Inspection on 14/08/07 for Whitby Scheme

This inspection was carried out on 14th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Whitby Scheme 30/08/06

Whitby Scheme 07/03/06

Whitby Scheme 20/09/05

Whitby Scheme 03/02/05

Whitby Scheme 15/09/04

Whitby Scheme 27/11/03

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Whitby Scheme 14/15 Crescent Avenue and 2/5 North Promenade Whitby North Yorkshire YO21 3ED Lead Inspector Pauline O`Rourke Unannounced Inspection 14 August 2007 09:30 th Whitby Scheme DS0000007727.V343622.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 Scheme DS0000007727.V343622.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 Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitby Scheme Address 14/15 Crescent Avenue and 2/5 North Promenade Whitby North Yorkshire YO21 3ED 01947 603145 01947 825654 anchor.house@craegmoor.co.uk www.craegmoor.co.uk J C Care Ltd 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) Miss Nicola Jayne Craig Care Home 32 Category(ies) of Learning disability (32), Mental disorder, registration, with number excluding learning disability or dementia (32) of places Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered for 32 residents with a Mental Disorder and/or a Learning Disability of whom 2 may be over the age of 65 Date of last inspection 30th August 2006 Brief Description of the Service: The Whitby Scheme is registered to provide care an accommodation to people who have a learning disability and/or a mental health problem under the age of 65. They can admit up to 32 people. The registered provider is J C Care a subsidiary of Craegmoor Healthcare. The registered manager is Miss Nicola Craig. The Whitby Scheme consists of three properties. Anchor and Haven House are adjacent to each other with the third house, Endeavour, being approximately a half a mile away. The properties are not suitable for people who have profound physical disabilities or mobility problems. The people who live in the Whitby Scheme generally have mental health problems combined with a learning disability. Several people display challenging behaviour and some may be the subject of supervision orders. The primary aim of the Scheme is to promote independence and to treat people as individuals with individual needs. The Scheme also endeavours to provide an element of rehabilitation by developing individuals life and social skills. Where appropriate people are assisted to relocate independently within the community. The properties are within walking distance of all main community facilities including shops and banks and are convenient for the public transport services. Anchor and Haven House have a private parking area; Endeavour House relies on available on-street parking. None of the properties has large gardens but the staff have maximised the use of rear yards/patio areas. The properties are, however, adjacent to public parks and beaches, which people often use. The current fees at the time of the site visit on 14th August 2007 ranged from £664 to £1200 per week and do not include costs for toiletries, hairdressing and social activities. Information about the home is provided in a Service User Guide, this is available on request. The Commission of Social Care Inspection produces a report and this is available from the manager. Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence for this report. These sources include: • • • • Reviewing information that has been received about the home since the last inspection. Information provided by the registered person on a Annual Quality Assurance Assessment form. Comment cards returned from 12 people in the Scheme, four relatives, one social care professional and two healthcare professionals. A visit to the home carried out by one inspector that lasted for six and a half hours. During the visit to the home people who live in all three establishments, and five staff were spoken with. Care records relating to four people, three staff members and the management activities of the home were inspected. Care practices were observed, where appropriate, and time was also spent watching the general activity within the home. This enabled the inspector to gain an insight of what life is like at The Scheme for the people living there. The manager was available to assist throughout the visit for feedback at the close. What the service does well: All the people who use, or want to use the service at The Whitby Scheme have to tell someone of the help they need. This information is used to make a care plan. The care plans used are detailed and tell the carers everything from how people like to get up, go to bed, what they like to do during the day and how it is best to communicate with them. This helps to make sure that people receive support in the way they prefer. These care plans are reviewed regularly to make sure the information is up to date. The people who live in the Whitby Scheme can access community activities such as shopping, going out for a drink or going out for the day to somewhere like Beamish Museum. They enjoy picnics, barbeques and parties between the three houses. Feedback for people in the Scheme said ‘I was asked if wanted to move in to the home, given info about the home, and can make own decisions each day’ and ‘The home is clean and the staff treat me well and listen to what I have to say. I have some good friends in the home. I can do what I like except when I need my medication or when I have jobs to do’. Feedback from relatives included ‘The home staff especially the Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 6 manager and key worker are very committed to the care of my brother. It provides a homely, friendly atmosphere, which is apparent every time I/we visit the home. The staff are approachable and always happy to help’ and ‘I have found the management and support/care staff very obliging, cheerful and helpful. I believe the care package being given to my son is good. I am grateful for the opportunity to express this’. A social care professional said ‘This home has managed this service user better than any other placement. The service user on the whole settled well. Fair but firm management of service user behaviour is proving successful with boundaries laid down and consistent approach of staff. The staff work well with the people in the schemes and offer support and encouragement in their daily living tasks and the manager operates an open door policy. People in the home and staff said that she is very approachable and friendly and makes time for people in the home. People are supported in the community if they want to be and several people have voluntary jobs in local charity shops. People are encouraged to live their own life. 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. The summary of this inspection report can be made available in other formats on request. Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. All people who come to the Whitby Scheme have a full assessment of need to ensure that their needs can be fully met. EVIDENCE: People who come to live at one of the three houses in the Whitby scheme have a full assessment of need carried out before they are admitted. Four files were seen and one of these was of a person who was recently admitted to Endeavour House. There was pre-admission information provided by health care professional and supporting information gathered by the manager who visited the person in hospital. Another person had been admitted as an emergency and all the necessary assessments were carried out within the first forty-eight hours. A fuller assessment is carried out once the person has been admitted to the scheme. This is carried out with the person it is about and is available in picture and written format. This information is then considered along with the information gathered form the health care professionals and the manager. All of the files seen contained a full assessment of need from which a care plan is developed detailing how needs that have been identified are to be met. Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 9 Information about the Whitby Scheme is available in Statement of Purpose and Service User Guide. Each person is given a copy of the Service User Guide. The manager confirmed that she visits people before they are admitted to the Scheme as part of the assessment process to assess their suitability for the service taking into account the skills of the current staff group and the current mix of people living in the service. Everyone admitted to the service is done so on a trial basis and a multi disciplinary review is held before the placement is determined to be permanent. Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use the service are able to make decisions on a day-to-day basis about their lives and this allows them to remain as independent as possible. EVIDENCE: The case files seen contained a person centred care plan pertinent to the individual. The care plans were available in written and pictorial format. These plans are developed with the person they were about and information regularly updated. The care plans cover social, health, medication, health and keeping safe, mental health, personal care, communication, independence, and a health action plan. The files also contain information about ‘what should happen if I become sick or die’ a contract, communication sheet, risk assessments and an evaluation sheet. During the visit one person was completing the plan with their key worker and others seen showed evidence that people are involved in their own care plans. Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 11 Staff were aware of the differing needs of the people in the home and since the last inspection training has been provided in differing aspects of mental health. Individual risk assessments were in place to manage verbal aggression and care plans included information about how service users’ were to be supported in their relationships and with sexual awareness. People spoken with during the visit said that they were able to decide how to spend their days. Feedback received from people in the home states ‘, I can do what I like during the day’ and ‘they can follow their own routine on a day-to-day basis’. During the visit people were seen making decisions about how they spent their day and staff were supportive in the choices they made. People in the home spent time with each other and by themselves depending on what they wanted to do. Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People enjoy a good lifestyle both in and outside the home in order to meet their social and leisure preferences and needs. EVIDENCE: Each person has an individual programme of activities aimed at developing their skills and their interests and social needs were recorded within their care plans. Several people in the scheme work on a voluntary basis in local charity shops. Craegmoor employs an educational tutor and people within the homes are encouraged to take advantage of this service. External training is also sought for people within the home within the local community. People spoken with said that they enjoy going out in to the local area and go shopping or visit pubs. Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 13 The case files contain information about family networks and how contact is maintained on a regular basis. Feedback received from a relative said ‘It provides a homely, friendly atmosphere and this is apparent every time I/we visit the home. The staff are approachable and always happy to help’. And ‘The home usually meets the needs of my relative and they keep in touch with me’. One person said ‘I ring my mum every week and the staff help me organise a visit several times a year’ another one said ‘I go home to see my family once a month and I have been on holidays with my dad’. There is a visitor’s policy and this is displayed in all three establishments in the Whitby Scheme. Feedback received from the people in the home said that ‘I can do what I want during the day and know who to speak to if I am not happy. The home is clean and the staff treat me well and listen to what I have to say’. During the visit staff were seen speaking with people and entering their rooms in a respectful manner. Staff waited to be invited in to people’s rooms before entering. Where they may need to enter without permission this is clearly stated in the care plans giving reasons why this needs to happen. During the visit the atmosphere was relaxed and people could access all areas of the building and the interactions observed between people living in the home and staff was relaxed and respectful. The people in each scheme establishment plan the menus and there are alternatives to the daily choice. The meal observed was relaxed and people came to the dining room, as they wanted. Staff were aware of who had eaten and who hadn’t and made sure that those people received something to eat. Several people bought their own food and cooked their own meals and the staff supported them in doing this. People also have the opportunity to learn how to bake and prepare meals during their stay. People spoken with said that the meal were good and there was always plenty available if they wanted more that was originally offered. Drinks and snacks are available throughout the day and night. Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s health and personal care needs are met on an individual basis. The staff employ the principles of respect, dignity and privacy in all interactions with them. EVIDENCE: All of the case files seen contained a person centred care plan these include specific information about the level of support required, how staff should respond to specific behaviours, and what their daily routine consists of. The people spoken with said that they could follow their own routine unless they have jobs or appointments to keep. They also said that staff provide the support they require in a way that protects their dignity. Feedback received form a relative said ‘I believe the care package being given to my son is good. I am grateful for the opportunity to express this’. A social care professional said ‘This home has managed this service user better than any other placement. The service user on the whole settled well. Fair but firm management of service user behaviour is proving successful with boundaries laid down and a consistent approach from staff’. Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 15 Evidence was available to show that people access health services when needed such as chiropody, dental and optical services. People are registered with a local GP surgery and continue to receive support from the local mental health team. A health professional said ‘They monitor the mental health of service users effectively and will request support and advice’. Feedback received from a relative said ‘Seeing my relative gets medical attention when needed and checking when any behavioural problems arise’. This indicates that specialist help is sought through the local mental health team. The medication records, storage and administration were accurate and secure, in line with the company policies. Where medication is dispensed that has serious side effects staff are aware of what they need to do if the side effects occur. One person administers his or her own medication and a risk assessment is in place. The storage of this medication was secure as the person has a locked cupboard to store it in. All the staff had attended some medication training that had been run by Boots and had also received some inhouse training. Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People in the home and their representatives are able to express their concerns through the complaints procedure and are protected from abuse, so their rights are protected. EVIDENCE: Each of the three establishments had a copy of the complaints policy in plain view and people spoken with were aware of who they would complain to if they had any concerns. Feedback received from people in the home said ‘I can do what I want during the day and know who to speak top if I am not happy’. And ‘They know who to go to if they are not happy and the carers always listen and act on what they say’ and ‘I know how to make a complaint, and who to speak to if I’m not happy’. A recent concern received by the Commission of Social Care Inspection was passed to North Yorkshire Social Services to investigate. No further action was taken following this investigation. The home has not received any complaints directly since the last inspection. Staff were aware of the complaints and the Whistle Blowing policy. There is an Adult Protection Policy in place that is in line with ‘No Secrets’ and the staff have training to make them aware of this as part of their induction. It is also part of an on-going training plan. Staff were aware of the necessary procedure to follow if there were any suspicions of abuse. A recent Adult Protection issue has been dealt with in accordance with the procedure. A multi Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 17 disciplinary assessment was carried out and disciplinary action was taken accordingly. There have been several occasions where people within the service have been violent and/or aggressive in their behaviour or language towards other people in the home and appropriate action has been taken. This has involved reviewing risk assessments and behaviour management plans. The manager has implemented the missing persons policy when necessary and has worked in conjunction with the local police to ensure people are safe and returned to the home. Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people in Anchor House and Haven live in well-maintained, clean properties that allow them to access all areas, promoting their independence. Although Endeavour House provides permanent accommodation it appears more like a hostel for the people who live there, this does not promote a homely environment. EVIDENCE: The service is split over three establishments. Endeavour House – This property is laid out over three floors with a total of fourteen bedrooms throughout the building. On the ground floor there is a dining room, lounge, a smoking room, a kitchen and laundry room. There is limited space to the rear of the building for use by the people in the home. The décor in the property is tired and some areas of the home have been identified as requiring updating by Craegmoor. The handyman and decorators Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 19 were in the building updating several areas. The bedrooms seen had been personalised by the occupant and they held keys to their rooms. The dining room is in the process of being updated and this will include new furniture. Endeavour House provides permanent accommodation although it seems more like a hostel and the people who live there treat it as such. Haven – This is a six-bedroom property and is split over two floors. It is domestic in style and character and all areas seen were well decorated. The bedrooms have been personalised. Anchor House – This is a nine-bedroom property and is split over two floors. It is a large domestic dwelling and the people who live there have personalised their own space. The properties are within a ten-minute walk of each other. All of the properties were clean and odour free and there are maintenance programmes for each property. There is a health and safety meeting held every three months to discuss any environmental issues and to record ongoing improvements. A recent improvement includes replacing fire doors with new ones. Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live in each of the establishments are supported by welltrained staff in sufficient numbers that they are seen as individuals and the care provided is pertinent to their needs. EVIDENCE: People in the homes said that ‘the staff treat me well and listen to what I have to say’ and ‘The staff treat me well, I can do what I like during the day’ and ‘and the carers always listen and act on what I say’. During the visit people in the home said that ‘the staff are very nice –always helpful’ and ‘They’re ok you can talk to them’. During the visit interactions between people in the home and staff were observed and they were respectful and patient. Staff spoken with said they have received their statutory training, training in Control, Prevention and Intervention techniques to equip them in claming down difficult situations as well as training in mental health issues, drugs and alcohol awareness and learning disabilities. Fifty percent of the staff have a National Vocational Qualification in Care level two and a further six staff are in the process of completing this. Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 21 The staffing rotas in all three establishments showed that the homes were adequately staffed. The staffing has been increased in Endeavour House since the last inspection from three carers per shift to four per shift. Staff spoken with said the increase has been beneficial to the people in the home as they have more time to spend with them. Feedback from one professional indicated that he had concerns about the staffing level although he had discussed this further with the manager. On the day of the visit there were only three staff members on duty, however this was due to an unplanned absence do happen and whilst the manager makes every effort to cover the shifts this is not always possible. The current staffing levels allow for support and guidance to be offered, if people require a lot of one-to-one time then further resources would have to be provided. Craegmoor operates a thorough recruitment policy and the three staff files seen contained all the appropriate documentation. One member of staff who had recently started working for the company confirmed that they did not start until their Criminal Records Bureau disclosure had been returned. People who live in the houses have not been involved in the selection of staff. Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a well managed home where the administration of the home is based on openness and respect. This allows them to retain their individuality and independence EVIDENCE: The Registered Manager is in the process of completing her Registered Manager Award. She is experienced and continues to update her training in the care of people with learning disabilities and mental health. Discussions with the manager highlighted her knowledge of her role and responsibilities towards the people who live in the home and staff. Staff spoken with said that the manager was accessible and operated an open door policy. They felt confident that if they had any concerns that she would deal appropriately with Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 23 them. People in the home were seen relating in a positive way to the manager and she was available if people wished to speak to her. Feedback received from relatives said ‘I have found the management and support/care staff very obliging, cheerful and helpful’ and ‘The home staff especially the manager and key worker are very committed to the care of my brother’. Craegmoor carries out an annual Clinical Governance Audit. This involves an unannounced visit and issues looked at include, administration, marketing, and all the standards relating to the care of adults with a learning disability or mental health problem. Some of the elements are broken down further to look at individual care issues. As part of this process the manager has to complete a monthly Data form looking at health reviews, weight loss/gain, educational courses, missing persons incidents and Care Programme Approach Compliance. Alternate months an overview audit is carried out and this looks at what other staff have been monitoring and includes finance, human resources, customer satisfaction, lifestyle and personal health care issues. Audits are also carried out on medication and health and safety issues. Information from meetings held by staff and people who live in the home and the monthly management visits also feed in to the quality assurance programme for the home. This information is then used to develop an annual improvement plan. All the working practices within the home are safe and staff keep accurate accident records, this information is used to inform the care plan and in requesting specialist input either through training or actual support. Staff have received training in the health and safety procedures and all the policies are read by the staff. The records relating to health and safety issues that were seen during the visit were up to date Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 24 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 4 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 3 3 3 X 3 X 3 X X 3 X Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Whitby Scheme DS0000007727.V343622.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!