Inspection on 06/06/05 for Whitby Dene

This inspection was carried out on 6th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Whitby Dene 24/07/07

Whitby Dene 13/12/06

Whitby Dene 13/07/06

Whitby Dene 10/11/05

Whitby Dene 10/01/05

Whitby Dene 17/05/04

Whitby Dene 22/01/04

Whitby Dene 01/07/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Whitby Dene 316 Whitby Road Eastcote Ruislip, Middlesex HA4 9EE Lead Inspector Jane Collisson Unannounced 6th June 2005 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 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 Older People. 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. Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Whitby Dene Address 316 Whitby Road, Eastcote, Ruislip, Middlesex,HA4 9EE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 868 3712 0208 866 6792 Care UK Community Partnerships Ltd Ms Razia Mehdiali Ghogham Care Home 60 Category(ies) of Old Age and Dementia registration, with number of places Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 10/1/05 Brief Description of the Service: Whitby Dene is a purpose built care home owned and managed by Care UK. Located in a residential area of Eastcote, there is a small parade of shops within walking distance. The home provides personal care for sixty older people. On the ground floor are a 20-bed dementia unit and a 10-bed Intermediate Care Unit which offers short-term rehabilitation. The first floor has accommodation for 30 frail elderly people. There is also provision for respite care for two service users and one emergency bed is retained. The majority of the beds are commissioned through the London Borough of Hillingdon. There is a large enclosed garden and a car parking to the front. There are lounges and dining rooms in each of the units. All bedrooms are single and each has an en suite toilet and washbasin. There are assisted bathrooms in all areas and additional toilets near to communal areas. The home has a Registered Manager, six team leaders, a large team of senior carers, support workers and ancilliary staff. The Intermediate Care Unit is staffed by support workers from the home, a physiotherapist and an assistant, funded by the Primary Care Trust, and an occupational therapist and an assistant, funded by the London Borough of Hillingdon Social Services. Regular visits from a doctor are also made to this unit. District nurses visit all areas of the home, on a daily basis, to give nursing input such as wound care, diabetes treatment and monitoring of other health care needs.General Practitioners, dentists, opticians and chiropodists are accessed as required. Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 6th June 2005, for nine hours, from 9.50am to 7.10pm. The Registered Manager was present at the inspection. The home had ten vacancies, five in the Intermediate Care unit. Improvements in the management of the home were found and there was a pleasant, relaxed atmosphere in the home. The last inspection of the home, which was announced, took place in January 2005 and thirty three requirements were made. The majority of these have been fulfilled with six remaining outstanding or only partially completed. An additional eight requirements were made on this inspection, including an Immediate Requirement for the home to have regular fire drills with all of the staff. The Registered Manager reported that these had commenced shortly following this inspection. There have been problems with the drainage for some time and repairs were in the process of being carried out. An area of the garden had to be cordoned off and the Registered Manager confirmed that risk assessments and procedures were in place to ensure service users’ safety whilst this work was being undertaken. All of the units were visited on this inspection and the majority of the service users were seen. Activities were taking place in the dementia unit. The garden is maintained by the handyman and the Activities Coordinator, who had taken some service users to the garden centre in the afternoon. Service users are encouraged to assist in the garden if they wish to do so. The families of two service users were met during this inspection and expressed their satisfaction with the care provided. Many of the service users, because of dementia or frailty, were not able to fully express their views about living in the home. Those staying temporarily in the Intermediate Care unit, generally for up to six weeks, were very appreciative of the support offered. A concern regarding communication was identified in this unit. The Registered Manager is aware of the concerns and said that steps are being taken to improve this situation. The Registered Manager has now been in post for almost a year, following a long period of management staff changes. The atmosphere was relaxed and staff were positive about working in the home and about the management. Although there were repairs required in areas of the home, these were in hand. The home is generally well maintained and provides a pleasant environment. Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 6 Changes are planned for the dementia unit to provide a relaxation area that should be of benefit to the service users. What the service does well: What has improved since the last inspection? What they could do better: The Registered Manager needs to ensure that all of the health and safety procedures, such as fire drills, take place on a regular basis. Prospective service users and their representatives need to be informed of the fees that may be payable to enable them to make an informed decision about moving into the home and should be supplied with details of contacts from the Local Authority regarding their care and support. Care plans need to be produced, when the assessments are completed, to ensure that it can be seen that the service users’ needs and preferences have been taken into account and support will be provided appropriately from when the service users enter the home. The home has specialist units for dementia and rehabilitation and it needs to be shown that the staff have both basic and specialised training to provide the best possible support to the service users. Staffing levels in the dementia unit need to be kept under regular review to ensure that activities and supervision can be maintained. The home reports a high number of falls. Whilst major injuries are few, and risk assessments are carried out, it needs to be shown that these are updated appropriately after accidents to try and prevent reoccurrence. Better recording of meals taken by the service users is required to show that a nutritious and balanced diet is provided. Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 7 Whilst the opportunities for training have improved, the induction records need to be available for inspection and all staff, including bank staff, need to have all of the basic training courses. Some further work is required on recruitment and employment procedures. The requirement for staff to have one-to-one supervision needs to commence to both support and develop the staff team. A review of the quality of care provided in the home is needed to highlight improvements and to identify any shortfalls so that action can be taken to address these. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4, 6 The information to assist permanent service users and their families to make a decision about living in the home are in place. The information available in the Intermediate Care unit requires updating and communication, with the service users and their families, improved to ensure they know about the home and its procedures. The assessment processes are in place but there is room for improvement. EVIDENCE: The requirements regarding the Statement of Purpose and the Service Users Guide, made at the inspection in January 2005, have been carried out. A “Welcome to Whitby Dene” pack is available and service users and their representatives now have the information to support them with their choice of home. However, the information in the Intermediate Care unit needs to be improved. The Registered Manager was aware of this and was putting in place meetings with the service users and the representatives, upon admission, to ensure they are aware of the services available. The written information about the unit is also due to be updated. Although a sample copy of the contract is provided in the Service Users Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 10 Guide, the full details of the fees payable may not be available until some weeks after the service user has been admitted. The Registered Manager has had a meeting with the London Borough of Hillingdon to try and resolve this issue. It was a requirement at the previous inspection that service users should be aware of this information to enable them to make a decision about entering the home and every effort must be made to ensure that service users have this information. Service users are also required, under the Care Homes Regulations 2001, to have a copy of the Local Authority agreement and this also needs to be made available to them. At the previous inspections made to the home, the quality of the referral information from the Local Authorities, regarding prospective service users, was found be variable. The Registered Manager said that there have been improvements but further progress can be made. The home’s senior staff carry out a pre-admission assessment of each service user. One recently admitted service user did not have any care plans in place to demonstrate that her needs had been fully considered and her wishes taken into account. These should be prepared from the assessment so that appropriate care is being provided from admission. It has been a concern at previous inspections that service users in the dementia unit did not have sufficient specialist facilities or staff input to provide the necessary stimulation. The Registered Manager explained that plans were in hand for improvements, including the use of visual prompts, such as photographs, an orientation board and having the handrails painted in contrasting colours. The second lounge in the dementia unit is seldom used and the Registered Manager said that a relaxation room is planned which will have a water feature and other soothing equipment. Not all of the staff have had dementia training. For the staff who work regularly in the unit, training in specialised activities and more advanced courses in dementia care should form part of the staff team’s development. The Intermediate Care unit, for ten people, provides an opportunity for service users who have been in hospital to have rehabilitation, usually for up to six weeks, to enable them to return to their own homes. The service users and relatives met during this inspection were appreciative of the support the unit provides. An Occupational Therapist and assistant, employed by London Borough of Hillingdon and a part-time locum Physiotherapist and assistant, employed by the Primary Care Trust work in the unit. The care staff are employed by the home. Some communication concerns were identified, of which the Registered Manager was aware and was taking action to improve. There is no separate manager for the unit. Because of the number of different disciplines involved in this unit, and the high number of changes of service users, it is recommended that consideration should be given to having separate management cover for the unit. Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 The information on care plans and recording of health needs have improved and in the files examined were found to be satisfactory. The service users were seen to be treated with respect. EVIDENCE: It has been an ongoing concern that the information received from the care managers referring service users was, at times, inadequate and sometimes illegible. Referrals were being made at short notice and details faxed to the home. This has resulted in the full details of the service users not being available. In the files sampled, some improvements were noted, but the Registered Manager said that discussions are still ongoing to improve this situation. At the present time, standardised Care UK documentation is being used for care plans and risk assessments. A new computerised system is to be introduced. The service users’ files examined on this inspection showed that care plans were in place, except for one new service user, including those for personal care, mobility, nutrition and orientation. A night care plan is in place for each service user which includes their preferences and how often checks will be made by staff. Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 12 Risk assessments on moving and handling, skin integrity, the risk of falls, and nutrition are made and reviewed. Notes in the files examined indicated that the service users’ health care needs are being met satisfactorily. Notes were seen on appointments with the General Practitioners, opticians and other professionals. The District Nurses were in the home on the day of the inspection, and said that they visit daily to carry out a variety of tasks, including changing dressings and diabetic testing. The home’s staff report appropriately to the Commission for Social Care Inspection when falls, and other accidents occur. There have been a large number recorded, although these have diminished recently. Risk assessments were not always being updated after accidents, to minimise reoccurrence. One risk assessment seen was reassessed after a service user fell recently. The risk assessment did not indicate that the risk had increased significantly, although service user’s history suggested otherwise. The staff carrying out risk assessments need to have had sufficient training to make the assessment and this needs to be demonstrated. The occurrence of falls needs to be monitored to see if any patterns emerge where action could be taken to reduce them. The Registered Manager said that staff have had medication administration training from the pharmacist, and competency testing by another home’s manager. This was in response to a requirement to evidence that staff have had required training to ensure that service users’ health and welfare needs are being met. This information was not included in the training record supplied and needs to be added. The wishes of the service users, in respect of the gender of the staff who provide personal care, is now being recorded and evidence of this was seen in the files. It is not the Registered Providers’ policy that same gender care should always be given but that choice should be offered. Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15 There was evidence that the service users have some opportunities to participate in social activities and that improvements have been made to train and encourage staff to provide them when the Activities Coordinator is not present. However, for the large number of service users in the home, particularly those with dementia, there is insufficient time or staffing for individual activities to take place. EVIDENCE: There is one Activities Coordinator employed in the home who provides the activities programme for up to sixty service users. Not all of the service users’ care plans had details of the activities they enjoyed. It has been the subject of previous requirements that the provision of activities needs to be kept under review to show that those available meet the needs of all of the service users. The Activities Coordinator has been involved in helping to train staff to provide activities when she is not available, particularly at weekends. Some activities were taking place on the day of the inspection, in the dementia unit, and several service users had percussion instruments to accompany the recorded music. The Activities Coordinator also took some service users to the garden centre and is encouraging those who are able to assist with light gardening. The Registered Manager intends use one of the lounges in the dementia unit as a relaxation area with a water feature and this should be Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 14 beneficial for those who find the larger, more crowded, lounge too busy. This may have implications for the staffing levels as sufficient staff will be needed to ensure the adequate supervision of the service users and this needs to be kept under review. A diary is kept of those activities held and who participated in them. Scrabble, card games, bingo, reminiscence and manicures were seen to have taken place. Church services are held on a regular basis. The Activities Coordinator raises funds for any social events, outings and items required for the activities, as there is no budget for these. A Garden Fete was due to be held in July for this purpose. Although there have been improvements, it remains to be shown that there are sufficient staff to provide activities, including one-to-one time, for all of the service users, particularly those in the dementia unit. There needs to be sufficient staff to enable service users who wander to be supervised. This is particularly important in the summer, when they may prefer to walk around the garden or could benefit from a visit to the local shops or pub. Service users are able to have friends and family to visit and there is sufficient space in the bedrooms for service users to entertain them in private if they wish to so do. Service users confirmed that there are no restrictions. Two families were met during this inspection who expressed satisfaction with the home and were complimentary about the staff team. The Registered Manager has arranged meetings for service users’ representatives but has not found these to be well supported. Lunch was being served during this inspection and a choice of chicken casserole or vegetable plait was available. Few seem to choose the second option, which is normally vegetarian, and it may be that there needs to be a better variety. At the last inspection, there was a limited choice of vegetables being served but three, in addition to potatoes, were served at this meal. However, these were all found to be quite bland in taste. The Registered Manager had recently undertaken a survey with the service users about the food but this had not yet been analysed. One service user remarked that the food was of “poor quality” with “too many baked beans”. Other service users said that they were generally satisfied with the food although none were aware of what was to be served on the day. Menus were not displayed in a suitable format, such as in large print or on a board, for them to see. It is recommended that work is carried out to provide the service users with more accessible information to encourage them to see the choices available. The Registered Manager said that there was to be a review of the catering budget shortly which was noted to be £15 per week per service user at the last inspection. Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 15 It was required at the last inspection that the home needs to show that the meals are recorded in sufficient detail to ensure that their nutritional needs are being met (Regulation 17 (2), Schedule 4 (13) of the Care Homes Regulations 2001). This included any special diets provided. There was no evidence of this being carried out in sufficient detail, apart from a record of the meal chosen, and needs to be addressed. Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 The procedures are in place should complaints and adult protection issues arise. Service users need to be reassured that any concerns, however, small, are worth raising with staff and that they will take action to resolve them. EVIDENCE: Only one complaint had been recorded since the last inspection, which has been satisfactorily resolved. Service users spoken to were aware of the complaints procedures and to whom they would complain. However, one service user felt that it was not worthwhile making a formal complaint about a small concern. It is recommended that the management and staff, in consultation with the service users, look at ways, in which “grumbles” can be recorded and action taken to resolve the concerns. A requirement to have adult protection training for all the staff has been met, and the London Borough of Hillingdon’s Adult Protection officer has undertaken the training. No issues have arisen since the last inspection. Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 25, 26 The home is generally maintained in good condition, providing a pleasant environment for the service users. The bedrooms are of a reasonable size to allow service users space for their own items or to entertain their visitors. EVIDENCE: There were some outstanding maintenance items due to be carried out at this inspection as the maintenance person employed in the home was on holiday. The work on the drains, which have been found to be inadequate for the building, was in progress. The home is generally well maintained and pleasantly furnished. been no changes since the last inspection. There have The garden provides an accessible area for the service users to enjoy, and seating is provided close the lounges. The maintenance person and the Activities Coordinator maintain the garden to a good standard and service users who wish to do so are encouraged to assist. Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 18 The bedrooms all exceed the National Minimum Standards of 12 square metres in size and have sufficient space for service users to have two armchairs or a table if they wish to do so. The Registered Manager said that service users are asked about the items they would like to have. One service user confirmed that she had been able to bring an item of her own to the home. All the rooms seen were pleasantly decorated. At the last inspection, the lighting in some of the bedrooms was found to be too low, particularly for the service users who enjoyed reading. The Registered Manager said that brighter lighting had been provided for those service users who wished to have it. There had been a concern regarding the odour of urine in some areas of the home at the previous inspection. Some of the bedrooms carpets have been replaced where this was a particular problem. A programme of carpet cleaning takes place by the maintenance staff member employed and there was only a faint odour in one area on this occasion. Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 The procedures for recruitment, and maintaining employment records, need to be robust enough to ensure the protection of the service users. Staff training takes place but it needs to be ensured that all of the staff have the core and specialised training to meet the needs of service users. EVIDENCE: Because of the changes in service users’ needs, their dependency levels were required to be kept under review to ensure that the staff ratios are sufficient to meet them. The Registered Manager confirmed that there were no changes to the number in the staff team but continuing care assessments have been undertaken in relation to those service users who need more assistance and plans to have additional staff for service users whose needs have increased were in place. The Registered Manager said that new staff had undertaken their induction in April, for three days, and the records confirmed that nine staff had undertaken this training. The Registered Manager said the training is line with the Training Organisation for Personal Social Service guidance. The induction records were not in the home for inspection and these must be made available. The records showed that most permanent staff have undertaken the basic training courses, including moving and handling. It needs to be ensured that bank staff also have the required expertise in the areas of basic training, whether in their other jobs or by participating in the home’s courses. Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 20 At the last inspection, the recruitment procedures needed to be improved. The Registered Manager said that a new Recruitment Officer is now in post and they will be able to look at the identified shortfalls in the documentation. The Registered Manager had started the process of looking at the information on visas and the “right to work” of the staff in post. She had found some records incomplete and was taking action to update these. A list of the training courses undertaken by the staff was provided. It was required that all staff must have the specialist training which is relevant to the work they undertake. Although training courses have taken place this year for dementia, not all of the staff have had this training. As the home has a unit for twenty people with dementia, it is essential that all of the staff who are likely to work in this area have had this training. Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 38 The management of the home was generally good with evidence of better team work, and a more relaxed, but organised, atmosphere. Formal supervision has not commenced and this is an area which must be addressed to support and develop the staff team. EVIDENCE: The Registered Manager has been in the home for nearly a year, following three years with a number of managers and acting managers in post. This has now provided a period of stability for the home, resulting in a more relaxed and organised atmosphere in the home. She has the NVQ 4 Level in Care and has obtained the Registered Managers Award. Staff and visitors were complimentary about the current management of the home and evidence of good team working was observed which is of benefit to the service users. Comments included “a great improvement” and staff felt Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 22 that a good quality of care was being provided to the service users. The Registered Manager has commenced the process of gaining the views of the service users and their representatives. One survey has been carried out to obtain their views on the food provided. When all of the surveys have been completed, the home needs to provide a report of the quality of care for the service users and the Commission for Social Care Inspection. This needs to show that action is being taken to address any shortfalls. It must be borne in mind, when quality issues are being surveyed, that a third of the home’s service users have dementia and many, in the Intermediate Care unit, are only resident for a short time. The views of the staff and relatives, who support the service users, are important in adding to the overall quality of care and should be utilised in the surveys. Regular Regulation 26 visits are made to the home by representatives of the Registered Providers and submitted to the Commission for Social Care Inspection. It is a requirement of the Care Homes Regulations 2001 that staff are regularly supervised. It has been required at several inspections that the supervision of staff must commence to assist them to support the service users, particularly those who they key work, and for their own personal development. The systems are in place for this to be carried out but it has not started. The Registered Manager said that the Team Leaders will be responsible for supervising up to ten staff each, excluding regular bank staff. In order for the National Minimum Standard of a minimum of six supervision sessions a year to be met, sufficient time needs to be allowed within the rota hours for this to happen. No annual appraisals have been carried out. The Registered Manager said that no major changes have been made to the policies and procedures for the home since the last inspection. After the last inspection in January 2005, the Registered Manager sought the advice of the London Fire and Emergency Planning Authority in response to a requirement made. The London Fire and Emergency Planning Authority visited in March 2005 and the Authority’s representative gave information on the British Standards for the testing of fire points to the home. The maintenance person has been following this guidance. It was found at this inspection that no fire drills had been held in the home since 2004. An Immediate Requirement was issued for these to be commenced for all staff by the end of June 2005 and for all staff to have participated by the end of July 2005. The Registered Manager was able to informed the Commission for Social Care Inspection, by the 10th June, that the fire drills had commenced. Once all of the staff have participated, the number of drills that should be undertaken by all staff in a year, a minimum of two for day staff, and four for night staff, must be maintained. A system to evidence that all of the staff have taken part in the required number of drills needs to be kept. Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 2 2 x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 3 3 x x 3 x 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 2 x x 2 x 1 Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 24 YES 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. 1. Standard OP2 Regulation 5 (1) (b) Requirement Prospective service users must be informed of the information on fees payable which must be detailed in their terms and conditions. (Previous timescale of 31/3/05 not met) The service users must be supplied with a copy of the Local Authority agreement, where appropriate. (Previous timescale of 31/3/05 not met) Care plans must be produced following assessment to demonstrate that the service users’ needs and choices have been taken into account and support provided appropriately. (Partially restated from the previous inspection.) All staff working with service users with dementia should be suitably trained, with specialised activity training and more advanced courses in dementia care available for those working on a regular basis in the unit. Risk assessments must be updated appropriately after accidents to minimise reoccurance. Staffing levels must be kept Timescale for action 31/8/05 2. OP2 5 (3) 31/8/05 3. OP3 15 (1) (2) (a) & (b) 31/7/05 4. OP4 18 (1) (c) (i) 31/8/05 5. OP8 13 (4) (c) 30/6/05 6. OP12 18 (1) (a) 31/08/05 Page 25 Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 7. OP15 17 (2), Schedule 4 (13) 8. OP28 9. OP29 17 (2) Schedule 4 (6) (g) 18 (1) (c) (i) 19 (1) (a) & (c) 19 (4) (c) under review in the dementia unit to ensure that sufficient staff are on duty to supervise service users in all areas of the unit and provide appropriate activities. The home must show that service users have a balanced and varied diet and meals must be recorded in sufficient detail to ensure that their nutritional needs are being met. These records need to include those on the special diets provided, such as vegetarian and diabetic. (Previous timescale of 31/3/05 not met). The induction records of staff must be available for inspection. (Partly restated from previous inspection). The Registered Providers must ensure that the recruitment and employment procedures are carried out in accordance with legislation and there is ongoing monitoring to ensure compliance. All staff must have manual handling training and updates, including those working for the home’s bank. The Registered Manager must ensure that all of the staff undertake the core training courses and have updates as required. A review of the quality of care is required to provided on a regular basis and a report provided to service users and the Commission for Social Care Inspection. Regular supervision is required to commence and systems must be put in place to ensure that 31/7/05 31/7/05 31/7/05 10. OP30 13 (5) 31/8/05 11. OP30 18 (1) (c) (i) 31/8/05 12. OP33 24 (1) (2) & (3) 31/8/05 13. OP36 18 (2) 31/8/05 Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 26 14. OP38 23 (4) (e) this is carried out. (Previous timescale of 31/3/05 not met). All staff must participate in regular fire drills. (Immediate Requirement issued for the drills to commence by 30/6/05 and all staff to have participated by 31/7/05). 31/7/05 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. 2. 3. Refer to Standard OP6 OP15 OP16 Good Practice Recommendations That consideration should be given to providing separate management cover for the Intermediate Care unit. That more accessible information is provided to the service users to enable them to be better informed about the menus and choices of food available. That the management and staff look at ways of encourage the service users and the representatives to voice their concerns and grumbles so that these can be recorded and action taken. Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 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 Whitby Dene G61-G10 S27127 Whitby Dene V228671 6.6.05 Stage 4.doc Version 1.30 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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