Care and Social Services Inspectorate Walescareinspectorate.wales/docs/cssiw/report/inspection_reports/2118_e.pdf · Care and Social Services Inspectorate Wales Care Standards Act

Care and Social Services Inspectorate Wales

Care Standards Act 2000

Inspection reportChildren`s Residential Care

Walton Lodge

Haverfordwest

Date of publication – 24 August 2011

You may reproduce this Report in its entirety. You may not reproduce it in part or in any abridged form and may only quote from it with the consent in writing of Welsh Ministers.

Children`s Homes Report Format (XE0005.0000733147) Version 5.02 August 2006

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Care and Social Services Inspectorate Wales

South West WalesFirst Floor

Winchway HouseWinch Lane

HaverfordwestSA61 1RS

01437 75220001437 752216

Name of children`s home: Walton Lodge

Contact telephone number: 01437 721234

Registered provider: St David’s ASC (Marlowe) Ltd.Stephen Miller

Registered manager: Michael Shane Morrissey

Number of places: 4

Dates of this inspection episode from: 14 May 2011 to: 22 July 2011

Dates of other relevant contact since last report:

Date of previous report publication: 18 October 2010

Inspected by: Samantha Brace

Lay assessor:

Other regions contributing to this report:


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IntroductionWalton Lodge was registered in 2003 for four young people, male or female in the age range of 8 – 18 years on admission, with a condition that the age range of children residing together within the home, at any one time would not exceed four years.

Walton Lodge children’s home is a four bedded-detached house set in its own grounds and rurally located. The home is overlooked by one property and is accessed by a short private lane. The gardens are of an adequate size and are well maintained with trees and shrubs on its borders. Ample parking that is accessible to the home is available at the bottom of the garden. Although rurally located, local towns are easily accessible by car although public transport from the village is infrequent.

Summary of inspection findings:

What does the home do well?

The information gained from this inspection evidenced that Walton Lodge was a residential provision for young people, which operated within the boundaries of their statement of purpose. Information provided via observation, questionnaires and discussion evidenced that the young people who were residing in this setting were well cared for and had settled into routines satisfactorily. The premises presented as homely, clean and well furnished. Building and decorative work were underway to ensure that standards inside and externally were maintained.

It was observed that the day to day functions of the home were clearly centred on the young people who live there. At the time of inspection the inspector spoke with two of the three young people in placement who confirmed they were happy with their placements and were involved in making day to day decisions about their care e.g. input into menu and activity choices. Relationships observed between young people and staff appeared positive and documentation viewed evidenced that staff continued to respond professionally to difficult situations that arose with young people and had provided child focussed support during these periods. The eclectic mix of young people resident at the time of inspection appeared to be well managed by the staff team.

What has improved since the last inspection?

Stable manager and senior staff team and full staffing compliment in place.

What needs to be done to improve the service?

a.) prioritiesNone

b.) other areas for improvement The manager is continue to monitor the need for staff to complete the PRICE

training programme and ensure risk assessments are in place for when staff members who have not undertaken the training are on shift.

It was recommended that the training programme be reviewed to see if training could be delivered differently to encourage staff participation.

Training list kept in the home is to be updated. It was recommended that the stair carpet was replaced as part of the internal


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refurbishment. The office and the staff sleeping in areas would benefit from redecoration and

reorganisation as it looked well worn and both office chairs were broken.

Inspection methods

This inspection of Walton Lodge was conducted under the reform of regulations and this report includes the views of young people, professionals and staff that have an involvement with the home.

The manager and responsible individual were required to complete an annual data collection form (ADC) and a self assessment of service (SAS) document detailing specific details of the service. During the course of the inspection further evidence was obtained via direct observations and access to the company’s records. Details of the methodology used during the inspection were as follows:

Two unannounced visit to the home;One announced visit to company offices to view personnel files;Eight questionnaires to staff (six returned);Three questionnaires to young people (three returned);Discussions with staff on duty during the inspection visit;Discussions with three young people;Direct Observation and the viewing of documentation.

A detailed report about the findings of this inspection can be found in the following pages and will include any requirements and recommendations. It was not practically possible for every aspect of the operation of this home to be observed during the visit. The absence of reference to a particular fault or issue does not mean that such a fault does not exist. It was the responsibility of the registered persons to ensure that in all respects the home operates in accordance with the relevant Laws, Regulations and National Minimum Standards.


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Section one choice of home

Inspector`s findings: Walton Lodge was registered in 2003 for four young people, male or female in the age range of 8 – 18 years on admission, with a condition that the age range of children residing together within the home, at any one time would not exceed four years.

At the beginning of the inspection the occupancy of Walton Lodge consisted of two young people who had the opportunity to comment on the care that was provided within this setting. A third young person was admitted to the home during the inspection process.

Information on the home could be accessed via the internet (www.the-marlowe.co.uk), the homes statement of purpose and previous CSSIW inspection reports. The statement of purpose for the home had been developed and information provided by the manager confirmed that this document was reviewed regularly. Information gained from this inspection evidenced that Walton Lodge was at the time of inspection operating within the boundaries of their statement of purpose. Other key documents relating to the delivery of services were contained in the company’s main policies portfolio and were intended for reference alongside the statement of purpose.

Discussions confirmed that ideally the admission process for Walton Lodge followed a period of assessment. The service manager for the organisation would initially deal with referrals directly with the placing authority. Referrals were then discussed with the manager of the home, where decisions were made if the placement of that young person would be suitable. Following information sharing with the staff team, contact was initiated between the manager and the young person and their family and a visit to the young person at home was undertaken. Staff said that young people together with their families (where appropriate) were actively encouraged to visit the home prior to admission in order to meet with staff and other young people in placement. A handbook for children and young people developed by the organisation was given to young people during these initial stages of placement and could be used as an induction tool during their admission to the home.

No social workers responded to contact made by CSSIW during the inspection process, so their views on the service or admission process could not be ascertained.

Requirements made since the last inspection report which have been met:

Action required When completed Regulation number

Requirements which remain outstanding:

Action required(previous outstanding requirements)

Original timescale for completion

Regulation number


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New requirements from this inspection:

Action required Timescale for completion

Regulation number

Good practice recommendations:


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Section two - Planning individual needs and preferences

Inspector`s findings: During the course of this inspection the inspector had access to files relating to the young people placed at the home. There was evidence that information relating to young people was accessible, comprehensive and appropriately documented. Files contained relevant information on profiles, contact records and consents for activities. Records included the home’s care plan, file notes and monthly progress reports together with daily record sheets and weekly planners. Information was also available on individual profiles, planning meetings and other information related to the young person’s health needs.

Young persons’ files were stored within the locked office at the home.

It was evidenced that prior to admission to the home the manager or a senior staff member started an organisational care plan for each young person. This was updated and amended during the first few weeks of placement to allow for the young person to have initially settled and to give staff the opportunity to get to know the young person better. The care plans observed during the inspection were linked to the plan of care that was provided by the placing authorities once the looked after children (LAC) documentation was received. Evidence was observed that these care plans were reviewed when appropriate.

Evidence was observed that during the review process young people in placement were encouraged to participate and express their views. The inspector observed documentation that evidenced that statutory reviews were being undertaken. These reviews were recorded and the documentation was seen to be placed on the young person case file.

It was observed that the mix of young people in placement at the start of the inspection was appropriate: however the impact of the admission of the third young person could not be judged at this time. Discussions with the manager and staff indicated that any placements to the home were carefully monitored to ensure that staff could appropriately supervise and support the young people.

Appropriate consideration was observed to be given to the confidentiality, privacy and dignity of young people. Staff said that they and the young people met together informally on a daily basis, at mealtimes and during leisure activities. It was noted that more formal get-togethers such as recorded ‘house meetings’ and key working sessions were being provided to ensure the young people had opportunities to discuss items with staff members and share their views.

Therapeutic work that was requested within care plans was being provided by an in-house psychologist and an assistant on a regular basis. Female and male staff members work within this home to ensure the young people have appropriate role models of either gender.


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Regulation number



Regulation number



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Section three – Quality of life

Inspector`s findings: St David’s Alternative Support Centre (ASC) had policies in place on how young people were catered for with regards to clothing, pocket money and any monies required for leisure activities etc. This information was documented in section 19 of the statement of purpose and formed a part of the care planning for each young person. Information on these issues was also observed to be available to young people in the children’s guide.

Discussions and information received evidenced that the management and staff of Walton Lodge were clear that budgeting was to be an essential part of every young person’s living skills development. Evidence was observed that young people were provided with pocket money appropriate to their age and understanding. Pocket money was issued on a Tuesday and Friday with a portion being paid into savings. The young people were provided with a key to their bedrooms if appropriate and they had access to lockable lockers sited inside the staff office to store any valuables.

It was verified within documentation viewed and discussions with staff that education and leisure opportunities had been promoted for the young people within this setting. Staff and the manager stated that young people within the home were enabled to pursue their particular interests and were encouraged to become involved in off-site activitiesappropriate to their understanding and needs. It was evidenced during the inspection that young people were treated as individuals and although some joint activities were undertaken, they were also encouraged by staff to attend activities separate from each other. Two of the young people spoken to during the inspection confirmed that they had been provided with opportunities to pursue leisure activities but at the time of the inspection, neither wanted to attend any regular clubs or activities. When identified, young people could be supported in attending their activities by staff that used designated vehicles belonging to the company. It was noted that young people resident at Walton Lodge had a range of activities available to them at the home, which included a table tennis table, TV and DVDs together with books, games, arts and crafts etc.

Discussion with the manager evidenced that risk assessments on young people’s activities were undertaken. Therefore, all potential risks would be explored prior to young people engaging in pursuits. This area was not inspected thoroughly during this inspection episode.

Contact arrangements as stipulated in the young persons’ placement plans were observed to be adhered to. Much evidence was observed that staff had facilitated appropriate contact with family, friends, health practitioners and social workers from the young persons’ home areas. Appropriate written records were seen of external contacts and visits.

There was access to a payphone within the home that accepted coins and phone cards.Where it was deemed appropriate young people were allowed mobile phones but the manager said that certain restrictions were implemented such as handing them in to staff at night. If social workers indicated that any phone contact was limited this would be recorded in the care plan and use of the mobile phone would then be closely monitored by staff.


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It was noted that each young person’s care plan contained details of how that young person would be educated. Wherever possible young people who were long term placements within this setting would be encouraged and supported to attend mainstream school. However, where this was not possible an educational facility was provided by St David’s Alternative Support Centre school, which was regulated and approved by ESTYN. This educational provision was situated at the same site as the main offices for the organisation with separate teaching staff employed. At the time of the inspection one young person was using the in-house educational facilities. The other young person had left mainstream education and was being supported in looking for higher educational opportunities in a local college. The in- house school was winding down towards summer leave so the educational aspect of their care was not looked at in any detail.

The staff were actively supporting one young person maintain a part time job in the local village.






Regulation number



Regulation number



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Section four- Quality of care and treatment

Inspector`s findings: During the period of inspection it was evident through discussion and documentation that staff at Walton Lodge were aware of the background of each young person and the circumstances that led to their admission to the home. In the main, staff were observed to be professional in attitude and appropriately firm when necessary. The relationships between staff and two young people that were observed during the inspection were deemed to be appropriate. Staff members observed and spoken to were professional in attitude and caring.

Each young person was appointed a key-worker to provide individual support and guidance through key-working sessions. Evidence was observed that staff would source an advocate – independent of the home – for the young person if they had not already been appointed one by the placing authority.

Discussion with and information received from staff indicated that clear boundaries were set for the young people with expectations of what was required from them with regards to behaviour. Young people were made aware of consequences of their actions including sanctions and methods of control (restrictive intervention) which could be used. Staff commented that good behaviour was encouraged and acknowledged via positive reinforcement.

Documentation received evidenced that an appropriate behaviour management policy was in place at Walton Lodge together with periodic training. Discussions with staff identified that individual support had been provided to young people when required and that they were expected to focus on promoting socially appropriate and acceptable behaviour in young people in line with policy documentation.

Discussions and information observed indicated that staff were aware of their responsibilities to the young people in residence and that restraints were only used when the care and safety of young people, staff or property were at risk. Since the last inspection of the service the organisation had introduced new physical intervention training for all staff. The training had changed from Non Violent Crisis Intervention (NVCI) to Protecting Rights in a Caring Environment (PRICE). Any instances of restraint were observed to be appropriately recorded within incident reports and in a separate bound book. One staff member spoken to had not undertaken the PRICE training and information observed indicated that there was not another course available until early September 2011. It was discussed with the manager that staff could not be using different methods of intervention within the home and he confirmed that the staff member was working alongside others and would not be expected to be involved in any physical intervention until the training had been completed. Incident reports were sampled and were observed to have been recorded appropriately, recording intervention used and sanctions applied. It was observed that the manager formally checked records as part of monitoring for the home. This information was also assessed by IQA Wales in line with Regulations 32 and 33.

Evidence observed during the inspection and within the SAS indicated that the particular provisions of Regulation 20(2) were in place with regard to health support for young people. Medication records and supplies were not checked as part of this inspection


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episode.

The kitchen and dining area were observed to be the place where a large amount of socialising between the staff and young people occurred. Evidence indicated that the food was of a good quality and there was plenty available within the fridges and freezers observed by the inspector. Fresh fruit was also available for the young people.

Evidence was observed that staff were attempting to involve the young people in placement in the planning, shopping and preparation of food should they wish and the manager said that the staff worked with individual young people to try to develop independent living skills appropriate to their age and ability.






Regulation number



Regulation number

Good practice recommendations: The manager is continue to monitor the need for staff to complete the PRICE training programme and ensure risk assessments are in place for when staff members who have not undertaken the training are on shift.


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Section five – Staffing

Inspector`s findings: Information submitted prior to the inspection within the Self Assessment of Service (SAS) and discussion with the manager confirmed that the organisation have a rigorous and effective recruitment procedure which deemed staff suitable to work with young people. This information verified that all staff had current Criminal Records Bureau disclosure checks that were updated every 3 years. Following the completion of the induction standards framework during their probation period, staff were registered with the Care Council for Wales. The manager said that potential new members of staff were formally interviewed and references were taken up prior to the commencement of employment. No volunteers were used to carry out any duties. Individual staff personnel files were examined during this inspection episode and were observed to contain the information required by Schedule 2 of The Children’s Homes (Wales) Regulation 2002. They also contained interview notes and contracts of employment. It was noted on each files viewed that the contract of employment was not signed by the employee. This was discussed with the office manager who confirmed that staff were provided with the opportunity to return signed copies but if they did not the covering letter sent out with them explained that non return would constitute acceptance of the conditions.

Information provided in the SAS received 14 June 2011 indicated that the staffingcomplement of the home consisted of one manager, three senior residential care workers and thirteen residential care workers. Discussions with the manager and staff team indicated that the home was operating with a full staffing compliment although one staff member was on maternity leave. Discussions with staff evidenced that they had received an induction into the home, which had covered a variety of areas such as the statement of purpose, current legislation, company policy and procedures and an understanding of the national minimum standards. During probation, staff were expected to complete a Candidates Induction Standards workbook with their mentors and this could be cross-referenced to the NVQ qualification when registered. Evidence of completed workbooks was observed within personnel files. Fourteen of the sixteen staff members (not including the manager) had or were in the process of undertaking an NVQ qualification at level 3 in caring for children & young people, two staff members required registration onto an appropriate course. The manager confirmed that these staff members would be registered once induction had been completed. To meet the requirements of Regulation 25 (1A) from 1 July 2010 80% of the care staff must hold a relevant qualification. At the time of inspection Walton Lodge was meeting this quota.

Staff spoken to during this inspection identified that they were provided with appropriate leadership by the manager and senior staff members of the home.

A collection of policy and procedure documents were in place to guide staff and promote good practice. Some training was provided to probationary staff on policy and procedures, however the manager stated it was an expectation that staff continue to update their knowledge of these documents on a regular basis. The documentation included comprehensive information about the way in which the company expects its staff to work.

Discussion with the manager and staff and observation of training files confirmed that mandatory training was being accessed by staff members at regular intervals and annual


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updates were being provided on key areas including Child Protection and Physical Intervention. It was stated that some of the training provided had not been reviewed for a number of years and because of this staff were finding the training repetitive. Although staff commented that they understood that some training was difficult to change due to the message being given, the inspector still recommended that the training programme be reviewed to see if it could be delivered differently to encourage staff participation. A list of upcoming training for staff was kept within the home but at the time of inspection was out of date and needed updating.

Documentation and discussion evidenced that appropriate levels of supervision and appraisal were being maintained for staff within this setting. Individual supervision or appraisal documentation was not examined during this inspection period.

Staff indicated that they had no concerns with the care that was provided at the home. They also indicated that they felt valued by the management of the home and that they were given the opportunity to contribute their ideas and make suggestions.

A staffing rota was seen at the time of inspection, which showed that on average, two staff members were on duty to support three young people resident. This was acceptable as no young person had been identified as requiring 1:1 support within the documentation provided by placing authorities.

A staffing rota was seen at the time of inspection, which showed that there were generally a minimum of two staff members on duty throughout a 24-hour period to support two young people, with a third staff member providing cover to another house within the organisation. However the manager confirmed that with the admission of a third young person to Walton Lodge, the cover being provided to other houses had ceased. This encouraged staff to complete 1:1 work with the young people in placement.

Walking night staff were in place within this setting provided by agency staff members. St David’s ASC continued to have a contract with Allied Health Care which detailedinformation to ensure agency staff had the appropriate checks undertaken to enable them to work within a children’s home. This document was not inspected during this episode






Regulation number



Regulation number


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Good practice recommendations: It was recommended that the training programme be reviewed to see if training could be delivered differently to encourage staff participation.Training list kept in the home is to be updated.


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Section six – Conduct and management of the service

Inspector`s findings: St David’s ASC had a company structure as outlined in their operational guidelines that informed lines of responsibility and accountability within the service. Structures were in place for policy and decision making together with lines of communication between directors, managers and care staff.

It was the opinion of the inspector during this inspection episode that the managementand administration of Walton Lodge was efficient and sound. Observation, records, discussion with staff, young people and ongoing contact with this home confirmed that the manager was capable and effective. The manager of this home had NVQ 4 in caring for children & young people and an Institute of Learning & Management (ILM) management qualification. Evidence was observed that the manager was also registered with the Care Council for Wales.

Reports produced by IQA Wales, an independent quality assurance firm employed to undertake the statutory monthly visits to the home in compliance with Regulation 32, were focussed, objective and critical where appropriate. A Regulation 33 report for June 2011 was observed by the inspector which had been completed by a senior staff member. The report followed the requirements of Schedule 6 and recorded evidence of consultation with social workers, young people and staff members. An annual quality assurance document for the service with actions was not observed as part of this inspection.

The responsible individual visited the region on a regular basis and may have contact with the manager of the home on these occasions. However this would not necessarilybe through a visit to the home and would more likely occur during the weekly anagement meetings held at the registered office. Monitoring of the home was undertaken by the regional care manager on behalf of the company director, who was the registered person.

Discussions with staff indicated that the manager monitored the practices and routines in the home as part of a daily schedule. This was observed in practice during the inspection. Lines of accountability for the manager were clear.

The manager maintained the weekly budget in conjunction with staff members, which was used for the purchase of food, provision of pocket money and also monies for personal and recreational use. No issues were highlighted in relation to finance and access to the company accounts was not requested during the inspection.




Action required(previous outstandingrequirements)


Regulation number


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Regulation number



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Section seven – Concerns, complaints and protection

Inspector`s findings: Organisational procedures for complaints & representations were observed to be in place as required by Regulation 24 and it was indicated that young people knew how to make complaints on any aspect of their care. The Children’s Guide included contact numbers for the Children’s Commissioner, Child-line, NSPCC and CSSIW. It was stated that young people could also access an advocacy service via their placing authorities should they require additional support. Discussions and evidence observed indicated that staff were aware of their responsibilities in respect of the safety of young people in their care.

Evidence observed during the inspection indicated that the young people were empowered and supported in following complaint processes and that each concern was taken seriously and appropriately addressed. The manager gave the young person a written response to each complaint recorded. No complaints remained outstanding at the time of the inspection.

The safety and welfare of children within the home was promoted by accessible policies and guidance which were available to staff and young people living at Walton Lodge. The home had a company child protection policy that was observed to be consistent with Local Safeguarding Children’s Board procedures. The lead person for all child protection concerns was the manager, who informed the responsible individual accordingly. Information recorded within the SAS verified that all complaints, child protection and other significant events were dealt with in line with company policy and procedure, All Wales Child Protection procedures and other appropriate legislation.

A company policy on bullying was in place. The document identified the effects of bullying and offered strategies for prevention and response. A statement on equal opportunities was an integral element of the company’s policy on dealing with bullying. There was a ‘no blame’ approach to bullying but it was stated the all incidents were monitored and action taken if necessary. The SAS indicated that each home within the organisation was assigned a person who had received appropriate training and who the manager perceived as having the right skills to deal with any bullying incidents.

A policy for children and young people absent without permission was in place and gave comprehensive guidance to staff with regards to the definition of absconding and strategies to use with young people who go missing. The home voluntarily notified CSSIW in the event of a young person absconding and all significant events were notified to appropriate persons, as required by Regulation 29. The SAS identified the writing of significant event forms as an area of development for senior carers within the home.




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Regulation number



Regulation number



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Section eight – Physical environment

Inspector`s findings: Walton Lodge children’s home is a 4 bed-detached house set in its own grounds and rurally located. The home is overlooked by one property and is accessed by a short private lane. The gardens are of an adequate size and are well maintained with trees and shrubs on its borders. Since the last inspection, the garden area had been levelled and some shrubs on the lawn had been removed to provide a better play area. Ample parking that is accessible to the home is available at the bottom of the garden. Although rurally located, local towns are easily accessible by car although public transport from the village is infrequent.

The design and location of the home were in keeping with the current statement of purpose. The accommodation continued to serve the needs of the service users. Young people had their own bedrooms that were observed to have been decorated appropriately and with the input of the young person. Evidence was seen that the young people were provided with opportunities to personalise these rooms and the rooms observed during the inspection were seen to contain items that were personal to each young person.

At the time of inspection the home was observed to be undergoing building and decorative work both inside and out. The outside of the building had scaffolding up so that the house could be re-rendered, window sills and windows needing attention could be replaced and general maintenance to gutters and the roof could be undertaken. This work was being undertaken by an outside contractor; therefore the staff were aware thatextra risk assessment and supervision was required at this time.

Internally the home was generally in good decorative condition and homely in appearance. It was noted that the manager has continued with the upgrading of internal decorative work, with the dining room already benefiting from repainting. The furnishings and fittings in the home were of a good quality and were observed to be in good condition. However the carpet on the stairs was very stained from the actions of some previous residents and although staff had tried to deep clean it, the stains had remained. It was recommended that the stair carpet was replaced as part of the internal refurbishment. The home was warm and hygiene was observed to be of a good standard. There were facilities for young people’s use including good cooking facilities and laundry equipment.

Adequate bathing facilities were seen to be available. All facilities were clean, adequately heated and offered privacy for the young people. Some damage had occurred to a door in the upstairs bathroom which had been replaced but was in need of painting.

The staff office was kept locked to ensure the security of files and information and provided space for staff sleeping in to use. The office was tidy and well organised, however this and the staff sleeping in areas would benefit from redecoration and reorganisation as it looked well worn and both office chairs were broken.

The inspector did not identify any unnecessary hazards or risks within the home. Health and safety matters were the responsibility of the manager and any issues were discussed in supervision and in line with Regulations 32. It was recorded in the SAS that all staff were provided with training in First Aid and Food Hygiene, cleaning schedules were in


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place and one staff member was assigned responsible for fire safety. Specific documentation relating to these items was not inspected during this inspection episode.






Regulation number



Regulation number

Good practice recommendations: It was recommended that the stair carpet was replaced as part of the internal refurbishment.The office and the staff sleeping in areas would benefit from redecoration and reorganisation as it looked very worn and both office chairs were broken.


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Section nine – Specialist provisions

Inspector`s findings:

N/A to this setting.






Regulation number



Regulation number



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A note on CSSIW’s inspection and report process:

This report has been compiled following an inspection of the home undertaken by Care and Social Services Inspectorate Wales (CSSIW) under the provisions of the Care Standards Act 2000 and associated regulations.

The primary focus of the report is to comment on the quality of life and quality of care experienced by service users.

The report contains information on how we inspect and what we find. The report is divided into distinct parts reflecting the broad areas of the National Minimum Standards.

CSSIW`s inspectors are authorised to enter and inspect children’s homes at any time. Inspection enables CSSIW to satisfy itself that continued registration is justified. It also ensures compliance with:

The Care Standards Act 2000 and associated regulations, whilst taking into account The National Minimum Standards for Children`s Homes.

The home’s own statement of purpose.

Children’s homes are inspected annually by CSSIW At each inspection episode there are visit/s to the service during which CSSIW may adopt a range of different methods in itsattempt to capture service users` and their relatives`/representatives` experiences. Such methods may for example include self-assessment, discussion groups, case tracking and the use of questionnaires. At any other time throughout the year visits may also be made to the service to investigate complaints and to respond to any changes in the service.

Readers must be aware that a CSSIW report is intended to reflect the findings of the inspector at a specific period in time. Readers should not conclude that the circumstances of the service will be the same at all times.

The registered persons are responsible for ensuring that the home operates in a way which complies with the service specific regulations. CSSIW will comment in the general text of the inspection report on their compliance. For those regulations which CSSIW believes to be key in bringing about change in the particular service, they will be separately and clearly identified in the requirement section.

As well as listing these key requirements from the current inspection, requirements made by CSSIW since the last inspection, which have been met and those which remain outstanding are included in this report. The reader should note that requirements made in last year’s report which are not listed as outstanding have been appropriately complied with.

Where key requirements have been identified, the provider is required under Regulation 33B (Compliance Notification) to advise CSSIW of the completion of any action that they have been required to take in order to remedy a breach of the regulations.

The regulated service is also responsible for having in place a clear, effective and fair complaints procedure which promotes local resolution between the parties in a swift and satisfactory manner, wherever possible. The annual inspection report will include a summary of the numbers of complaints dealt with locally and their outcome.


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CSSIW may also be involved in the investigation of a complaint. Where this is the case, CSSIW writes a summary of that complaint. CSSIW will also include within the annual inspection report a summary of any matters it has been involved in together with any action taken by CSSIW.

Should you have concerns about anything arising from the inspector’s findings, you may discuss these with CSSIW or with the registered persons.

Care and Social Services Inspectorate Wales is required to make reports on registered facilities available to the public. Most reports are public documents and will be available on the CSSIW web site: www.cssiw.org.uk. However, in order to protect the interests of children the reports on children’s homes will not be available on the web site. Persons requiring a copy of a children’s home inspection/complaint report should contact theregional office for the area within which the home is located.

Documents

Care and Social Services Inspectorate Walescareinspectorate.wales/docs/cssiw/report/inspection_reports/2118_e.pdf · Care and Social Services Inspectorate Wales Care Standards Act