dealt with by the manager. During discussions, service users informed the Inspector that they would talk to the manager or member of staff if they were unhappy or feeling sad. Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 19 The home has a Safeguarding Policy and Procedure that was last reviewed in June 2006, and a copy of the recent Surrey Multi-Agency Safeguarding Procedures is available in the office for staff to read. Staff informed the Inspector that they had attended training in regard to Safeguarding Adults. This was verified through the sampling of four staff training files. Scenarios in respect of abusive situations were discussed with two members of staff. They were able to demonstrate an understanding of Safeguarding Adults issues and the procedures to be followed. The Commission For Social Care Inspection was informed of a Safeguarding referral that has been brought to a satisfactory conclusion, and the manager had made the appropriate referral to the Protection Of Vulnerable Adults (POVA) list. The manager informed the Inspector that service users have individual bank accounts, and the home holds small amounts of money for each person. Service users’ monies are checked every day at staff handover time. This was observed during this site visit. Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are provided with satisfactory communal and individual living space making it a safe and comfortable place to live. EVIDENCE: A tour of the communal parts of the home was undertaken, and several bedrooms were viewed. The accommodation is divided into three self-contained living areas. These are Rose Flat, Wishing Well Cottage and Treetops and together, provide living areas for twenty people with learning disabilities. Rose flat has six bedrooms. Wishing Well and Treetops have seven bedrooms each. Each living area has a kitchen, laundry, toilets and bath/shower, lounge and dining room. Rose Flat and Treetops are located in the original building and Wishing Well Cottage is a detached bungalow built in the grounds, at the side of the original house, and linked by a service corridor. Bedrooms viewed were brightly decorated and included a television, stereo/radio, photographs and personal belongings. Service users had objects Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 21 they had made in their bedroom, which included rugs, pictures and model airplanes. Service users informed the Inspector that they liked their bedrooms, and they chose the colour of the décor. All bedrooms had restrictors fitted to the windows, and service users had their own keys. Toilets and bathrooms were clean, and brightly decorated with wall tiles. Liquid soap and paper towels were provided in all bathrooms and toilets. Specialist bathing equipment was in the bathrooms that enable the needs of the ageing service users to be met. Lounge areas were appropriately decorated and furnished with sofas, televisions and stereos. Service users have unrestricted access to the communal parts of the home. There are laundry rooms that have washing machines and tumble driers. The floor of the laundry is sealed and all Control of Substances Hazardous to Health (COSHH) were kept secure in locked cupboards. The home has an Infection Control Policy and Procedure. The manager informed the Inspector that training in regard to Infection Control is covered in the Health and Safety and the Staff Induction Workbook. The home was in the process of replacing the fire doors to the bedrooms, and an ongoing damp problem in the corridor that is being attended to by the maintenance man. The manager informed the Inspector that the home does not have a development plan for the refurbishment of the home. A good practice recommendation has been made in regard to this. There is a garden that is appropriately maintained by one of the service users. There is a vegetable patch that the service user had prepared ready for the planting of vegetables. The service user had discussions with the Inspector in regard to how he attends to the garden, and how he enjoys looking after it. On the day of the site visit the home was clean, tidy and free from offensive odours. The AQAA informs that improvements during the last twelve months have included new floor coverings and the purchase of a new vehicle. Plans for improvement include more flooring to be renewed, further decoration to be undertaken and the grounds maintenance to be improved. Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing are satisfactory. Staff have the qualities and training to meet the needs of the service users. People who use the service are protected by the organisation’s recruitment policy and procedures. EVIDENCE: The home has a multi-cultural staff team that includes male and female staff. Staffing at the home consists of the registered manager, deputy manager, four senior support workers and support workers. There is one waking night staff and one sleep in duty every night. The manager informed the Inspector that there are currently twelve staff working at the home. The home works an early and late shift duty rota. There are a minimum of four staff on the early shift, two during the day and five staff on the late shift. The home currently has one waking night staff and one person covering a sleep in duty every night. The manager stated that the home is not at full capacity, and that the staffing structure at the home is sufficient for the needs of the fifteen service users currently living at the home. The manager informed the Inspector that the home continues to use the same agency staff to cover staff shortages. Staff recruitment is ongoing, and a Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 23 review of the staffing at the home is to be undertaken in light of the falling numbers of residents living at the home. The home is registered to accommodate up to twenty service users. Information provided in the AQAA, and discussions with the manager and staff informs that the home meets the National Minimum Standards in regard to 50 of staff holding the NVQ level 2 and above. Two of who hold the NVQ level 4. The sampling of four staff training files provided evidence of NVQ training that had been undertaken. The home follows the organisation’s Recruitment Policy and Procedure that was last reviewed in October 2005. The recruitment files of two recently recruited members of staff were viewed. These each contained the relevant documents as detailed in Schedule 2 of The Care Homes Regulations 2000, as amended, including an application form, full employment history, two written references, Criminal Record Bureau clearances and proof of identification. The recruitment files require attention in respect to ease of use, and would benefit from having an index of the contents. The manager stated that this was already being addressed. During discussions, service users informed the Inspector that there was always a member of staff available to help them, feel that there is always enough staff on duty and that staff at the home are very nice and helpful. Staff had received induction training and supervision records were viewed. The organisation has a staff induction book that includes all the Common Induction Standards. Other training viewed on the staff training files sampled included Communication with Autistic Spectrum Disorders, Speech and Language, Equality and Diversity and Loss and Bereavement. Under ‘What we could do better’ in the AQAA, the organisation has stated that more thorough development plans for individual members of staff and more detailed approach to training staff in understanding learning disabilities are required. Plans for improvement in the next twelve months include using a different induction format and seeking training in understanding learning disabilities. Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39, 40 and 42 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The arrangements for management and administration ensure the home is run in the best interests of service users, and their safety is promoted and safeguarded. EVIDENCE: The manager informed the Inspector that she has been working for the organisation for many years, and has managed the home since the 1990s. The manager holds the Certificate of Qualification in Social Work (CQSW) and attends the entire mandatory training as required. During discussions staff were complimentary about the manager, stating that the manager is very good, supportive and provides formal one to one supervision every six weeks. Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 25 Quality assurance is undertaken through regular meetings with service users, records of which are maintained at the home. Minutes of these meetings were also produced using the widget symbols and key words. The home holds daily staff handover meetings, which were evidenced during the site visit, and staff meetings take place every six to eight weeks, minutes of which were also sampled during the site visit. Annual surveys are undertaken to ascertain the views of service users, their relatives and other associated professionals. The last survey took place in December 2007. The manager informed the Inspector that a summary of the surveys is currently being produced. The organisation conducts monthly Regulation 26 visits, and copies of these reports were available at the home. Discussions took place with the manager in regard to the Policies and Procedures, as some had not been reviewed since 2000 onwards. The manager informed the Inspector that she has identified a member of staff who has the responsibility for reviewing all the Policies and Procedures to ensure they are in up to date and in line with current legislation. The sampling of staff training files provided evidence that staff are receiving mandatory training as required. During discussions staff stated that they receive regular training, one member of staff stated that the training opportunities provided by the organisation are very good. Staff at the home follow the organisation’s Health and Safety Policies and Procedures that were last reviewed in July 2004. Evidence of staff training in this area was viewed in the training files sampled. Information provided in the AQAA returned to the Commission For Social Care Inspection informed that health and safety records are appropriately maintained and up to date. During this site visit the following records were viewed, annual servicing and monthly testing of the fire alarm systems, fire drills, Portable Appliance Testing (PAT), although the AQAA informed that this had not been undertaken, and daily records of fridge/freezer temperatures. The fire risk assessments viewed had been dated January 2008. The manager informed the Inspector that the local fire and rescue team are to visit the home on the 5th March 2008. The home undertakes weekly checks on the hot water temperatures. The AQAA informs under ‘what has improved in the last twelve months’ that the manager has maintained the service at it’s existing standard, and continues to look at ways of improving service delivery. Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 26 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 X 3 3 X 3 X Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 27 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 YA24 Good Practice Recommendations The manager should produce a development plan for the refurbishment of the home. Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Whitmore Vale House DS0000013830.V357949.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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