Inspection on 09/11/07 for Wharfedale House

This inspection was carried out on 9th November 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wharfedale House 07/11/06

Wharfedale House 10/11/05

Wharfedale House 26/05/05

Wharfedale House 26/10/04

Wharfedale House 09/06/04

Wharfedale House 15/02/04

Similar services:

Snydale Care Home

Staveley Birk Leas Nursing Home

Fairmount Nursing Home

Currergate Nursing Home

Brookfield

Castlethorpe Care Home

Elmleigh Convent

Woodlands Respite Care Centre

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

CARE HOME ADULTS 18-65 Wharfedale House 16 Wharfedale Lawn Wetherby Leeds West Yorkshire LS22 6PU Lead Inspector Valerie Francis Key Unannounced Inspection 9th November 2007 09:30 Wharfedale House DS0000001522.V355214.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 Wharfedale House DS0000001522.V355214.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. Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wharfedale House Address 16 Wharfedale Lawn Wetherby Leeds West Yorkshire LS22 6PU 01937 585667 01937 547300 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) www.leonard-cheshire.org.uk Leonard Cheshire Disablility Patricia Macey Care Home 18 Category(ies) of Physical disability (18), Physical disability over registration, with number 65 years of age (8) of places Wharfedale House DS0000001522.V355214.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 are within the following categories: Physical disability - Code PD and PD(E) The maximum number of service users who can be accommodated is: 18 2. Date of last inspection Brief Description of the Service: The home was first registered in 1998. Leonard Cheshire is the registered provider. Wharfedale House is located in the Wetherby area of Leeds with close access to Wetherby shopping centre and local recreational facilities, which are in walking distance from the home. There is a good bus route to Leeds city centre and Harrogate, which is used by some service users with support from staff. The building is purpose built, to accommodate eighteen younger adults with physical disabilities. There are also some older people accommodated at the home whose primary care need is their physical disability. The building is set in large grounds with a car park shared with people living in the surrounding bungalows. There is a large garden to the back and to the side of the building. A patio and benches are available to the side of the building, which can be used by service users to sit out in the good weather. The home has seven bedrooms downstairs and six upstairs; each floor has a lounge/dining room and a kitchen. The kitchen on the first ground is used as the main food preparation area. The laundry is on the first floor. All bedrooms have telephone; en-suite toilet and level access showers. There are also four self-contained flats, three singles and one double for people who wish to be more independent but need staff support. Bedrooms are equipped with aids and adaptations to meet the needs of the occupant. The scale of fee charges range from £490 to £918.42 per week. Things that are not included in the fee are hairdressing transport, to social events. Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk The inspection was carried out by one inspector over two days, on the first day the inspector was accompanied by an “Expert by Experience”, who is a person because of their shared experience of using services and /or ways of communicating, visits a service with and inspector to help them get a picture of what it is like to live in or use the service. During this visit they were asked to look at the peoples daily life and social activities and their experience in the home. These views have been included in this report. The inspection started on the 8th November and was completed 9th November 2007 with feedback to the manager. No arrangement had been made with the home to carry out the inspection. The evidence used in this report came from a number of sources. • • A review of the information held on the home’s file since its last inspection. Information sent to us by the registered provider in a document called the Annual Quality Assurance Assessment (AQAA). This form gives the home and the organisation the opportunity to put forward their views how they provide their service to people using it or wanting to. Before the visit, survey questionnaires were sent to the home to give to people who use the service and relatives, visiting professionals who were involved in the home were sent questionnaire for them to complete. Fifteen surveys were sent back to us by people who live at the home, one by a relative and one completed by a health care professional. The unannounced visit to the home, which lasted about fourteen hours. This visit included a tour of the premises and talking to people who live at the home, their friends/relatives, staff and management. Menus, staff rotas, people’s care plans were looked at and staff watched looking after people during the inspection process. DS0000001522.V355214.R01.S.doc Version 5.2 Page 6 • • Wharfedale House Thank you to everyone for the returned questionnaires and for the hospitality and assistance on the days of the visit. Requirements and recommendations made during this visit can be found at the end of the report. What the service does well: Staff are knowledgeable about peoples’ care needs. The following comments are representative of how people feel about the home: • • • Very happy with all that is done here When I ask for something it is always done for me Staff are friendly and take an interest in their residents Staff said, “that there is a good atmosphere in the home. People living there get good care” The manager was said to be supportive and approachable”. Each person’s room is individual to them and shows their interests and preferences are catered for. What has improved since the last inspection? What they could do better: Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 7 People contract of terms and conditions should be written in plain English so people could clearly understand their rights and who is responsible. The home should consider other formats to present the information that is available including the complaint procedure so that people will be able to access information independently. 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. Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 8 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 Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 & 5. People who use the service experience good quality outcomes in this area. People are provided with enough information to enable them to make an informed choice about the home. The admission process is good and includes introductory visits. We have made this judgment using available evidence including a visit to this service. EVIDENCE: There is a statement of purpose and service user guide that give information about the service provided at the home, these documents are reviewed annually. Other information about the registered organisation and guidance for service users on protecting vulnerable adults is also available at the home. Although there was a range of information in place, this was not available in formats that are suitable for the people who live at the home. The manager said she will discuss and work with people living at the home and staff to provide the home’s information in several formats to meet the needs of the people who use the service. Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 10 There was information seen that showed that people are assessed before they move into the home and them and their relatives or carers also have the opportunity to visit. People who want to use the service can and have a day and over night stay if they wish and it was appropriate. The file of the last person to move into the home was looked at; it contained a detailed assessment of that person’s needs. There is also a reassessment process carried out if people’s needs change whilst they are living at the home. The manager said that the home would work with other agencies outside the home to make sure that people’s cultural needs are met. The manager said although people living at the home are not directly involved in the admission process of a new person coming to live at the home, people are informed of any pending admission. Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. People who use the service experience good quality outcomes in this area. Care plans and risk assessments provide clear detailed instruction on how people’s needs are to be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People’s care plans are detailed and give specific information to staff about care and support needed. Staff have a good knowledge of residents’ needs. They were able to accurately describe the care and support they give and talk about the detail of how people like to be supported in their daily routines. Some staff said they had received training in care planning and risk assessment. It was evident from discussion with people who use the service that they are involved in their care planning process. People have signed their care plans and risk assessments to show they are in agreement with the plan. Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 12 Three care plans were seen and although there was some good information in care plans, one of the plans had gaps of care needs, and the manager said this was due to very basic information accessible at the time of the assessment. There was not enough information to put together a comprehensive plan. This person was being continually being assessed so that a detailed plan can be put in place. Care plans have been regularly evaluated and reviewed, with changes being made as needed. Key-workers have a monthly meeting with residents to do this. Although care plans are linked to risk assessments there was one person who was identified as being at risk of choking but there was no care plan in place how this would be managed and minimised. Staff and the manager have a good attitude to risk taking and furthering people’s independence. During the inspection people were seeing going out independently to shops in the local community. The organisations form “ the right to take risk” document had only been completed for two of the people whose files were seen. Although most people said that they could go to bed when they wish. One person said this sometime determined by staff. This was brought to the attention of the manager, who said this would be discussed with staff at their team meeting. One person indicated that she could do things for herself, but if she wanted any help from staff she knew it would done without any problem. Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17. People who use the service experience Adequate quality outcomes in this area. People who use the service are not satisfied with their lifestyle; there is room for more development in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Generally people who use the service spoke positively about the staff and the manager. It was clear that the people are encouraged to go out independently. People were seen going out shopping independently or being taken out by friends. However throughout the inspection, people who were more dependent on staff to take them out said they were bored and they was nothing much to do. Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 14 People indicated that the times that they did not go out there was little or nothing to do. Some people who use the service said they used to play board games, but this had not happened for some time. Staff in their survey formation said the home could do better by “recruiting and maintaining a more permanent staff team, which would offer more opportunities to the service users to access recreational activities, as often the day is centred around meals and nothing else.” Since the last inspection a part- time activity person had been appointed, and recently a part time activity coordinator, who has been working with people looking at their social needs. It was noted during the inspection that the televisions in each communal sitting room were on. It was not clear if it was custom and practice for them to be on, there were occasions where people were having difficulties interacting with their visitors and during meal time there was no conversation as the television was on and no conversation appeared to be encouraged. A carer was playing dominoes with one of the people who live at the home but it was noted throughout the game there was no conversation with the person. People commented that they were generally happy within the home, and commented by saying. • “ People really nice.” “ I am extremely happy.” • One person said, “staff look after me well and I have the freedom to go out when I want and do what I want.” • “ The home is comfortable, people were nice and I am as independent as I can be.” The manager said although people who use the service do not attend staff meetings. There are however regular meetings with the people who live at the home where matters relating to them and the home are discussed. The issue of people getting seven days holiday a year paid by the home or the funding agency has been discussed for some time. The manager said all efforts have been made by the organisation to assist people when they can, but this matter has been and will be raised with the funding agency at the time of people’s assessment to move into the home. Each person has a member of staff (key worker) who supports people in their day to day life. This includes going out shopping or doing their washing. One person said, “ I feel they do everything they can to make the people living there happy looked after and make sure they know that this place is their home. And treat it as they would, when they lived at home. Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 15 The staff respect them, they always know on doors before they enter their rooms.” People are encouraged and supported to keep in contact with their relatives by key workers arranging for people to visit their relatives at home. Food was an issue at the last inspection people said this has improved. There are four weekly menus that were said, to have been planned with the people who live at the home. The manager said there are regular menu planning meetings, which involves a representative from the people who live at the home. The outcome is discussed at the next resident meeting. The manager said she plans to discuss meals with people individually to make sure that people have the opportunity to discuss freely their likes and dislikes. People were asked about the food served, peoples’ comments were “it’s fine “”ok” “no problems” and “ food lovely.” However others commented “ food bland” ”because I needed to be help I am last and usually my food is lukewarm and I do not enjoy it then.” “I can have my meals in my room if I wanted,” “ my carer help me to cook my meals.” Would eat more if I was assisted sometimes,” “get too much”” I like plan cooking.” There is a nutritional screen tool, which is used, as a risk assessment tool to assess people nutritional needs. To makes sure people are not nutritionally at risk, any risk identified has a care plan in place with regular monitoring of people’s weight and any special diet put in place. Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20. People who use the service experience Good quality outcomes in this area. The home has good systems in place to make sure health, personal care needs are met, and people receive the right support from healthcare professionals. Medication procedures are carefully followed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The healthcare survey returned indicated that the home always seeks advice and acts upon it, and always respects individuals’ privacy and dignity. One relative survey indicated that home always meet the needs of their relative living at the home. Care files had information about health appointments. Files confirmed people had recently attended healthcare appointments, including GP and chiropody. Individual weight records were maintained for people the frequency of time depended on the outcome of their nutritional risk assessment, which determine if they were at risk of being over or under weight, which at time mean the a dietician referral is made. Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 17 The home uses a monitored dosage system although some medication is received in boxes. Medication storage was looked at and the medication was well organised. Medication records were looked, staff who administered medication had been on a safe handling medication course over twelve weeks, and had access to the organisations, medication procedure and the RPS guidelines for residential home. Plans are in place for individual lockable cupboards in people’s rooms for the storage of their medication. All staff who administer medication were in the process of undertaking a refresher course on safe handling of medication, which the manager said should reduce error in medication administration. Some people have taken the opportunity to self medicate and they are in contact with their General practitioner and look after their own medication. Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. People who use the service experience good quality outcomes in this area. Satisfactory procedures are in place and people who live at the home are very comfortable talking to staff and management and will report their concerns, therefore people who live at the home are protected. This judgement has been made using available evidence including a visit to this service EVIDENCE: The home has a complaints procedure, which is discussed at resident meeting. Despite the procedure having all the required information, it was not in a format that could be understood by al the people who use the service. The manager said she would discuss the matter with the people living at the home and staff and will try to provide the procedure in formats that would meet the needs of the people living at or moving into the home. During discussions with staff people said they would speak to the manager, their key worker or family if they had any concerns. One person indicated in their survey questionnaire that their complaints are not always looked at. During the inspection it was noted that people who live at the home were asking staff for advice. Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 19 All new staff have safeguarding adult training as part of their twelve week induction training. Staff have access to the organisation’s adult protection procedure, the local authority multi agency procedure and the Department of health No Secret document. During discussion with staff it was clear that staff were aware of the procedure to follow if an incident occurred and the different type of abuse. Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. People who use the service experience good quality outcomes in this area. The home is pleasant, well maintained and people who live at the home are very comfortable in their surroundings. This judgement has been made using available evidence including a visit to this service EVIDENCE: A tour of the building was carried out. Communal areas, bathrooms and bedrooms were visited. The home has now employed two domestic staff, one being the housekeeper and a part time cleaner. The matter of cleanliness was an issue at the last inspection, there are now cleaning plans in place to make sure that all area of the home is kept clean and odour free. People who live at the home go freely around the home and use all communal areas. Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 21 Bedrooms were very personal, the décor reflected the preferences of the people who live there. Most rooms had photographs, pictures and personal items. Different equipment was available to help maintain skills and promote independence and moving and handling equipments. The home has a programme of replacement and redecoration, which was ongoing. Since the last inspection there has been a series of work carried out, most of the bedrooms have been redecorated, the manager said the replacement of furniture was part of the home’s programme of redecoration and replacement for bedrooms. The manager said repairs and maintenance problems were dealt with within in a reasonable timescale. Some redecoration and replacement of furniture had been carried out in the communal sitting rooms, the manager said the carpet on the top floor hallway would be replaced when the work in the kitchen has been completed. There has been a plan for the replacement of the kitchen furniture and equipments to the first floor for some time. This would provide the home with a commercial type kitchen with the fitments and equipments to suit. On the day of the inspection arrangement was made by the fitter to install the kitchen and equipments. The standard of the cutlery and crockery was worn, although they had been washed they were remnants of the food when they were last used. The drawer where they were stored was packed with other items and crumbs. Bedrooms were clean and tidy. People commented that there have been some changes in the standard of cleanliness. There • • • • • was however several issues identified. The bathroom o the ground floor had tiles missing Toilet cistern cover missing. Light switch pull coming a way from the ceiling this. Diffuser light covers missing. Vent needed cleaning. The home was clean and tidy no bad smell detected, people indicated that cleanliness throughout the home had improved. The cleaners worked with people in their flats to keep them clean. The environment is well maintained and risk assessments are in place to ensure health and safety. Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 22 People at the home would benefit further with additional communal space, so that they can have a quite room, for those people who do not want watch television. Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35. People who use the service experience good quality outcomes in this area. People have access to staff that are trained and supervised to ensure they can meet the care needs of people living at the home. People do not always have access to staff who they know. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection three new staff have been employed at the home one of which is a care staff and two domestic. There are still three full time care worker positions vacant, which at the time were covered by staff overtime or agency staff. People who live at the home were very relaxed with staff and were pleased to see staff when they arrived. Some people were chatting, laughing and joking, with staff. Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 24 The home generally has a high turnover of staff, despite this some staff have worked at the home for a number of years, staff had good knowledge of the people who live at the home and were able to provide information about individual likes and dislikes. Two files of the last staff employed at the home were looked at. In the main recruitment is properly managed by the organisation. Interviews are held, references and CRB (Criminal Record Bureau) checks are obtained before staff start work and checks are made to make sure staff are eligible for work. Three people who live the home said that they had been involved in staff interviews, which was some time ago. And they said they enjoyed being part of the panel that chooses the staff who would be supporting them on a day to day basis. 50 of staff had a National vocational Qualification (NVQ) at level 2 or above. Staff said they thought the staff team were very well equipped to work with the people who lived at the home. During the visit a training matrix and training plans for all staff were seen. There were copies of training certificates in people’s files, these confirm that staff have had training to help them provide good quality care. This training includes adult protection, food hygiene and moving and handling. From information in the AQAA (Annual Quality Assurance Assessment) staff have access to a good training plan, for the support of people and the staff development Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42. People who use the service experience good quality outcomes in this area. The home is very well managed and it successfully meets the needs of the people who live there. We have made this judgment using available evidence including a visit to this service. EVIDENCE: The (AQAA) Annual Quality Assurance Assessment tells us that the registered manager has experience in management and is working towards National Vocational Qualification in care and management. People who live at the home, relatives and staff were very complimentary about the manager and they thought the home was well managed. Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 26 People who live at the home meet every month; the minutes from these meetings stated that different topics were discussed. There was evidence that people who live at the home are encouraged to put forward their views. A representative from the home is involved in the regional financial meeting when the financial affairs regarding the home’s budget are discussed and the information is feed back in residents meeting. Part of the home’s quality assurance is the in house annual self assessment where the views of people who use the service, relatives and staff are sought, the outcome is discuss at residents meeting. The organisation has a three yearly service audit, to make sure the service is being run in the best interest of the people using the service. Once a month there are visits by line management to the home who looks at the general conduct, these visits are called Regulation 26 visits. The manager confirmed the visits were completed regularly. The (AQAA) Annual Quality Assurance Assessment tells us that policies and procedures were available and regular maintenance and health and safety checks were completed at the home. Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 27 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 3 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 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 2 X 3 X X 3 X Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes 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 YA12 Regulation 15 (2)(n)(3) Requirement The registered provider must make sure that people living at the home have activities so that they do not become bored and apathetic. Residents must be given full support to carry on with their daily life. Timescale was made at the last inspection for 31/12/06. The registered manager must make sure that people’s rights and wishes are respected. Timescale for action 31/01/08 2. YA16 16 (2)(m) 31/01/08 3. YA16 3 31/12/07 4. YA24 23 The registered manager must 31/01/08 make sure that the matters identified in the report relating to the environment are resolved. The kitchens must be kept clean at all times, so that it is in keeping with food hygiene regulations. Previous timescale 16/01/06. Although some effort has been made this still need to be resolve. Previous timescale 16/12/06. 31/01/08 5. YA30 23 Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 29 6. YA32 18 7. YA32 18 The registered manager must make sure that all staff can communicate effectively with people who living in the home. People must receive care from staff who they know and can meet their needs. 31/12/07 31/01/08 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 YA14 YA1 Good Practice Recommendations The matter of the 7 days holiday for people in long term care, should be given serous consideration. The home should consider other formats to present their information that is a available this should also include the complaint procedure so that people will be able to access information independently. Longer cords to the call bell should be fitted in all areas, so that people can have easy access. The toilets should have clear instruction on how the communal toilet door lock and open. The registered person should give some consideration to provide the home with additional communal space, so that people have a quite space. 3. 4. 5. YA29 YA29 YA29 Wharfedale House DS0000001522.V355214.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. 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