CARE HOMES FOR OLDER PEOPLE
Kyffin Taylor House Deyes Lane Maghull Liverpoool L31 6DJ Lead Inspector
Trish Thomas Unannounced 24 August 2005
th 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 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. Kyffin Taylor House F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Kyffin Taylor House Address Deyes Lane Maghull Liverpool L31 6DJ 0151 526 4133 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Parkhaven Trust N/A Care Home 20 Category(ies) of OP Old Age (20) registration, with number of places Kyffin Taylor House F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: Serice users to include up to 20 OP. The service should employ a suitably qualified and experienced manager who is registered with the CSCI. Service users to include up to 7 DE who must be at least 55 years of age. Service users to include up to 7 DE(E) The service is registered to provide personal care to a maximum of 20 service users. Date of last inspection 30/11/04 Brief Description of the Service: Kyffin Taylor House is a care home which is owned by Parkhaven Trust and the manager is Mrs. Joan Quinn. The home is registered for 20 older people (including 7 dementia respite beds), situated on a private estate on Deyes Lane Maghull. All bedrooms are for single occupancy, there being ten bedrooms on the ground floor and ten on the first floor. Communal areas include two lounges and a dining room. There are good views from the windows of the surrounding gardens, which are well maintained and secure, and include a patio with seating and extensive flower garden at the rear. There is a visitors and staff car park at the front of the building. There is level access to the exterior for residents who have poor mobility. The home has a passenger lift and call facilities to summon staff, are available throughout the building. The home is staffed throughout the day and night and staff receive mandatory training and undertake NVQ from levels 2 to 4. The home employs a chef, meals are home cooked and special diets are catered for as necessary. The home is situated close to bus routes and local shops and amenities. Kyffin Taylor House F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The un-announced inspection took place on the morning of 24/8/05 and a complaint investigation was carried out during the inspection. Inspection methods used during the visit were, discussion with staff, reading care notes and records, discussion with residents and direct observation. On duty on my arrival in the home were, Deborah Chamas (Senior Care Assistant) and three care assistants, one domestic assistant, one kitchen domestic assistant and a chef. Mrs. Joan Quinn, Manager, came on duty for the afternoon shift. This was the first inspection since the dementia respite service for 7 residents, has been registered within the number of 20. There were 4 residents receiving respite services at the time of inspection, in addition to the permanent residents. Staff appeared to be extremely busy and the senior person on duty, was undertaking care tasks in addition to her administrative duties. All records requested were made available for inspection. Residents looked well cared for, and for the majority, there appeared to be no problems at that time. The experience of the resident, who was the subject of a complaint and referred to in the body of the report, are as a result of inadequate information at the time of admission, lack of structure in the admissions and discharge process, inadequate staffing during busy periods and gaps in service specific training and staff experience. Requirements and recommendations are made in the relevant section of this report. In the past, Kyffin House was a home for 20 elderly people. The newly established respite service, according to four permanent residents, has had an impact on the daily routines of the home. They said that staff were now under a lot of pressure and appear to be busier than before. Some of the respite residents appeared to have integrated well with those in permanent residency and be made welcome. A resident who displays repetitive behaviour and wandering, was a cause of irritation, (and anxiety) to more frail permanent residents, who are used to the previous routines. Requirements and recommendation are made to ensure that the service continues to be in accordance with the terms and conditions of residency and the aims and objectives of the home. It is important in addressing the needs and welfare of residents, that the service is managed in a manner, which respects the rights and dignity of every resident in the care of Kyffin Taylor. Kyffin Taylor House F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 6 What the service does well: What has improved since the last inspection?
A manager has been appointed who is qualified and experienced in providing residential care and respite services to people who have dementia. Mrs. Quinn has applied to CSCI for registration as manager of Kyffin Taylor. She was previously the registered manager of a local authority dementia respite dementia unit. Kyffin Taylor House F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 7 What they could do better:
Standards with relate to the complaint investigation undertaken at the time of inspection. Standard 3 Regulation 14 (1) (2) as to assessment. The manager must ensure that professional assessments for service users admitted to Kyffin Taylor, are in accordance with Care Home Regulations 14 (1) (a-c) (2) (a and b). By 14th September 05. Standards 4 and 27 Regulation 18 (1) as to meeting needs and staffing. The manager must ensure that there are sufficient numbers of staff on duty to meet residents’ assessed needs. By 30th September 05. The manager must provide appropriate training for staff providing care to people who have dementia. To be arranged by 30th September 05. Standard 7 Regulation 15 (1) as to care planning. The manager must ensure that, for the respite service, residents’ care plans include behavioural strategies (with regards to approach and motivation) and proof that specific programmes have been carried out. (For example support with diet/ continence). By 14th September 05. Standard 27 as to staffing. The manager should, with regards to the purpose of the home (as in 27.1), review the admissions and discharge procedures to ensure that sufficient staff are on duty to support residents of the respite service at the time of their admission and discharge. By 30th September 05. Standard 36 as to staff supervision. The manager should address training needs and good practice in provision of dementia care and record keeping, in the next planned supervision sessions with staff. Standard 29, Regulation 19 Schedule 2 as to fitness of workers. The manager must ensure that the home’s recruitment procedure is followed for all staff who work in the home. By 14th September 05. General requirements and recommendations based on observations during the inspection.. Kyffin Taylor House F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 8 Standard 37 as to record keeping. The manager should ensure that appropriate language is written in residents’ care notes (as discussed during the inspection). Standard 37 as to record keeping. The manager should ensure that staff add their signatures to all daily care notes which are written by them. Standard 7 Regulation 13 (4) (c) as to health and welfare. The manager must ensure that, in response to residents’ presenting behaviour, risk assessments are carried out (examples, attempting to climb out of the windows/ and or leave the building. By 14/9/05. Standard 7 Regulation 13 (4) (c) as to health and welfare. The manager must ensure that all staff are aware of the home’s policy on missing residents. By 14/9/05. Standard 28 Regulation 19 (5) (b) as to fitness of workers. The manager must arrange for a minimum of 50 of staff to have achieved NVQ2. By 31/12/05. Standard 12 Regulation 16 (2) (m) (n) as to facilities and services. The manager must provide a structured programme of activities in accordance with the range of needs of the residents of Kyffin Taylor. By 30/9/05. Standard 12. The manager should increase the input of the activities co-ordinator if necessary in accordance with the requirement above. Standard 18 and 10 Regulation 13 (6) as to welfare. The manager must ensure that service users are protected from abuse by reviewing the way in which the service is managed for permanent and respite residents. By 31/10/05 Standard 19.2 Kyffin Taylor House F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 9 The manager should replace the wooden base units in the kitchen in accordance with the Environmental Health Officer’s recommendation. 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. Kyffin Taylor House F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 10 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 Standards Statutory Requirements Identified During the Inspection Kyffin Taylor House F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,4 The home was not meeting Standards 3 and 4. Standard 3. Shortfalls were noted on the level of information accompanying a resident who was admitted into the home and who was the subject of a complaint investigation. Standard 4. There was evidence during the inspection that the home has not met the needs of two respite residents who have dementia. Standard 6. The home does not provide intermediate care and will not be assessed against standard 6. EVIDENCE: Standard 3. Assessments for permanent service users were satisfactory. Shortfalls were noted in the standard of assessment for a resident admitted to the dementia respite service. A complaint was investigated during this inspection and the information provided on his admission to the home did not fully reflect the resident’s presenting needs during his stay in Kyffin Taylor House. On admission, there was no mental health assessment or comment on this gentleman’s level of dementia. As this was his first stay in Kyffin Taylor, this information would have been useful in assessing his ability to adjust to a strange environment and carers who are unknown to him. He is used to a male carer the social services’ care plan. The absence of male carers in Kyffin Taylor, could have contributed to his refusal to accept personal care and to get
Kyffin Taylor House F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 12 out of bed. According to daily report notes compiled in the home, the resident’s needs with regards to diet, mobility and continence, appeared to be higher than those stated on the initial assessment. The care plan compiled by staff in Kyffin Taylor after admission, states that his “dementia is advanced and he does need a lot of support.” The manager confirmed that levels of initial assessment from the placing authority differ, some are very detailed and form the basis of the home’s care plan, others are less detailed and the care plan is based on the home’s assessment. Standard 4. There was evidence during the inspection (from direct observation) that the needs of one resident, who was receiving dementia respite service, were not being met. This gentleman had some insight into his situation and was restless and displaying repetitive behaviour, such as repeating questions to staff. He asked constantly about his wife and when he would be going home. The staff on duty appeared to be very busy at this time, he was offered a cup of tea and remained in the office with me and then accompanied me to the lounge. His behaviour appeared to be causing some irritation to permanent residents, one was observed speaking sternly to him. He said to me in response, “I am having abuse in there.” Another permanent resident called me over and said that this gentleman had been trying to get out to go home on the previous day, and she was worried he would wander into her bedroom by mistake. Provision of a dual service in one home can affect the quality of life of all in residence, as in the example stated above. It was evident that the recently established dementia service is having an impact on the lives of permanent residents. Four residents said that they were aware of the recent changes in the home. They did not object, but thought the staff have seemed very busy in recent weeks. There appeared to be no time during the morning, for staff to support residents on a one-to-one basis or to provide the structured activities necessary for those who have dementia. The following judgement was reached by reading an individual’s care notes and by discussion with his family and a visitor to the home when he was in residence. The personal care needs of the respite resident who was the subject of a complaint (no longer in residence), had not been met. The complaint is upheld. Kyffin Taylor House F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,10 The home was not meeting standards 7 and 10. Standard 7. The care plans for permanent residents were satisfactory. Shortfalls were noted in the care plan in place for one respite resident with regards to behaviour management strategies and continence support. Standard 10. Staff were observed treating residents with respect and those in residence appeared to be well cared for. As a result of provision of two services in one home, and the pressures on staff time, the dignity of one resident was not being respected by fellow residents. EVIDENCE: Standard 7. Care plans for permanent residents were satisfactory. Reference was made to two respite residents’ care notes. The shortfall is assessed with regards to the resident, who was the subject of the complaint. When living in his own home, this gentleman, who has dementia, likes singing, watching television and he receives support from a long-term agency carer. The care plan, CM2, provided by the referring authority on admission, gave only basic details of this gentleman’s needs. There was no mental health assessment or comment on his level of dementia and ability to accept a strange environment and carers. The level of information provided to the home, was not an adequate basis on which to commence a relevant care plan at the time of
Kyffin Taylor House F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 14 admission. The internal assessment and care plan, carried out by staff in the home, was dated four days after his admission. In the days between, staff had experienced difficulty in motivating this resident, he remained in bed, was incontinent and he refused personal care. His family and a visitor have expressed concerns to CSCI on his condition when they visited him in Kyffin Taylor House. He was found to be in bed on two occasions during the afternoon and his family assisted him to get up. He appears to have regressed during the early days of his residence in the home, being incontinent, non cooperative to personal care, and on one occasion, unable to walk. A continence programme was established four days after admission to Kyffin Taylor. There was no evidence that this had been adhered to by staff. There was no written strategy formulated as a response to his refusal to accept personal care. There was no record of this gentleman’s food and fluid intake. The care notes indicate he had a poor diet at times, the instruction was to “push fluids”. Staff in the home are experienced in providing care to residents who have capacity to make decisions and they are aware of the individual’s human rights. They lack experience and training in approaching people with dementia who may make a decision, which is not in their best interests, as in refusal to accept personal care. Good practice was noted in the care notes of a second respite resident, whose wife had made written contribution to his care plan. With regards to this gentleman’s presenting behaviour (attempting to leave the building the previous day). On reading his care plan the following shortfalls were noted. There was no updated risk assessment in place, nor was there a behaviour management strategy. Standard 10. No shortfalls were observed with regards to privacy. The dignity of one resident was not protected by the way in which the dual service is managed in the home. (Referred to in Standard 18). Kyffin Taylor House F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,14,15 The home was not meeting Standard 12 and 14. The home was meeting standard 15. The lifestyle experienced in the home was not matching the expectations and preferences of some of the residents, or their ability to exercise choice and control. Standard 15. There is a good choice of meals and drinks on offer in the home, and the dining room is suitable for the purpose. EVIDENCE: Standard 12. A consultation process took place with existing residents, prior to registration of the dementia respite service and they chose to remain in the home. The permanent residents could not have been expected to foresee the effects of a dual service on their own quality of life in Kyffin Taylor. From direct observation, two of the permanent residents presently in the home, are experiencing difficulty in understanding and tolerating the needs of respite residents, who may present repetitive behaviour and wandering. Four permanent residents said that staff appear to be under pressure and busy since the respite service was established. The lifestyle now experienced in the home does not presently meet their aspirations and preferences on admission with regards to their day-to-day experiences and access to staff and activities. The in-house activities co-ordinator visits the home three times a week. Consideration should be given to increasing this input. Activities must be
Kyffin Taylor House F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 16 aimed at the abilities and preferences of all residents and there must be flexibility in provision of one-to-one support for those who are assessed as in need of this, to manage their behaviour. A record must be kept of all activities provided and there should be ongoing consultation with residents. Music was playing in the lounge during the morning of the inspection. One resident likes knitting and sewing and is usually content in busying herself with this during the day. Staff appeared too busy providing personal care and baths and doing laundry, to organize anything further that morning. The senior member of staff was constantly called to the office to answer the telephone, in addition to supporting residents. All residents spoken with at this time appeared to be well groomed and well cared for. Standard 14. With regards to the respite residents, there would appear to be limitations on their choices regarding where to spend their time, as some of the long-term residents will not accept them in one of the lounges. There is a lack of adequate staff support to provide diversionary activities to manage the behaviour of those who have dementia and this in turn, affects quality of life of and choices for all residents. A number of permanent residents have adapted well to the changes, a minority were anxious regarding the ongoing admissions to what had previously been a stable resident group. There was evidence that three of the respite residents had settled well, and a number of permanent residents were extremely supportive towards them and positive regarding the service provided in the home. Standard 15. Residents who commented said they were satisfied with their meals and drinks are served regularly throughout the day (and at night, on request). The dining room is light and airy and was well presented at the time of inspection. The kitchen was visited and there were adequate food stocks in store. Kitchen records were up to date and menus satisfactory. The kitchen and equipment was maintained to a satisfactory standard. A recommendation is made under standard 19 with regards to replacement of wooden base units in the kitchen. Kyffin Taylor House F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 17 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Standard 18. The home was not meeting standard 18 with regards to interaction observed between residents. EVIDENCE: Standard 18. Incidents between two permanent residents and a respite resident, are referred to in standard 4. Accepted definitions of abuse recognize that it can be verbal and can occur between residents. There are now two levels of capacity present in Kyffin Taylor between the permanent and respite residents. Permanent residents, (who have rights within their terms of residency in Kyffin Taylor), may now witness the behaviour associated with advanced dementia on a day-to-day basis. For some, this was observed to be a cause for irritation and anxiety, in what has previously been their peaceful environment. Respite residents have the right to be protected by the care provider and treated with respect, regardless of their presenting behaviour. The manager must now ensure that the rights of all residents are protected in the day-to-day management in the home. Staff were observed treating residents with respect at all times throughout the inspection. Kyffin Taylor House F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 The home was not meeting standard 19, a shortfall was observed in the kitchen area. EVIDENCE: The gardens and building are comfortable and generally well maintained. The organisation employs a maintenance section which carries out repairs and decoration. The latest Environmental Health Officer’s Report recommends that the wooden base units in the kitchen are replaced. The recommendation is repeated in this report. Kyffin Taylor House F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30. The home was not meeting standards 27,29 and 30 with regards to staff numbers, staff vetting and training. EVIDENCE: Standard 27. As stated previously in this report, staff appeared to be under pressure during the inspection and one resident was not receiving sufficient support in managing his anxiety and restless behaviour. Staffing must be flexible to meet the needs of respite residents and the admissions and discharge procedure. Standard 29. A shortfall is noted and is detailed in the complaint investigation referred to in this report. Standard 30. NVQ achievement rate in the home is below 50 . (About 35 ). One member of staff was due to commence this training, two staff were due to complete final NVQ units. Two senior staff members were due to commence NVQ4. The manager is an NVQ assessor. Mandatory training is ongoing. Staff have undertaken some training in dementia. The outcome of the complaint (upheld) has identified a gap in staff training with regards to management of dementia and challenging behaviour and the associated records, which must be maintained. An update on Protection of Vulnerable Adults has been arranged with the local authority training unit. Kyffin Taylor House F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38 The home was not meeting standard 37 with regards to content of a minority of care notes. Records should be maintained in accordance with the Data Protection Act 1998 and residents’ access to personal files. The home was meeting standard 38 in the matters referred to below. EVIDENCE: Standard 37. Two instances of inappropriate language was noted in care notes and discussed with the senior on duty at the time of inspection. Instances were also noted, where the writer had not signed care records. Standard 38. Fire book last fire instruction 21/7/05, last system test 18/8/05. Emergency lighting and extinguishers, 20/7/05. Lift Certificate Aug 05. Gas Certificate 1/11/04 Electrical Certificate 1/11/05. Kyffin Taylor House F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 1 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 x 14 1 15 3
COMPLAINTS AND PROTECTION 2 x x x x x x x STAFFING Standard No Score 27 1 28 x 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 x x x x x x 2 3 Kyffin Taylor House F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 3 Regulation 14 (1) (2) Requirement The manager must ensure that professional assessments for service users admitted to Kyffin Taylor, are in accordance with Care Home Regulations 14 (1) (a-c) (2) (a and b). The manager must ensure that there are sufficient numbers of staff on duty to meet residents’ assessed needs. By 30th September 05. The manager must provide appropriate training for staff who provide care to people who have dementia. To be arranged by 30th September 05. The manager must ensure that, for the respite service, residents’ care plans include behavioural strategies (with regards to approach and motivation) and proof that specific programmes have been carried out. (For example support with diet/ continence). The manager must ensure that the home’s recruitment procedure is followed for all staff The manager must ensure that, in response to residents’ presenting behaviour, risk Timescale for action 14/9/05 2. 4 and 27 18 (1) By 30/9/05 3. 7 15(1) By 14/9/05 4. 5. 19 7 19 Sched.2 13 (4) Ongoing from 14/9/05 14/0/05 Kyffin Taylor House F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 23 6. 7 13 (4) 7. 8. 28 12 19 (5) 16 (2) 9. 18 and 10 13 (6) assessments are carried out (examples, attempting to climb out of the windows/ and or leave the building. The manager must ensure that all staff are aware of the home’s policy on missing residents. By 14/9/05. The manager must arrange for a minimum of 50 of staff to have achieved NVQ2. The manager must provide a structured programme of activities in accordance with the range of needs of the residents of Kyffin Taylor. The manager must ensure that service users are protected from abuse by reviewing the way in which the service is managed for permanent and respite residents. 14/9/05 31/12/05 By 30/9/05 By 31/10/05 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. Refer to Standard 27 Good Practice Recommendations The manager should, with regards to the purpose of the home (as in 27.1), review the admissions and discharge procedures to ensure that sufficient staff are on duty to support residents of the respite service at the time of their admission and discharge. By 30th September 05. The manager should address training needs and good practice in provision of dementia care and record keeping, in the next planned supervision sessions with staff. The manager should ensure that appropriate language is written in residents’ care notes (as discussed during the inspection). The manager should ensure that staff add their signatures to all daily care notes which are written by them. The manager should increase the input of the activities coordinator if necessary in accordance with the requirement above. The manager should replace the wooden base units in the
F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 24 2. 3. 4. 5. 6. 36 37 37 12 19 Kyffin Taylor House kitchen in accordance with the Environmental Health Officer’s recommendation. Kyffin Taylor House F53 F03 S5416 Kyffin Talor House V246617 240805 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection 2nd Floor Burlington House Crosby Road North Waterloo L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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