Care Home: Whitby Dene

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What the care home does well The home is spacious and comfortable, with good communal areas and personalised bedrooms suited to the needs of people who use the service. The unit for people who have dementia, in particular has been decorated and set out in an advantageous manner. The home is well maintained and refurbished when needed. Professional quality monitoring systems in the home are good. People who use the service and their relatives have a chance to meet with the Registered Manager and discuss any issues that are pertinent to them. Surveys are sent out to people to ascertain their opinion of the home. The Registered Manager has a clear vision for the home and systems for monitoring the quality of the service. She has worked towards ensuring Statutory Requirements are met and standards are improved. What has improved since the last inspection? Improvements have been made to care planning and care records since the last inspection. Life history books are now being developed and parts of the care plan are being replicated so they are readily accessible and kept in peoples bedrooms.The home is developing further the activity programme. A full time Activity Organiser is employed, different and new ways of engaging people in daily activities and choices are being promoted. Improvements have been made to the fabric of the home, and the garden. New carpets, flooring and chairs have been purchased for the home. The Registered Manager is monitoring staff training and dates for further training on a weekly basis. CARE HOMES FOR OLDER PEOPLE Whitby Dene 316 Whitby Road Eastcote Ruislip Middlesex HA4 9EE Lead Inspector Susan Woolnough-Singh Key Unannounced Inspection 14:00 6th July 2008 X10015.doc Version 1.40 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 Dene DS0000027127.V364610.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 Older People. 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 Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitby Dene Address 316 Whitby Road Eastcote Ruislip Middlesex HA4 9EE 020 8868 3712 0208 866 6792 manager.whitbydene@careuk.com manager.burroughs@careuk.com Care UK Community Partnerships 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) Ms Razia Mehdiali Ghoghai Care Home 60 Category(ies) of Dementia (60), Old age, not falling within any registration, with number other category (60) of places Whitby Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 60 24th July 2007 Date of last inspection Brief Description of the Service: Whitby Dene is a purpose built care home owned and managed by Care UK Partnerships Ltd. Located in a residential area of Eastcote, there are local shops within walking distance and Eastcote Station and shops are under a mile away. The home provides personal care and support for sixty older people. The category of registration for Whitby Dene has changed since the last inspection. The unit for Intermediate Care has been closed. The ground floor has a 30-bed Dementia Care Unit. The first floor has accommodation for 30 frail older people. Whitby Dene also offers Respite Care. There is a large enclosed garden and ample car parking. Each unit has its own dining room and lounges. All bedrooms have single occupancy, with en suite toilet and washbasin. There are assisted bathrooms and toilets in all areas. The fees range from £425 per week to £522 for respite care. Whitby Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality Rating for this service is two star. This means that people who use this service experience good quality outcomes. This was an unannounced inspection of Whitby Dene. All of the key National Minimum Standards for Older People were assessed. The inspection commenced on Sunday 6th July 2008 at 14.00. We also made inspection visits on 9th July 2008 and 25th July 2008. The last date was to meet with the Registered Manager who had returned from Annual Leave. The inspection field visit took a total of 13.40 hours. The Inspector spoke with four people who live at Whitby Dene seven relatives/cares and six members of staff. We received four completed surveys from people who live at the home, six surveys from relatives/carers and four surveys from staff. A tour of the building took place, care records’ staff personnel records and health and safety records were examined. What the service does well: What has improved since the last inspection? Improvements have been made to care planning and care records since the last inspection. Life history books are now being developed and parts of the care plan are being replicated so they are readily accessible and kept in peoples bedrooms. Whitby Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 6 The home is developing further the activity programme. A full time Activity Organiser is employed, different and new ways of engaging people in daily activities and choices are being promoted. Improvements have been made to the fabric of the home, and the garden. New carpets, flooring and chairs have been purchased for the home. The Registered Manager is monitoring staff training and dates for further training on a weekly basis. 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 Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Whitby Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who move into the home have their care needs assessed. Whitby Dene does not accommodate people for intermediate care. EVIDENCE: We looked at the care assessments for two people who had recently moved in to the home. The assessment covered the areas in which people would need help and support.. The London Borough of Hillingdon has a contract with Whitby Dene. Social Services are responsible for undertaking the assessment of need. Whitby Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A plan of care is available for each person who uses the service. The computerised care plan/records had been kept up to date and were detailed enough to give guidance on the care required. The system is efficient and provides clear records. People spoken with said that health care and personal needs were individually catered for. There are systems in place for the safe administration of medication. EVIDENCE: We looked at the Care plans of four people. All of the care records are stored on a computer programme. Staff receive training in the use of this programme. We found the programme accessible and user friendly. The Whitby Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 10 Registered Manager informed us that a paper copy of basic care plans is also being compiled to be kept in peoples bedrooms. We saw a sample of these. The information viewed on the care plan incorporates the following information and assessments: Individual guidance on daily care - communication, diet, personal care/hygiene, safe environment and activities. Manual Handling Continence care Skin care (tissue viability) Healthy diet Physical and cognitive ability and any equipment used. Mobility and a strategy for moving and handling. Preferred activities. All of the information above was up to date. Staff completed a report daily at the end of each shift on the welfare of the person. There is also a record of visits made by health care professionals such as General Practitioner and Audiologist. Hospital appointments and admissions are recorded. The Regulation 37 incident reports forwarded to CSCI cover any action that has been taken if a person is ill or has had an accident. These are sent on a regular basis. We looked at the area for the storage of administration of medication on one floor. A local Pharmacist provides a pre dispensed blister pack method of medication administration. Medication administration records had been signed there is also a front sheet to be signed to confirm that the medication administration process has been completed correctly after each administration. We discussed with a senior carer the method of training for staff. Medication training for staff in the safe administration of medication is carried out in the home. A Team Manager guides staff through the policies procedures and guidelines. Practical demonstrations are also given. Staff also access on line learning whereby they are tested on their learning this is then assessed as part of the programme. The Registered Manager and two senior members of staff are required to agree that the training has been successful for individuals. There is a system for returning unused medication. This is returned to the Pharmacy and a record is made of this. Whitby Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities are planned and are advertised in the reception area. The home is currently working towards promoting daily activities for people who live in the home. The employment of a full time activity organiser will improve the outcomes for people. People are to receive visitors when they wish. People are able to make decisions within the routines of daily living. People receive a choice of meals in a pleasant environment. EVIDENCE: We received completed surveys from people and their relatives/carers. We received four surveys from people who live at Whitby Dene and six from relatives/carers. The surveys indicated that overall people who use the service and their relatives felt that their care needs were always or usually met. Whitby Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 12 Relatives commented on the survey that staff were observed to be very busy, the majority commented that the home is kept to a high level of cleanliness and the staff are respectful and courteous. We spoke with four people who use the service. We asked people for their opinions on the menu, health care, choices in daily living, activities, complaints and the care they receive from staff. We observed on all the days of the inspection that people were attended to when they needed to be. Senior staff were seen to direct staff where necessary. People said there was a choice of menu and where meals could be taken. People where generally satisfied with the food. One person said they chose their meal but did not always get their choice. On health care, one person said that they were not satisfied; on further discussion it appeared that this was with the medication prescribed by a General Practitioner. People confirmed that activities were available and named bingo and table games such as dominoes. The piano lady, outings and church services are some of the activities available. People did not recall a complaints procedure but named staff they had confidence in and would talk to if they had a concern. One person commented that staff often leave and another that staff always look very busy. We spoke with one person who was not of the Christian faith. This person spoke of his/her religious needs and opinions and indicated that he/she was satisfied with the home on this basis. We spoke with seven relatives. Two relatives indicated that they were pleased with their choice of home. They had looked at other homes in the area, and felt that Whitby Dene had been the right choice; they commented that the home was very good and a small kitchen could be used to make refreshments when they visited. They felt that the staff were caring but had observed them to be very busy. Bingo and musical entertainment had been observed. One relative commented on the high standard of cleanliness. Two relatives commented in length on how busy the staff are and how someone always needs attention it was noted that medication administration times in particular were very demanding on staff. One relative felt that the basic ingredients used for cooking could be of a better quality and more fruit and vegetables should be provided to meet the five a day target. Planned activities are advertised on a notice board in the reception area. The activities seen on the activity board are religious worship on set days, games, entertainment, hairdressing and manicures. We spoke with the Activity Organiser. He had just been appointed to this post on a full time basis. Some of the most recent projects he had undertaken were to decorate the corridor walls with photographs and pictures such as old Whitby Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 13 photographs of the Royal Family and Movie stars. Some work had also taken place in the garden with the involvement of people who use the service. The activity organiser was in the process of completing the NVQ in Activities and Dementia. A new activity concept has been introduced since the last inspection. This is an activity based care plan, the idea behind this being that activities of daily living should be encouraged. Where people retain certain skills, usually household skills, they are to be encouraged to use these in the home. The Activity Organiser had received training in this and staff were receiving information on implementation in supervision. We were informed that this was in the initial stages and not incorporated into individual care plan at the time of the inspection. Some work had been done on compiling life histories for people. Two of these has been completed and were seen. These included important information about people’s life experience such as family, life events and employment. We looked at the Menu, which is kept in the dining rooms. This looked varied with mainly traditional British dishes. There is a choice at lunchtime and for tea/supper. We were able to look at photographs taken by the activity organiser. These were clear and depicted main meals and puddings. We were informed that the photographs are used to assist some people to make a choice. Whitby Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service are able to make complaints. Complaints had been made and investigated. Training is available for staff in the protection of vulnerable adults. EVIDENCE: The home has a Complaints Procedure, which is displayed on each unit. This includes the timescales and the relevant contact details. The Inspector looked at the complaints record book two complaints had been made since the last inspection. We were able to see that one complaint had been investigated. The investigation report was thorough his had been forwarded to the London Borough of Hillingdon and had not been concluded at the time of the inspection. The second complaint had been investigated by the London Borough of Hillingdon and not substantiated. People spoken with said they would talk to staff if they had any concerns. Some people said they knew the Registered Manager and would approach her. The home forwards very detailed and comprehensive Regulation 37 reports to the Commission for Social Care Inspection. which describe any incidents in the Whitby Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 15 home such as falls or illness and the action the home has taken to keep people healthy and safe. We were provided with a spreadsheet of the staff training update for 2008. The spreadsheet indicated that the majority of staff had undertaken Protection of Vulnerable Adults training in 2007 and 2008. Staff also receive annual training from the Safeguarding Vulnerable Adults Officer, London Borough of Hillingdon Social Services. The Registered Manager also provides training for new staff. Whitby Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A safe and well maintained home is provided. The home is personalised and attractive due to the work that has been done to make an interesting environment for people who use the service. Bedrooms are comfortable and personalised; people and their families are encouraged to bring in items from home. The home is clean and hygienic. EVIDENCE: We toured the building and the grounds, and met with people (and relatives) in their bedrooms. The home is very clean throughout; there were no unpleasant odours on the day of the inspection. Whitby Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 17 Changes have been made to both the Dementia Care Unit and Frail Elderly Care Unit since the last inspection. The ground floor is now for thirty people with dementia. At the time of the last inspection ten places were available for intermediate care on this floor. The facility has now moved to another Care UK home in the London Borough of Hillingdon. Carpets had been replaced by laminate flooring in the hall and some bedrooms. This provides a more suitable and hygienic surface for the Dementia Care Unit. Two lounges on this floor have now been made into one. The work was carried out quickly and one large lounge has been created. A small room at the end of this corridor, which was formerly used as a photograph gallery, is now available for people who smoke. There are seating areas in the hallway, which were being used. The walls are decorated in an interesting manner with pictures and past time scenes. The first floor for elderly frail people is also attractively decorated and new carpets have been laid throughout the hall and some bedrooms. All new armchairs had been purchased for the lounges. We were able to view a number of bedrooms during the tour and whilst talking with people who live in the home. These were often very personalised with family photographs and ornaments. We looked at the kitchen as part of the tour. We observed that the kitchen, fridges, freezers and storage areas were clean and uncluttered. We met with the maintenance person. His main role is to supervise contractors, monitor health and safety and attend to any repairs that are required. The maintenance person has his own office where it could be seen that he had a clear schedule of work and up to date records. The grounds are being maintained to a high standard and looked attractive on the day of the inspection. Some novel garden ornaments had been placed to give people an interesting view of the garden. Flowerbeds were colourfully planted. Whitby Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a set shift pattern of numbers of staff on duty at all times. This is kept under review by senior staff. The appropriate recruitment procedures are in place for the protection of people who use the service. Staff receive induction training and health and safety training to enable them to carry out their roles as carers. The majority of staff have been trained to NVQ Level 2. EVIDENCE: Whitby Dene accommodates sixty people. There is accommodation for thirty people of the Dementia Care Unit and thirty on the Elderly Frail Unit. Information provided at the time of the inspection indicated that there were no vacant rooms. On the first day of the inspection nine people were receiving short-term care (respite care) on the Dementia Care Unit and three on the Frail Elderly Care Unit. We looked at the staff rota for a three week period. The staff establishment consists of the Registered Manager, two team leaders, and one for each floor Whitby Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 19 and day care support workers. During office hours the Registered Manager, Administrator, Maintenance Coordinator and Activity Organiser are on duty. During waking hours a Team Leader, one Senior Carer and four care staff are on duty in the Dementia Care Unit. On the frail Elderly Care Unit a Team Leader, Senior Carer and two care staff are on duty. Two cooks, a laundry person and house workers are employed. The night staff team consists of four carers and one senior carer. We looked at the recruitment files of two staff that had recently joined the team at Whitby Dene. The required employment checks had been made. The staff files contained an application form, identity verification, Crimminal Records Bureau checks and two references and a health check. One member of staff was waiting for an employment contract. The files were organised well with information easy to locate. We had the opportunity to meet with and talk to the National Vocational Qualification Assessor. He explained his role as assessor, which is to observe staff working with people and to assess their learning. He indicated that he was impressed with the staff at Whitby Dene and their development and learning. He explained that some people are assessed by written work and others are interviewed and this is taped. Sixteen staff had completed NVQ Level 2 in care and a further fourteen have just completed NVQ 2 and are waiting for certificates. Two senior members of staff had finished NVQ Level 4. We were given a spreadsheet of the training update to June 2008. Staff have received induction training on commencement of employment and mandatory training in health and safety matters. Training has also been undertaken in Protection of Vulnerable Adults and Safe Handling of Medicines for staff who administer. In house training takes place on a facility called L.BOX, which is a computer-training programme. The participant reads the subject matter and then they are assessed on their learning. A Team Leader carries out moving and Handling training we confirmed that this person has received training for trainers. We spoke with six members of care staff during the inspection process and received four completed questionnaires. People spoken with were able to competently explain the role and the aims of the home. One person was very pleased with the opportunity to develop skills and participate in training. Comments on the survey indicated that staff were clearly unhappy with the form of training offered, namely the computer-training package. Staff said that this was often carried out in their own time and were of the opinion that this is a method of saving money for the Registered Provider. Staff would like interaction with a tutor and other participants. Some staff felt that it was not an efficient method of learning as the question and answer assessments could be carried out on behalf of others, this resulting in some staff not having learnt sufficiently. Whitby Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 20 Staff commented that team members had left and that at times vacant shifts had not been covered, this had put tremendous pressure on existing staff. We spoke with the Registered Manager by phone, after the inspection visit with regard to training and staffing issues. We were informed that Care Uk Community Partnerships Ltd have consulted with staff with regard to types of training as workshop based training is a preferred method for some. It was decided that the learning outcomes for staff using the current training methods were satisfactory. A minimum number of staff on duty is retained. The occupancy level fluctuates according to the number of people using the service. Whitby Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the competence, experience and qualifications to manage the home in the best interests of the people who use the service. Good quality monitoring systems are in place whereby the strengths and weaknesses of the home are identified. There are systems in place for the management of people’s personal allowance. Arrangements are made for the monitoring of health and safety practice. Whitby Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Registered Manager was registered with the Commission for Social Care Inspection in 2004. The Manager has NVQ level 2,3 & 4 and the Registered Managers Award. Two requirements were made at the last inspection, these had been met. The Registered Manager has good systems in place for monitoring staff training. We were able to look at the Quality Assurance surveys (2008) that had been completed by people who use the service and relatives/carers. The comments and feedback with regard to satisfaction levels were positive. A quality review report on this was due to be compiled at the time of the inspection. A regular residents and relatives meeting is held. The last one took place on 28th June 2008. The minutes for this were seen. Some of the topics discussed were Protection of Vulnerable Adults, meals, health care professional visits, and activities. A discussion had taken place on staffing matters and pay. The Registered Manager had given information to the group on this. A list of publications on elderly care were recommended. The Inspector met with the administrator to discuss the management of personal fiancé for people who use the service. The administration of these takes place at Care UK Head Office. People receive a personal allowance; we saw two records of this. Expenditure is recorded with receipts and a balance. The person using the service signs for the transactions if possible. The majority of people who use the service, apart from two are not responsible for managing their own finances. Relatives/cares are responsible for ensuring people have a small fund to purchase everyday requisites such as toiletries and papers. There are good systems in place for the maintenance of the home and health and safety. The maintenance person ensures that all equipment is serviced when required. Monthly,weekly and daily monitoring audit schedules are available. Fire drills take place on a monthly basis with a record of staff that has attended. Staff receive training in food hygiene, manual handling, infection control first aid and fire safety. This information was presented in a spreadsheet and is monitored by the Registered Manager on a weekly basis. Whitby Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x x x x 4 x 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Whitby Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 24 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. 1. 2. Refer to Standard OP27 OP30 Good Practice Recommendations The Registered Manager should keep under review the number of staff on duty in relation to the care needs of people who use the service. The Registered Provider and Registered Manager should keep under review the method of training staff. Whitby Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Dene DS0000027127.V364610.R01.S.doc Version 5.2 Page 26 - 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. 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