Inspection on 25/07/06 for Whitby Drive (8)

This inspection was carried out on 25th July 2006.

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 no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Whitby Drive (8) 31/07/08

Whitby Drive (8) 13/10/05

Whitby Drive (8) 18/05/05

Whitby Drive (8) 07/12/04

Whitby Drive (8) 01/06/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Blenheim House

Prince Bishop Court

Park View (15)

Craigmore House

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

CARE HOME ADULTS 18-65 Whitby Drive (8) Biddick Washington NE38 7NW Lead Inspector Mrs Elsie Allnutt Key Unannounced Inspection 25 July and 4thAugust 09:45 th Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitby Drive (8) Address Biddick Washington NE38 7NW Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0191 4172448 0191 4172448 www.c-i-c.co.uk. Community Integrated Care Care Home 5 Category(ies) of Learning disability (5), Physical disability (3) registration, with number of places Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th October 2005 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 48 and 62 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. The home has developed a Service User Guide that informs prospective service users about the service, the aims and how these are met and a copy of the recent inspection report is available in the home for anyone to read. The fees charged by the home are £879.05p per week. Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took 9:00 hours over two days in July and August 2006. Questionnaires were sent out to service users and their relatives prior to the inspection, none were returned from service users and two were returned from relatives, both indicated that they were satisfied with the service delivered. The views of the four service users and six members of staff were sought, as were the views of one service user’s family member who was visiting on day one 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 and a tour of the building took place. What the service does well: What has improved since the last inspection? The manager and staff are now offering more opportunities to Service users to try different activities. These include visits to farms, a bird sanctuary and local country parks. Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 6 Service users are now also starting to share the responsibility of doing jobs around the house with the support and encouragement of staff. This is helping service users to be more independent. Staff have received instruction about how to help service users, who cannot move themselves, to safely move from one position to another. This means that staff now know how this is done correctly and safely. Staff have also learnt how to deal with situations, that they might hear about or see, that could make service users feel upset or hurt. They now know who to tell and how to protect people who do not know how to, or cannot protect themselves. What they could do better: Before anyone moves into the home they must agree with certain things. This includes what sort of care and support they will get from staff and what sort of behaviour is expected of them. They must also be told how much it will cost to live there and how this will be paid. This information must be written in a contract that is signed by the home and the person moving in or someone on his or her behalf. Care plans are records that tell staff how people living at the home like to be supported to look after themselves. So that staff know what sort of activities service users who have no speech might enjoy, the way service users act during and after taking part in a new activity should be written in the care plan. This will help staff to know what sort of things different service users like doing and so that they can support them to make more decisions about their lives. So that service users, who are unable to move and change their body positions themselves, do not become uncomfortable and bored, it is important that the care plan has clear instructions for staff to follow. These will tell staff how the service user likes to be moved and where they prefer to be at certain times during. It is important that service users know all of the staff are going to support and care for them. The manager must make sure that the staff team is the same each week, so new staff must be quickly found to replace the 3 staff that have left. The manager must also look at whether the number of staff on duty are enough to support the needs of all of the people using the service. It is important that the people living at the home are always kept safe. The manager must make sure that rubbish is not left in the garden. She must also make sure that it is safe for service users to go in and out of the garden safely by themselves and so that service users are not put at risk by having the windows opened very wide the manager must make sure that they only leave a certain amount of space when open. Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 7 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 Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4,5 Quality in this outcome area is good. This judgement has been from evidence gathered both during and before the visit to the service. A range of information, that is accurate and up to date, is available which enables service users to make a fully informed choice about where they would like to live. A detailed assessment process is in place and confirms that the home can meet service users needs. EVIDENCE: Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 10 The home has developed a comprehensive Statement of Purpose and Service User Guide. The Service User Guide has been tastefully developed into a format that is accessible to the service users with the use of photographs and illustrations. All of the service users living at this home have lived here since the home opened. Pre admission assessments were carried out prior to the service users moving into the home and the care plans in place reflect the assessed needs and risks identified as well as the changing needs. There is currently one vacant bedroom at this home and staff confirmed that a prospective service user is gradually being introduced to the home through planned visits. Records confirmed this. Records also confirmed that preadmission assessments are currently being carried out by the home as well as the referring agencies. Staff confirmed that they spent time observing the person and how they are cared for at a day facility. The manager stated special equipment needed to appropriately address the needs of the person will be acquired prior to the service user being admitted to the home. This will ensure that the home can meet the service users needs appropriately. The manager must make sure that a letter is sent to the service user confirming that the home can meet their needs prior to them moving in. Each service user has been given an up to date Contract that includes the terms and conditions of their stay and the full fees charged, identifying who is responsible for payment. Although the manager on behalf of the Provider has signed the new contracts, the service user or their representative has not. This was discussed with the manager who agreed to address it. Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. This judgement has been from evidence gathered both during and before the visit to the service. Each service user has a care plan that is easy to understand and considers all areas of their lives, including changing needs and how evident risks are reduced. However service users could be further empowered by being included in the development of their care plans. EVIDENCE: When reading through a sample of care plans there was evidence of confusion amongst staff regarding the style of recording. Although the home is using a care plan format that covers all aspects of health, welfare and social care issues, the manager confirmed that these are currently being reviewed. Staff confirmed that the aim is to develop person centred care plans, however although one of the care plans examined confirmed this, improvements could be made to others to include a more positive approach. The care plans generally lacked information about the individual service users’ preferences, Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 12 likes and dislikes, based on experiences offered. This was discussed with the manager who confirmed that plans are in place for all staff to receive training regarding person centred planning. In one care plan, the guidelines for staff to follow, clearly identified the amount of support needed by the service user and how their independence is promoted and maintained, for example in relation to a service user’s bathing needs it read, “ if you put the shower gel on to the sponge, and ask me to do it, I will wash my body myself.” This encourages a consistent approach by staff and at the same time promotes the service user’s independence and control over the task. The addition of a picture format system within the care plan also encourages service users to understand what is written about them. The manager confirmed that there are also plans to further improve this system. Risk assessments with guidelines to reduce evident risks were evident in the care files for staff to follow. However these are currently stored in a different section of the file to that of the care plans. A discussion took place with the manager about this and it was concluded that the care plans could be improved if the risk assessments and related management plans become an integral part of them. This will increase the awareness of the identified risks when the care plan is in use. Records and staff confirmed that the care plans are monitored monthly and reviewed annually. Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been from evidence gathered both during and before the visit to the service. The home is currently making efforts to improve the quality of life and lifestyles of individual service users by supporting them to take part in a variety of age appropriate community based activities. The service supports service users’ rights and successfully supports service users in maintaining relationships with family and friends. The food is of good quality and sufficient to meet the needs of service users. EVIDENCE: Service users were observed engaged in different activities during the day. A member of staff assisted one service user to go shopping while another two service users were individually assisted to go out for a walk and to have lunch out at a nearby pub. Prior to this a relative of one service user visited the home, during which time they positively promoted the standard of care delivered at the home. The Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 14 relative also confirmed that they are always made to feel welcome and are kept informed of their family member’s health and general wellbeing. Care plans confirmed that service users take part in varied activities, however staff stated that they continue to look for different experiences and venues to offer to service users. One care plan demonstrated how a service user was encouraged to take part in domestic tasks within the home and guidelines guided staff in relation to the amount of support needed by the service user to carry out the tasks. One service user assisted by a member of staff described how they had enjoyed a recent birthday by having a trip in a Rolls Royce and later how friends had been invited to a party in the garden. Although it was acknowledged that improvements have been made in the variety of activities being offered to service users, the way service users are supported to make decisions about their lives and how this might be recorded, was also discussed. It was suggested that the outcome of different experiences, and the observed responses to them, be recorded and used in care plans as a basis for supporting service users to make future informed choices about their lives. The manager was receptive to this. Records of menus and food being served at the home demonstrated that service users are offered a good range of healthy meals that meet their preferences and health needs. Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been from evidence gathered both during and before the visit to the service. Service users personal and healthcare needs are met in a flexible but consistent manner and when needed guidance is sought from medical specialists. Medication arrangements are appropriate for the needs of service users, however these are not always managed safely and could put service users at risk. EVIDENCE: Staff support service users to address their individual healthcare needs by; following guidelines in the care plans, supporting service users to access medical specialist advice and assisting them to visit local GPs and attend hospital appointments. The outcomes of such visits are recorded in the care files. A service user with complex needs was admitted to hospital the day before the inspection and good practice was observed when a member of staff was allocated to stay with the service user during the day to ensure that their needs were appropriately met, as well as to give emotional support. Staff were also observed sensitively contacting the service user’s family to inform them of their progress. Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 16 Service users generally appeared well and in good spirits. Records demonstrated that specialist advice is sought when necessary. Care plans recorded guidelines for staff to follow from a Speech and Language specialist and Continence Advisor. Records also demonstrated that an Occupational Therapist had carried out an assessment in the home in relation to the needs of a prospective service user. As a result the appropriate appliances and equipment are to be put in place prior to their admission. So that service users are protected against the current hot weather staff were observed applying sunscreen to the service users skin prior to going out in the sun and offering water to drink to avoid dehydration. Staff confirmed that they have received training relating to the safe administration of medication. Medication was observed being administered directly to service users following appropriate guidelines and the medication is appropriately stored in a separate locked medication cabinet. However in an interview with a member of staff it was evident that the appropriate procedures for the administration of medication are not always followed appropriately and medication is sometimes left unattended where service users could have been put at risk. It was also revealed that there had been dispute over the recording of medication. Although it was evident that the service manager effectively investigated this, it was not reported to the CSCI as required by Regulation 37. The manager was advised of this. Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been from evidence gathered both during and before the visit to the service. Arrangements are in place to help protect service users from abuse and to seriously address complaints and concerns about the service. EVIDENCE: The home has a Complaints Procedure that is also in picture format. Although no complaints have been recorded since the last inspection, two letters complimenting good practices in the home were evident. During the inspection concerns were raised relating to care practices carried out in the home. The actions taken by the home confirmed that concerns and complaints are taken seriously and dealt with in an appropriate way with satisfactory outcomes. The home follows the local authority’s policies and procedures in relation to the Protection of Vulnerable Adults (POVA). Staff confirmed that they have received training in relation to this and they were able to appropriately describe what action to take in a situation where they witnessed abuse. An allegation of abuse has recently been investigated by the home and it was confirmed that the home followed the appropriate procedures with satisfactory outcomes. The local authority’s adult protection procedure is available within the home, to guide staff on what to do and the people to contact in the event of witnessing abuse or having an alleged abusive situation reported to them. Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 18 The home has a Gender Sensitive policy that further protects service users from possible abuse. The home keeps clear records of service users’ financial affairs. These were appropriately kept and showed clear evidence of how service users monies were spent. Each service user has a bank account where any money belonging to them is paid into. Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 19 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 the following standard(s): 24,30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. The standard of the environment of this home is good, providing service users with a spacious, attractive, hygienic and homely place to live, however the environment could be made safer for service users by having window restrictors fitted to the windows and other identified risks addressed. EVIDENCE: This home maintains its high standards of décor and furnishings. Service users bedrooms are attractively decorated to suit individual preferences. However on the first day of the inspection due to the high temperatures being experienced, all of the windows in the home were opened wide. Although this created a more bearable temperature in the main part of the building, the space established by the opened window was big enough for someone to fall through from inside, or for someone from the outside to climb through. This could put service users at risk and was brought to the attention of the manager who agreed to immediately address the situation. Due to the high temperatures of the day the heat in the conservatory was excessive even though there were blinds at the windows, the door was open Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 20 and a fan was blowing. To further protect service users from harm and discomfort the staff were advised to temporarily close off the conservatory and to put a risk assessment in place regarding the evident risks in this area when the weather is so hot. The skin on the chin of one service user was noticed to be damaged, staff explained that this was the result of the service user falling on to the concrete when exiting through the conservatory door. The staff were advised to put a risk assessment together and to put plans in place to minimise the risk of harm without preventing the service user’s access to the garden. The home has a no smoking policy. Staff who smoke do so outside the back door and as a result of this a tin overflowing with cigarette butts was found in this area. The home makes an effort to recycle the household waste however the box they store this in is kept on the ground in the garden. The box includes opened cans and other rubbish that could be a hazard to service users. As service users have access to both these areas staff were advised to store the recycling rubbish box in a more appropriate place and to ensure that cigarette butts are discarded appropriately. As well as the health and safety issues, the absence of rubbish in the garden areas will help to promote a more positive image of people living at the home. The cleanliness of the home reflects good cleaning routines for which the home is complemented. Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34,35 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. Robust recruitment and selection procedures, regular training opportunities and supervision ensures that service users are appropriately supported and protected by a competent and qualified staff team. However the current staff shortages and poor relationships between staff could put service users at risk. EVIDENCE: Staff were observed working and interacting with service users in a sensitive and respectful way. Records and staff confirmed that the home meets the minimum staffing number needed to appropriately address the many complex needs of the people living at this home. However there are currently 3 staff vacancies at the home which means that vacant shifts are covered by staff working overtime or by using bank staff. Although the manager confirmed that in an attempt to provide consistency for service users, the same staff from the bank are used, this is not an ideal situation and could affect the quality of life experienced by service users. The manager confirmed that more staff will be recruited as soon as possible and confirmed that the current staffing numbers would be reviewed prior to a Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 22 new service user moving in, so that the home is confident that the number of staff on duty can meet everyone’s needs appropriately. Discussions with staff and observations in the home proved that currently there is some unrest amongst the staff team. The manager and service manager confirmed that this is under control and feel that the issues are being appropriately addressed so that the service delivered to service users is not affected. Staff confirmed that they receive training relating to their needs and records showed that all staff have or are working towards NVQ and are up to date with mandatory training. Examination of a sample of recruitment records showed that the company’s recruitment procedures are followed. Of the files examined all included, completed application forms, 2 references and satisfactory CRB checks. Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The manager has settled into her role with enthusiasm and is currently working towards maintaining the stability of the staff team, so that developments in the home result in positive outcomes for service users. EVIDENCE: The manager is now registered with the CSCI and is currently working towards appropriate qualifications, the Registered Managers Award (RMA) and NVQ4 in Care. She confirmed that she is up to date with mandatory training and attends training sessions related to her role. The manager stated that the next training session she will attend is related to Person Centred Care. There are plans in place for the manager to work with the service manager to establish a more stable staff team. The plans were discussed and a copy sent to the CSCI. Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 24 The home’s registration certificate, which is accurate and related to the service being carried out was on display, however the certificate for insurance regarding cover for liability was only valid until May 2006. The manager was advised of this. The manager discussed and demonstrated how the home’s quality assurance systems had been put into place and are now recorded in one file, which she felt, were easier and more practicable. Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 X 3 X X 2 X Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 26 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 YA5 Regulation 5(b) Requirement Service users, their family or their representative must sign the new Contract, explaining the terms and conditions of the service users’ stay at the home. (Timescale of 30/11/05 not met.) The home’s plan to train all staff how to use the new care planning system must go ahead as soon as possible. There must be enough information in the care plan in relation to how service users are supported to make decisions about their own lives. (Timescales of 30/11/05 not met.) Care plans must include details in respect of how service users are supported to change position or find comfort in another situation when, because of physical disability are unable to move or change position independently. (Timescale of 30/11/05 not DS0000015756.V299142.R01.S.doc Timescale for action 30/09/06 2 YA6 12(1)(4)(a) 30/11/06 3. YA7 12(2) 30/11/06 4 YA18 23(2)(c ) & 12(3) 30/11/06 Whitby Drive (8) Version 5.2 Page 27 met.) 5 YA20 YA42 37(1)(e) The registered manager must notify the CSCI of any event that takes place in the home that may affect the safety or wellbeing of any service user, and in particular in this case related to medication. 04/08/06 13(2) 6 YA24 YA42 7 YA33 The carer administrating the medication must follow the Royal Pharmaceutical Guidelines. 13(4)((a)(b)(c) The health and safety issues raised in relation to: • The lack of window restrictors • Safe access to the garden while maintaining the independence of service users. • The storage of rubbish in the garden. • The disposal of cigarette butts. • The excessive heat in the conservatory. Must be addressed by the registered manager. 18(1)(a)(b) To ensure continuity of care the registered manager must address the current staff vacancies. Prior to the vacancy in the home being filled the registered manager must review the staffing ratio to ensure that there are enough staff to appropriately address service users’ individual needs. The registered manager must ensure that staff maintain good personal and professional relationships with each other and service DS0000015756.V299142.R01.S.doc 31/08/06 31/08/06 8 YA37 12(5) 31/08/06 Whitby Drive (8) Version 5.2 Page 28 users. 9 YA37 12(1)(a) The registered manager must ensure that the certificate regarding the home’s liability and insurance cover is up to date. Risk assessments must be put in place regarding: • Access to the garden from the conservatory while maintaining service users independence. • The managing of the excessive heat in the conservatory when temperatures are very high. 31/08/06 10 YA42 13(4) 31/08/06 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 YA9 YA14 YA26 Good Practice Recommendations The risk assessments and risk management plans should be an integral part of the care plan. It is recommended that the variety of activities offered is expanded on as planned, and the types of holidays experienced are developed as discussed. The plans to replace a clinical type bed with a more domestic, comfortable design for a particular service user, should go ahead. (This was also a Recommendation of the last 2 reports). Whitby Drive (8) DS0000015756.V299142.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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. 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