CARE HOME ADULTS 18-65
8 Whitby Drive Biddick Washington Tyne & Wear NE38 7NW Lead Inspector
Elsie Allnutt Unannounced Wednesday, 18 May 2005 : 10:00
th 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. 8 Whitby Drive DB52-B02 S15756 Whitby Drive V220815 180505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service 8 Whitby Drive Address Biddick, Washington Tyne and Wear NE38 7NW 0191 417 2448 0191 417 2448 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) Community Integrated Care Care home only 5 Category(ies) of 5 x LD; 3 x PD registration, with number of places 8 Whitby Drive DB52-B02 S15756 Whitby Drive V220815 180505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 7th December 2004 Brief Description of the Service: 8 Whitby Drive is a home that provides a service for 5 people with learning disabilities all of whom have high dependency levels. The age range is between 47 and 61 years.The home is situated in a cul-de-sac of detached houses and bungalows. It is close to a school, pub and local shops and is close to local transport that provides access to Sunderland and Newcastle City centres. The building is a bungalow with a large conservatory at the back that accommodates a ball pool. There is an overhead tracking system and several other mobility appliances, which meet the needs of the service users.Each person living at the house has a single bedroom with the facility to lock the door for added privacy. There are also shared facilities that include a large lounge/ dining area, kitchen, utility room, bathroom and toilets. Attractive well kept gardens are accessed via French windows via the conservatory and a ramped access via the side of the building.Staff are available 24 hours per day, seven days a week to support people in their daily lives and to provide waking night cover. 8 Whitby Drive DB52-B02 S15756 Whitby Drive V220815 180505 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took 5 hours over one day in May 2005. The views of the five service users and six members of staff were sought, as were the views of one service user’s family members who were visiting at the time of the inspection. As all but one of the service users do not have verbal communication, an understanding about their views and feelings of the service was interpreted through the observations of body language, interaction with staff, discussions with staff and the examination of records. As part of the inspection process the service users’ care files and a sample of the homes records were examined. This home has recently appointed a new manager who at the time of the inspection had not yet taken up post. At the time of the inspection the staff on duty contacted the Service Manager and Temporary Manager who arrived to accommodate the inspection process. For the purpose of this report they will be referred to as the person in charge. What the service does well:
8 Whitby Drive provides a safe and comfortable environment that is well maintained, attractive and reflects the needs and preferences of the service users. Staff and service users create a warm and welcoming atmosphere in the home. The gardens are well maintained and well stocked and provide an attractive outlook. Service users are actively supported by staff to become involved in activities both in the home and in the local community. Service users confirmed their involvement in such activities and one service user supported by staff discussed with enthusiasm recent holiday breaks taken and trips out in the home’s vehicle. Meals are nutritious and attractively served and as far as possible service users are involved in the menu planning. Each service user is supported to maintain contact with their family and for one service user this was observed on the day of the inspection. Individual care files contain useful and appropriate information for example in relation to service users’ individual forms of communication and this enables staff to support service users in making choices and decisions. Service users demonstrated that they were satisfied with the service and the care and support given by staff.
8 Whitby Drive DB52-B02 S15756 Whitby Drive V220815 180505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: 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. 8 Whitby Drive DB52-B02 S15756 Whitby Drive V220815 180505 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection 8 Whitby Drive DB52-B02 S15756 Whitby Drive V220815 180505 Stage 4.doc Version 1.30 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 5 No progress has been made to develop a written contract that provides service users with full information about the care they will receive and its cost. EVIDENCE: As a result of inspecting care files and discussions with the person in charge of the home it was evident that service users have not been issued with a written contract in relation to their needs that is accessible. This was a requirement of the last report and must include a statement of the homes terms and conditions, information about the service to be delivered and the full cost this includes. 8 Whitby Drive DB52-B02 S15756 Whitby Drive V220815 180505 Stage 4.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,9 There is a clear and consistent care planning system in place for each service user that is regularly reviewed to adequately provide staff with up to date information they need to satisfactorily meet the service user’s needs. EVIDENCE: Care plans are in place, with appropriate detailed information, including risk assessments and clear risk management plans that include guidelines for staff to follow. One file includes a risk assessment and clear guidelines in relation to the safe use of bedrails and to ensure that all staff follow these consistently they have signed and dated this document. Discussions with staff and the examination of records proved that the changing needs of the service users are addressed at monthly and yearly reviews. 8 Whitby Drive DB52-B02 S15756 Whitby Drive V220815 180505 Stage 4.doc Version 1.30 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 & 15 Although service users are currently supported to take part in age appropriate community based activities there is room for these to be further developed so that more variety is offered. The home continues to successfully support service users in maintaining family links. EVIDENCE: At the time of the inspection two family members of one service user were visiting the home. Both were made to feel welcome by the staff and given a quiet area to talk to their relative. During a short conversation with the inspector both family members confirmed their satisfaction with the service. During the inspection it was evident that staff support service users in community-based activity. One service user was assisted to go on a planned shopping trip and the others took the advantage of a sunny day and went for a walk locally. All demonstrated their enjoyment of these events. Staff confirmed that this was a regular occurrence and other activities such as going bowling and using the local pub for meals out and drinks were also included in the activities programme. A discussion took place with the person in charge
8 Whitby Drive DB52-B02 S15756 Whitby Drive V220815 180505 Stage 4.doc Version 1.30 Page 11 who described plans to develop the activities programme further by using local community facilities and the knowledge of the service users preferences. This was encouraging. A discussion took place in relation to different venues for holiday destinations based on the preferences of service users while also recognising individual special needs. 8 Whitby Drive DB52-B02 S15756 Whitby Drive V220815 180505 Stage 4.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20 Service users’ healthcare needs are well met, as well as satisfactory systems being in place for the administration of medication, with clear arrangements to ensure service users medication needs are met. EVIDENCE: Records in the care files demonstrated that staff support service users to visit local GPs and attend hospital appointments. So that all staff are aware of such appointments and their outcome they are recorded in each care file. Staff pointed out how their recorded observations of one service user, had assisted health professionals in their assessment to provide a suitable back support for their wheelchair. Records also demonstrate that service users healthcare needs are regularly reviewed. Staff were observed satisfactorily administrating medication, following the homes procedures. Staff confirmed that they had received in house training in relation to the administration of medication and signed records in staff files confirmed this. The person in charge confirmed that plans are in place for staff to complete formal training with a local college in the form of a distant learning package on this subject. 8 Whitby Drive DB52-B02 S15756 Whitby Drive V220815 180505 Stage 4.doc Version 1.30 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 To further enhance the protection of service users from abuse further training must be offered to staff in relation to the local authority’s Protection of Vulnerable Adults procedures and in relation to addressing verbal and aggressive behaviour. EVIDENCE: Discussions with staff confirmed that they would take action if they witnessed poor care practices that may be considered as abuse. However the lines of action to be taken were not clear or consistent. Neither were staff aware of the procedures to follow in relation to the local authority’s Multi Agency Procedures for the Protection of Vulnerable Adults (MAPPVA). However a copy of the procedures were available in the home. None of the staff had attended training in relation to handling verbal and aggressive behaviour. A discussion took place with the person in charge who confirmed that arrangements had been made for staff to attend such training in the near future. The name of the person to contact in relation to issues related to the Protection of Vulnerable Adults and the MAPPVA procedures was given to the home. 8 Whitby Drive DB52-B02 S15756 Whitby Drive V220815 180505 Stage 4.doc Version 1.30 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,30 The standard of the environment within this home is good providing service users with an attractive, safe and homely place to live. EVIDENCE: Several areas of the home have been redecorated and refurbished since the last inspection. New furniture in the lounge now provides comfortable and homely facilities for service users to relax in, and new flooring and redecoration in one of the service users rooms provides hygienic, comfortable personal space. The person in charge stated that a new bed was to be ordered to replace a clinical type bed with a more domestic, comfortable design for one service user. The overall cleanliness and hygienic appearance of the home proved the effective use of cleaning procedures. A positive inspection from the Environmental Health Department had recently taken place. 8 Whitby Drive DB52-B02 S15756 Whitby Drive V220815 180505 Stage 4.doc Version 1.30 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34 Only limited progress has been made in addressing staff shortages and as a result there is a risk that service users do not receive consistent care. EVIDENCE: Although on the day of the inspection there was an adequate number of staff on duty to meet the needs of the service users, there remains concern in relation to the number of staff employed from agencies, to make up the staffing numbers. This was evident when examining the staff rotas. This was more evident at weekends when the rota showed that on occasions there are only two permanent members of staff on duty, but plans were also evident that in such cases agency staff were brought in. Although the home makes every effort to use the same agency staff this is not a good situation for service users as it does not provide them with consistency. Although the longest serving member of staff on duty had been at the home twelve months and others six months and six weeks, in discussion with them and observations of practice, all demonstrated a good understanding of the service users needs and how these should be addressed. Staff discussed the training they had received. For example one had just finished the induction programme and another was in the process of starting NVQ. The staff recruitment records were examined and found to be in order, however the CRB
8 Whitby Drive DB52-B02 S15756 Whitby Drive V220815 180505 Stage 4.doc Version 1.30 Page 16 certificate of the most recent member of staff was not available, this was still at head office. 8 Whitby Drive DB52-B02 S15756 Whitby Drive V220815 180505 Stage 4.doc Version 1.30 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,42 In the absence of a permanent manager staff are not always aware of who is charge of the home. This could have a detrimental effect on the care and safety of the service users. EVIDENCE: Since the previous manager left six weeks prior to this inspection a manager from another home within the Company has been overseeing the home three days a week. The days are unspecified and on the day of the inspection staff working at the home were unaware of when she would be in next, although they were aware of who she was, how to contact her, and showed respect to her in her role. Neither were they aware of who was in charge of the home in her absence. As a result of examining health and safety records it was found that the service users’ accident book was not compliant with the Data Protection Act. This was brought to the attention of the person in charge. As a result of a recent inspection from the Fire Department it was identified that a new smoke seal was needed for the utility door. As yet this has not been replaced. The fire records showed some discrepancies in relation to the
8 Whitby Drive DB52-B02 S15756 Whitby Drive V220815 180505 Stage 4.doc Version 1.30 Page 18 checking of emergency lighting and staff training/instruction. With the health and safety of the service users and staff in mind these issues must be addressed. 8 Whitby Drive DB52-B02 S15756 Whitby Drive V220815 180505 Stage 4.doc Version 1.30 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x 2 Standard No 22 23
ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 x x 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score x 3 2 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
8 Whitby Drive Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 2 x x x 2 x DB52-B02 S15756 Whitby Drive V220815 180505 Stage 4.doc Version 1.30 Page 20 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. 1. Standard 5 Regulation 5(b) Requirement A copy of the terms and conditions in respect of the accomodation provided and the full fees charged must be provided to service users. All staff must attend training in relation to the local authority’s Protection of Vulnerable Adult Procedures, and in the handling of verbal and physical aggression. (Timescale of 28.01.05 not met.) To ensure continuity of care the excessive use of temporary staff must be addressed.(Timescale of 28.01.05 not met.) Inidividual CRB certificates must be kept in the home until they have been examined by the CSCI during the nearest inspection. So that the service users and staff benefit from consistent leadership and management approach of the home, a permanent manager who is experienced and qualified to carry out the role must be put in place. The accident book must comply with the Data Protection Act. Timescale for action 30.06.05 2. 23 13(6) 30.09.05 3. 33 18(1)(a)( b) 17(2) 30.06.05 4. 34 Immediate 5. 37,38 8 30.06.05 6. 42 Data Protection 30.06.05
Page 21 8 Whitby Drive DB52-B02 S15756 Whitby Drive V220815 180505 Stage 4.doc Version 1.30 Act 1998 7. 42 13(4),23( 4) The issues recommended by the by the Fire Department in relation to the smoke seal on the utility door, and the recording of staff fire training/instruction must be addressed. Immediate 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. Refer to Standard 14 20 Good Practice Recommendations It is recommended that the variety of activities offered are developed as planned, and the holiday destinations expanded as discussed. It is recommended that the plans that are in place for staff to complete formal training, in relation to the administration of medication, with a local college in the form of a distant learning package goes ahead. The plans to replace a clinical type bed with a more domestic, comfortable design for a particular service user, should go ahead. In the absence of the manager the staff should know who is in charge of the home. 3. 4. 5. 24 38 8 Whitby Drive DB52-B02 S15756 Whitby Drive V220815 180505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Baltic House Port of Tyne South Shields NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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