Inspection on 30/08/06 for Whitby Scheme

This inspection was carried out on 30th August 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 4 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 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 David White Key Unannounced Inspection 30th August 2006 08:30 Whitby Scheme DS0000007727.V309815.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.V309815.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.V309815.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 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.V309815.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 7th March 2006 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. The current fees at the time of the site visit on 30th August 2006 ranged from £521 to £600 per week and do not include costs for toiletries, hairdressing and social activities. Whitby Scheme DS0000007727.V309815.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unannounced site visit undertaken on the 30th August 2006. This visit was carried out by one Regulation Inspector and took 10 hours with 7 hours preparation time. The home was able to return the requested information before this site visit, and surveys were sent out to relatives and other professionals who had contact with the home. Surveys cards were received from three relatives, two GPs and a health professional. Information was also used from the Regulation Inspector’s inspection record, which detailed the history of the home and relevant information about what had been happening in the home since the previous inspection visit. The site visit comprised of a full inspection of the premises. The care records of three service users were looked at which included service users’ assessments, care plans and medication records. Staff rotas and health and safety documentation were inspected. Time was spent talking to six service users, four members of care staff and the manager of the home. The activity in the home and the interaction between service users and staff was observed. The focus of the inspection was on a number of key standards, inspecting the case records of a number of service users to establish whether they corresponded with their experiences of life in the home. The manager was available throughout the inspection and the findings were discussed at the end of the inspection. What the service does well: Service users’ felt that their care needs were being met by “kind and helpful” staff. Service users’ had access to a range of activities to enable them to pursue their social and leisure interests. Service users’ said that staff encouraged them to be independent and to make their own choices. Service users’ were given the opportunity to voice their views and contribute towards how the home was run. Service users’ and staff said that the manager was “approachable and friendly” and felt that her management abilities had led to improved standards within the houses. Whitby Scheme DS0000007727.V309815.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Whitby Scheme DS0000007727.V309815.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.V309815.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 and 5. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Proper pre-admission procedures were in place and followed to ensure that service users’ needs could be met by the home. EVIDENCE: The home had a statement of purpose and service user guide which provided information to service users’ about the care and services provided by the home. Both documents were on display in each house. Three service users’ files were looked at and this included the file of a recently admitted service user. The documentation within this file showed that staff had collected information from a number of sources prior to admission so that they were able to make an informed decision as to whether the needs of the prospective service user could be met. The manager said that when a referral was received by the home she would initially visit the prospective service user with another senior member of staff to decide whether it would be appropriate to offer the person a trial period at the home. Each pre-admission assessment looked at the individual needs of the service user and a planned action of care was drawn up from this information. The daily records reflected the care that was being provided by the home. Whitby Scheme DS0000007727.V309815.R01.S.doc Version 5.2 Page 9 A recently admitted service user said that they had been provided with a range of information about the home and had been on a number of visits to the home before making a decision about moving there. Each service user was issued with an individual contract so that they were aware of the terms and conditions of living at the home. Service users’ were seen interacting well with each other at the time of the site visit and said that in general everyone got on well together. Whitby Scheme DS0000007727.V309815.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. The care provided to service users’ was good and generally the care plans detailed how service users’ needs were to be met, although in some cases the care plans did not reflect the needs which had been identified from the initial assessment of the service user. EVIDENCE: Three service users’ files were looked at and these all provided clear and easy to follow information about each service user. The plans contained a personal assessment of each service users’ needs on which the care plan was based. There was an emphasis on encouraging the independence of the service users’ and this was supported by a number of risk assessments in relation to aspects of daily living and safety. One service user said, “I am encouraged to be independent and make my own choices” and the care plans contained information about service users’ likes and dislikes. 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. Whitby Scheme DS0000007727.V309815.R01.S.doc Version 5.2 Page 11 One service user had a history of drug misuse and there was a written agreement in place between the service user and staff team as to what actions would be taken if drug misuse were to be suspected. Although the care plans were generally informative the information that was gathered from the initial assessment of the service users’ was not always accurately reflected within the care planning information and this could have lead to needs not being met. The initial assessment of one service user identified that this person had a tendency to lose weight and this needed monitoring and it was noted within the care records that the service user had lost weight since moving into the home. Whilst the care records for this service user did show that weight monitoring had been taking place the care plan did not make reference to weight loss as an issue or possible actions needed to address any weight loss problems. In another instance a service user had mental health problems that were monitored by a psychiatrist, however little reference was made to any mental health needs within the individual’s care plan. Despite the need for improvement in this aspect of the care planning documentation staff did demonstrate a good knowledge of the individual needs of the service users’ although they would benefit from a better understanding of the specific needs of people with mental health problems in order to meet all the service users’ needs. The care records showed that input from health professionals was given and recorded. A survey returned by a care manager said that the home was good at liaising with them in the planning of a service user’s care. Care plans reviews were carried out on a regular basis to address any changing needs and involved the service user as much as possible. The manager had put systems in place to ensure that the confidentiality of service users’ was maintained within the staff and service users’ meeting records. Whitby Scheme DS0000007727.V309815.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Service users’ enjoyed a good lifestyle both in and outside the home in order to meet their social and leisure preferences and needs. EVIDENCE: Each service user had an individual programme of activities aimed at developing their skills and service users’ interests and social needs were recorded within their care plans. Some of the service users’ attended the local day centre whilst others had voluntary employment in the community. Educational opportunities were available for service users’ and a service user said they had made plans to speak to the manager about enrolling on a bricklaying course at the local college. An educational tutor was employed by Craegmoor to visit the home to provide education, training and activities for the service users’ and external learning was available in computers, cooking, pottery and literacy. Service users’ said that they enjoyed the educational and leisure opportunities that were available to them and others said they liked the visits to the local pubs. Whitby Scheme DS0000007727.V309815.R01.S.doc Version 5.2 Page 13 A number of service users’ said they had enjoyed a holiday to Majorca earlier on in the year and one service user was planning to go on holiday to Tenerife with their family. A survey received from a health and social care professional said that staff had developed an increased awareness of the benefits in providing activities for the service users’ in the home. Visiting arrangements were flexible and service users’ could see family and friends whenever they wanted to maintain their relationships. Service users’ planned their menus with the staff in advance and said that there was always plenty of choice. Menus were on display in the home and alternative food options were available if a service user changed their mind about their original food choice. One of the service users’ enjoyed eating vegetarian food as well as some meat and was given monies to go and purchase foods to suit their preferred tastes. All the staff had received food hygiene training and a survey received from a health and social care professional said that staff had developed a better understanding of healthy eating options for service users and that menu choice had improved. Whitby Scheme DS0000007727.V309815.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. The health needs of service users’ are met with good access available to specialist services when required. EVIDENCE: Service users’ confirmed that personal support was given to them in accordance with their wishes and staff could be observed to be providing support in a dignified manner. Surveys received from relatives said that they felt that the care at the home was good and that staff communicated well to keep them well informed about the care being provided to their relatives. Care records stated how service users’ were to be supported and each service user had access to a GP, a chiropodist and to dental and optical services. Records were made of any input from specialist services so that the care staff were kept informed about the care being provided and of any actions they may need to take. The home’s medication system and facilities were inspected and proper procedures were being followed. The Medication Administration Records (MAR) were accurate and up to date and the manager on a monthly basis to monitor medication practices and to address any issues from this carried out medication administration and storage audits. Whitby Scheme DS0000007727.V309815.R01.S.doc Version 5.2 Page 15 One service user was receiving some medication that had potentially serious side effects, and proper monitoring arrangements had been put in place to identify possible side effects at an early stage to prevent harm to the service user. The majority of service users’ either chose not to self-medicate or were not safe to do so and this was supported through the risk assessment process. All the staff had attended some medication training that had been run by Boots and had also received some in-house training. Whitby Scheme DS0000007727.V309815.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service. Clear complaints and adult protection policies and procedures were in place to safeguard service users’ from risk of abuse. EVIDENCE: The home had a complaints procedure that was openly on display in the home and detailed how complaints would be dealt with. A complaints form was available at the entrance of the home to report any concerns and the manager said that complaints could also be made verbally if people did not want to use the complaints form to raise concerns. Service users’ knew whom they needed to speak to if they had a complaint and felt confident that the manager would address any concerns properly. A survey received from a relative stated that they were not aware of the home’s complaints procedures and the manager needed to consider how the complaints procedure was made available to all relatives including those who did not or who rarely visited the home. The home had not received any complaints since the previous inspection. The home had adult protection policies and procedures in place to support staff in knowing what to if abuse was suspected or had happened. All the staff at the home had attended abuse awareness training and staff were given further guidance within staff meetings. A recently appointed member of staff said that abuse awareness had been covered as part of their introduction to the home. In the past the home had managed adult protection matters poorly however in recent times the home had not had to deal with any issues of abuse so it was not possible to determine whether service users’ would be protected from harm in the event of or allegation of abuse. Whitby Scheme DS0000007727.V309815.R01.S.doc Version 5.2 Page 17 Since the previous inspection visit there had been an incident in which a service user had attacked two members of staff. Proper procedures had been followed to ensure people’s safety and care plans provided information about risk management strategies for service users’ who could be verbally or physically aggressive. One service user had been reported as missing on one occasion, however had been to visit family without telling anyone and had since done so again on a number of occasions. The manager was addressing this matter with the service user and family concerned. Whitby Scheme DS0000007727.V309815.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to the service. The living environment at Anchor and Haven was comfortable and pleasant for the service users’, however further improvements needed to be made to the premises at Endeavour House to ensure the comfort and safety of service users’. EVIDENCE: On the day of the site visit Anchor and Haven houses were well maintained and decorated to a satisfactory standard. The houses were bright and warm and service users’ commented about the pleasantness of their living environment. One of the service users’ had recently undergone some hip surgery and their bathroom had been adapted so that the service user was able to get in and out of the bath safely. At Endeavour House some of the premises had been updated although the assessment of whether the home was suitable for its purpose or if more appropriate premises needed to be found continues to be ongoing and needs addressing. New flooring had been fitted in the kitchen, the hallways had been re-decorated, the lounge had been upgraded, the majority of service users’ bedrooms had been re-decorated and further refurbishment work was planned. Whitby Scheme DS0000007727.V309815.R01.S.doc Version 5.2 Page 19 Despite this there were a number of serious concerns about the health and safety in the environment. On the staircase in two different areas there were spindles missing from the staircase banister and this placed service users’ at risk from tripping, falling and entrapment and a piece of wood with nails protruding from it had become loose from one banister causing potential risks to service users’ from tripping and injury. The maintenance worker who was present at the time of the visit immediately removed the piece of wood with the nails in it. Some flooring material in the first floor bathroom had not been replaced and again put service users’ at risk from tripping and there was a loose toilet seat in a bathroom which could have caused service users’ to slip or fall. These issues were discussed with the manager and immediate requirements were made in relation to all these matters at the time of the site visit. An independent company had recently carried out a fire risk assessment of the houses at the request of the manager and actions were being taken to address the issues identified from the assessment. Hot water temperatures were monitored and recorded by the maintenance man on a weekly basis and waterheating checks were carried out to prevent possible risks from legionella. The kitchens in the houses were clean and tidy and cleaning schedules were in place to maintain standards of cleanliness in the kitchen. Fridge and freezer temperature checks were carried out on a daily basis to promote safe food hygiene practices. Endeavour House had recently had an incident when fleas had been found in a service users’ bedroom. This matter had been dealt with by the pest control agency who believed that problem had been caused by a cat who lived at the home. The manager had taken measures to prevent a reoccurence of the problem. Whitby Scheme DS0000007727.V309815.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service. Proper recruitment procedures safeguarded service users’ from harm and staff training had improved, however staffing levels at Endeavour House needed to be increased to ensure all the service users’ needs could be met. EVIDENCE: All service users’ said that the staff were “kind and helpful” and one said “they can’t do enough for you”. Staff could be seen to be interacting well with the service users’ and the atmosphere within the houses was relaxed. Training opportunities for the staff had improved and each member of staff had an individual training programme. Staff said that they felt they were given enough training to enable them to have the skills to do their job. Most of the training provided was in relation to health and safety and staff said that they had not received any training specific to the needs of people with a learning disability or mental illness but felt that this would be “useful”. This was discussed with the manager who said she had arranged for some drug and alcohol awareness training and was also trying to access some mental health training for the staff. The home had a rolling programme of NVQ training and a new member of staff was able to confirm that they had received induction training when starting work at the home. Whitby Scheme DS0000007727.V309815.R01.S.doc Version 5.2 Page 21 The duty rotas showed that Anchor and Haven houses were adequately staffed and service users’ said that they were always able to access staff for support if they needed to. At Endeavour House there were usually three staff on duty through the day with the exception of when 1:1 support was being offered to a particular service user in which case there would be an additional member of staff. Endeavour House was a large home and the accommodation was over three floors. There were no lifts in the home so access to all floors could only be made via the stairs. Service users’ had complex needs and tended to stay mainly in the house and very few attended activities out of the home mainly through choice. Staff carried out cooking, laundry and cleaning duties as part of their daily routines and this had an impact on the amount of time they were able to spend with service users’. Staff said that service users’ needs were easier to meet when there was four staff on duty through the day particularly when service users’ needed staff support to attend appointments or go out. The staff files of two of the most recently appointed members of staff were checked and all the necessary pre-employment checks had been carried out prior to the workers starting in post. Supervision systems were in place in each home and staff meetings were held regularly and recorded. Regular staff meetings were held and these were recorded and staff supervision systems were in place. Whitby Scheme DS0000007727.V309815.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service. The houses were run in the interests of the service users’, however some health and safety matters needed addressing to safeguard the service users’ from harm. EVIDENCE: The registered manager of the home had worked at the houses over a threeyear period. She was undergoing NVQ level 4 and the Registered Manager’s Award to enhance her management skills. The manager had worked hard to make improvements at the home and staff and service users’ both spoke well of her with service users’ saying she was “very approachable, helpful and accessible”. Staff commented that the manager had improved standards within the houses and felt that she was “respectful” towards them. Two deputy managers were employed in both the Anchor and Haven house and in Endeavour House to support the manager. Whitby Scheme DS0000007727.V309815.R01.S.doc Version 5.2 Page 23 Service users’ and relatives were actively encouraged to be involved in the running and decision making at the home. The views of service users’ and relatives were sought by the use of questionnaires and service users’ meetings were held on a regular basis to give service users’ the opportunity to voice their views about the home and these were recorded. Attempts had been made by the manager to arrange relative meetings at the home but this had proved unsuccessful due to the lack of interest. However the houses had held open days and summer fairs and had invited families and local people to attend with the aim of developing relationships with the local community and these had proved to be successful. The manager and Craegmoor Healthcare had audit systems in place to monitor various aspects of care and health and safety practices within the home. A number of health and safety certificates were looked at and were satisfactory. Staff had received updated health and safety and fire safety training and fire drills were carried out on a regular basis. As previously mentioned earlier in this report under the heading of environment there were some serious concerns about some health and safety matters which put people at risk and which needed to be immediately addressed. On the staircase in two different areas there were spindles missing from the staircase banister and a piece of wood with nails protruding from it had become loose from one banister. Some flooring material in the first floor bathroom had not been replaced and was a tripping hazard and there was a loose toilet seat in a bathroom that could have caused service users’ to slip or fall. Whilst staffing levels in Anchor and Haven House were adequate, there was a need for improved staffing levels at Endeavour House and staff needed training in relation to the specific needs of people with a learning disability and mental health problems. Service users’ monies were discussed and the financial systems used by the home were looked at. In the home each service user’s money was held individually and records and receipts were well maintained in respect of incoming and outgoing monies. Service users’ also had their own bank accounts and cash cards so that they were able to access their monies at any time and they received bank statements informing them of their financial situation. A random check of the monies tallied with the records. Whitby Scheme DS0000007727.V309815.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 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 1 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 3 3 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 1 X Whitby Scheme DS0000007727.V309815.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. 1. Standard YA6 Regulation 15 Requirement Care plans must reflect how the identified assessed needs of each service user are to be met by the home. • The flooring in the first floor bathroom at Endeavour House needs replacing or securing so that service users’ are not at risk from tripping. On the first floor staircase banister at Endeavour House the piece of wood with nails protruding from it needs to be removed or secured so that service users’ are not at risk from injury or tripping. Arrangements must be made to replace the missing spindles from the staircase banister at Endeavour House to prevent risks to service users’ safety. Arrangements must be made to secure the loose toilet seat in the bathroom at Endeavour House to Timescale for action 30/09/06 2. YA24 13 & 23 01/09/06 • • • Whitby Scheme DS0000007727.V309815.R01.S.doc Version 5.2 Page 26 prevent harm to service users’ from falling. Immediate requirements were issued in relation to the above matters. Endeavour House must have at least four members of staff on duty between the hours of 8am and 5pm in order to meet all the service users’ needs. Staff must receive specialist training and development to equip them with the skills and understanding to meet all the needs of the service users. 3. YA33 18 30/10/06 4. YA35 18 30/11/06 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. Refer to Standard YA22 YA37 Good Practice Recommendations The registered person should consider ways of making sure that relatives who do not visit the home are made aware of the home’s complaints procedure. The manager should complete NVQ level 4 and the Registered Manager’s Award in order to further develop her management skills. Whitby Scheme DS0000007727.V309815.R01.S.doc Version 5.2 Page 27 f 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.V309815.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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