Inspection on 20/09/05 for Whitby Scheme

This inspection was carried out on 20th September 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Whitby Scheme 14/08/07

Whitby Scheme 30/08/06

Whitby Scheme 07/03/06

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 Terry Downey Unannounced Inspection 20th September 2005 09:00 Whitby Scheme DS0000007727.V253551.R01.S.doc Version 5.0 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.V253551.R01.S.doc Version 5.0 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.V253551.R01.S.doc Version 5.0 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 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) J C Care Ltd 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.V253551.R01.S.doc Version 5.0 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 3rd February 2005 Date of last inspection Brief Description of the Service: The Whitby Scheme consists of three properties. Anchor and Haven House which are adjacent to each other with the third house, Endeavour, being approximately a half a mile away. The Scheme is registered to provide residential social, and personal care for 32 people under 65 years of age who have learning disabilities and / or a mental disorder. The properties are not suitable for people who have profound physical disabilities or mobility problems. The service users generally have mental health problems combined with a learning disability. Several of the service users 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 service users as individuals with individual needs”. The Scheme also endeavours to provide an element of rehabilitation by developing individuals life and social skills. Where appropriate service users 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 are often used by the service users. The registered provider is J C Care a subsidiary of Craegmoor Healthcare. The registered manager is Miss Nicola Craig. Whitby Scheme DS0000007727.V253551.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the inspection process on 20th September 2005. The confusion that has been present at the previous inspections regarding the Scheme has now been resolved and the Scheme is going to stay as one but managed differently. Since the last inspection Miss Nicola Craig has been appointed the registered manager of the Scheme with three deputies one for each house organising the day to day management of the residents. At the time of the inspection the manager and one deputy were on holiday, and one deputy was on sick leave. Rebecca Lumsdon the deputy manager at Endeavour House assisted with the inspection with the help of senior staff from Anchor and Haven. During the course of the inspection it was possible to speak to sixteen residents and six members of staff. The inspection also involved a check on the requirements and recommendations from the previous inspection, a tour of the premises and a check on some of the records kept by the home. It was` not possible to check staff files as the manager was unavailable. The inspection took 8.5 hours which includes preparation time. Many of the residents have been at the home for many years so know each other well and have established routines. The staff team is becoming more settled and there was the feeling that a fresh approach is being adopted to encourage and challenge the residents to help them to develop their skills. The home was not very clean or well decorated and furnished in parts, especially in Endeavour House, but there was a pleasant atmosphere. Some residents were in the home doing life skills training others were at day services or voluntary work, and others were going in and out independently. Most of the residents were pleased to talk about their home and said they felt that the staff were encouraging and helpful and that it ‘ was a nice place to live’. The inspection showed that in the main the Scheme was well organised and that the staff were aware of their duties, and the residents were well cared for and had full well structured lives. A lack of understanding of the Protection of Vulnerable Adults procedure, and some Health and Safety shortfalls could however put the residents at risk. Whitby Scheme DS0000007727.V253551.R01.S.doc Version 5.0 Page 6 What the service does well: 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. Whitby Scheme DS0000007727.V253551.R01.S.doc Version 5.0 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.V253551.R01.S.doc Version 5.0 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 the following standard(s): 2,3,5. Residents know that if they choose to live at the Whitby Scheme they will be well cared for. EVIDENCE: The Statement of Purpose for the Scheme is well publicised in the houses so that staff and residents are made aware of the principles governing the care in the homes. The files for two recently admitted residents showed that comprehensive assessments were carried out involving carers and professionals from other agencies. This ensured at the staff in Scheme could meet their needs. The residents said that they had visited the home and stayed overnight on one occasion before being admitted. The residents said it was helpful when they moved as they knew the staff and some of the residents. Staff also found it helpful as they could assess the resident over a longer period. All the residents have an individual contract and reasonable steps have been taken to ensure it is explained to them. This makes sure that they are aware of the terms and conditions of their stay in the home. Whitby Scheme DS0000007727.V253551.R01.S.doc Version 5.0 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 the following standard(s): 6,7,9. The residents are encouraged and supported to make decisions affecting all aspects of their lives. EVIDENCE: Residents are supported and encouraged to look after their personal care in line with their care plan and all the residents were clean and well dressed. The staff encourage and support the residents to take part in daily activities both in and out of the Scheme. There is a programme of activities, vocational and educational, within the home and staff network to find suitable activities in the community. These were witnessed during the inspection with evidence of the work done in the home and people going to and returning from activities outside. The residents were pleased to talk about their achievements. Individual risks for each resident are identified and ways of minimising the risks considered. Whitby Scheme DS0000007727.V253551.R01.S.doc Version 5.0 Page 10 All the residents have a detailed care plan. This comprises several pages of written notes regarding all aspects of their lives. It is important to show that this is shared with the residents and signed by them to indicate that they agree with the content. The only way possible seems to be for each page to be signed which will require several sessions as the residents could not be expected to absorb all the contents of the plan at one session. Whitby Scheme DS0000007727.V253551.R01.S.doc Version 5.0 Page 11 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): 11,12,13,15,16,17. Residents have a varied lifestyle and are involved in the local community. EVIDENCE: Each resident has an individual programme of activities aimed at developing their skills. Many of them are in the home but some also attend the local day centre, and some have voluntary employment in the community. Residents are encouraged to maintain links with their family and friends and visitors are made welcome and are able to be seen in private. At the previous inspection it was recommended that staff involved in the preparation of food are trained in the nutritional values and preparation of balanced meals. The deputy manager said that all staff had now had the training and the residents were benefiting from this. Residents are consulted about the menus and are involved in their planning. They said that the meals provided were good. Whitby Scheme DS0000007727.V253551.R01.S.doc Version 5.0 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 the following standard(s): 18,19,20. The residents’ personal and healthcare needs are met. EVIDENCE: Residents have their personal needs identified in their care plan which includes instruction about how support is provided safely and in accordance with the residents preference. All residents are registered with a local GP and specialist health services are accessed via this service. The home has good communication with healthcare professionals and other agencies which ensures that the residents’ health needs a re met. Residents are encouraged to self medicate but only one does so at present. Staff are trained in the safe administration of medication Whitby Scheme DS0000007727.V253551.R01.S.doc Version 5.0 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 the following standard(s): 22,23. A lack of understanding of the Adult Protection Procedure could put residents at risk. EVIDENCE: The senior staff spoken to during this inspection were not fully aware of the Adult Protection Procedure and this must be addressed to ensure residents are not at risk. All senior staff must be made aware of the procedure and this should be reinforced with staff at staff meetings at least quarterly. The complaints procedure was effective in most cases but a complaint from a service user regarding a member of the night staff, was not recorded as being resolved and the deputy manager was not aware of the outcome. Whitby Scheme DS0000007727.V253551.R01.S.doc Version 5.0 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 the following standard(s): 24,25,27,30. The standard of the environment at Anchor and Haven is satisfactory but Endeavour House falls short of the required standard. EVIDENCE: Anchor and Haven houses are well maintained, and reasonably well decorated and furnished except for a shower on the first floor which has a broken tray which needs replacing. Endeavour House is not well maintained, well decorated or furnished. Some work has been done regarding decorating and a new suite provided in the lounge but there is stall a lot of work to do. The walls in room 8 are showing damage from damp, before the winter. The bathroom 9 needs refurbishment. The shower has no curtain and the sealant around the bath has deteriorated. There were no shades on the lights on the staircase The floor in the kitchen, recently repaired, has deteriorated again and is potentially dangerous. The kitchen work surfaces need upgrading and overall the house was very untidy. Whitby Scheme DS0000007727.V253551.R01.S.doc Version 5.0 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 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): 32,33,35,36. Staff are trained and well organised which ensures that the residents feel supported and the staff are aware of their duties. EVIDENCE: Staff spoken to consider that they are given enough training to meet the needs of the residents and they are not asked to do anything for which they do not have the skills. Staff said that they feel well supported by the managers which gives them confidence. The manager was not available so it was not possible to check the staff files or the recruitment procedure. The staff work long shifts 7am to 10 pm and then two days off which they say they prefer and that it is better for the residents as there are fewer changes. Staff also cover for each other’s annual leave by doing overtime which means they work very long hours at these times. The deputy manager also works this shift pattern so that when she returns she has to catch up with her management responsibilities, responding to ‘e’ mails, maintaining records, dealing with enquiries etc and so cannot be doing the caring duties as well. Whitby Scheme DS0000007727.V253551.R01.S.doc Version 5.0 Page 16 There have been concerns for some time about the staffing levels at Endeavour House and although the staff have been increased so have the responsibilities and the concerns are still present. It is recommended that the duty rotas are again looked at especially for Endeavour House to ensure that sufficient staff are employed, and are deployed in such a way as to ensure that the needs of the residents and the safety of the staff are met at all times. Staff meetings are not well attended as staff work the long shifts and are unwilling to come in on their day off. Night staff also seem unwilling to attend the meetings. With staff being shared between the homes more often under the new system staff consider it more important to have staff meetings so that they can share the information about the Scheme not just each house. It is important that a system is devised which ensures that all staff can attend the meetings or be able to share the information. Whitby Scheme DS0000007727.V253551.R01.S.doc Version 5.0 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 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, 38,39,41,42. The residents are beginning to benefit from a home which is being managed better. Some Health and Safety issues were identified which put the residents at risk. EVIDENCE: It was clear from discussions with the staff and residents that the new management system is working and they feel well supported. More activities are being organised to meet their needs and staff training has improved. A key worker system operates in the home. Residents felt that this was helpful to have someone to work closely with. Staff also felt that it helped the residents especially with communicating their care needs. Staff training is on going and relates to the specific needs of the residents which makes staff more confident in their role. Whitby Scheme DS0000007727.V253551.R01.S.doc Version 5.0 Page 18 Fire training must be given to day staff at least every 6 months and to night staff at least every 3 months. Fire records must be kept up to date. The checks on hot water temperatures and the checks to control the risk of legionella must be carried out. There was evidence that incidences which occur in the home and affect the well being of the residents are not being reported to the Commission under regulation 37. Whitby Scheme DS0000007727.V253551.R01.S.doc Version 5.0 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 3 3 x 3 Standard No 22 23 Score 2 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 X 1 1 X 1 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 1 X 3 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Whitby Scheme Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 3 X 1 1 x DS0000007727.V253551.R01.S.doc Version 5.0 Page 20 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA23 Regulation 13 Requirement Timescale for action 31/12/05 2 YA30YA28YA24 23 Staff must be made aware of the Adult Protection procedure and it is recommended that this is reinforced at staff meetings at least quarterly. 31/01/06 The homes must be made suitable by ensuring the following work is carried out. The shower tray in Anchor House needs replacing. Endeavour The kitchen floor must be repaired again. Some of the kitchen work surfaces are unhygienic The walls in room 8 require damp proofing. The bathroom room 9 requires refurbishment. Lamp shades must be fitted to the lights on the staircase. Generally the decorations were poor and the home was very untidy. Whitby Scheme DS0000007727.V253551.R01.S.doc Version 5.0 Page 21 3 YA33YA36 18 4 5 YA41 YA42 37 13 Schedule 3 The long shifts worked by 31/12/05 staff must be reviewed as they affect the staffing levels in the home because of the time staff require to catch up with things they have missed and also attendance at staff meetings. The staffing levels at Endeavour House must be reviewed again. Staff meetings must be held regularly and at times when staff can attend. Any incident affecting the well 30/10/05 being of a resident must be reported to the Commission. Fire training must be given to 30/10/05 day staff at least every 6 months and to night staff at least every 3 months Fire records must be up to date. Hot water temperatures and the control of legionella checks must be carried out. 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 YA6 YA22 Good Practice Recommendations A suitable way of ensuring that residents can indicate their involvement in the care planning process should be found. If complaints are resolved confidentially a record of such should be entered in the complaints record. Whitby Scheme DS0000007727.V253551.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Whitby Scheme DS0000007727.V253551.R01.S.doc Version 5.0 Page 23 - 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. 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