Inspection on 23/03/06 for Yanwath Care Home

This inspection was carried out on 23rd March 2006.

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 but made no statutory requirements on the home.

Other inspections for this house

Yanwath Care Home 27/02/08

Yanwath Care Home 23/10/07

Yanwath Care Home 07/09/06

Yanwath Care Home 15/12/05

Yanwath Care Home 20/12/04

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

CARE HOMES FOR OLDER PEOPLE Yanwath Care Home Yanwath Care Home Yanwath Penrith Cumbria CA10 2LF Lead Inspector Jenny Donnelly Unannounced Inspection 23rd March 2006 10:30 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 Yanwath Care Home DS0000061530.V284171.R01.S.doc Version 5.1 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. Yanwath Care Home DS0000061530.V284171.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Yanwath Care Home Address Yanwath Care Home Yanwath Penrith Cumbria CA10 2LF 01768 862835 01768 899678 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) Hemingway Group Limited Mr Andrew Phillip Shewan Care Home 49 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (49) of places Yanwath Care Home DS0000061530.V284171.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The home is registered for a maximum of 49 service users to include: up to 49 service users in the category of DE/E (Dementia over 65 years of age) The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. When single rooms of less than 12sqm usable floor space become available, they must not be used by wheelchair users. One named service user in the category of DE (Dementia under 65 years of age) may be accommodated within the overall number of registered places. 15th December 2005 Date of last inspection Brief Description of the Service: The Hemingway Group Limited own Yanwath Care Home. Mr Andrew Shewan is the registered manager. The home offers nursing care for older people with dementia. The home was purpose built approximately 15 years ago. It had two floors occupied by residents, and there was a passenger lift. The third floor was used for storage and staff rooms. The home had a majority of singe bedrooms with en-suite facilities. There were bathrooms with adapted bathing facilities, and several lounges/dining rooms for shared use. There was a large secure garden at the back of the home, with free access out from one of the lounges. The remainder of the home was secure, with keypad locks on exit doors. Yanwath Care Home DS0000061530.V284171.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. The manager was not present initially, as he was assessing a prospective resident in hospital, and returned to the care home later. The inspection comprised of a tour of the building, a review of care records, inspection of medicines, staff files and maintenance records. There were 39 residents in occupancy. The home does not operate to its maximum of 49, as double bedrooms are being used singly. During the inspection, social activities staff took seven residents out in the mini bus, to a local teashop. The home has recently applied for a change in their registration to take up to five people under the age of 65 years. This application was being processed at the time. Any key standards not reported on in this report, were inspected and found satisfactory at the last inspection of December 2005. What the service does well: What has improved since the last inspection? Further to the last inspection improvements had been made to medicine records, care planning, fire safety and dental care. The record keeping for medicines had improved following extra vigilance by the manager and training for staff. A new care plan system had been devised, based on a care pathways model, and staff were about to receive training on this. The fire officer’s recommendations regarding fire doors had been acted on, and the work completed satisfactorily. A new dental assessment had been introduced. Yanwath Care Home DS0000061530.V284171.R01.S.doc Version 5.1 Page 6 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. Yanwath Care Home DS0000061530.V284171.R01.S.doc Version 5.1 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 Yanwath Care Home DS0000061530.V284171.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: No standards in this section were inspected on this occasion. Yanwath Care Home DS0000061530.V284171.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 and 10 The management of medicines in the home was safe, and there were improvements in the medicine records. Residents were treated with respect, and their privacy was maintained. EVIDENCE: At the last inspection there were numerous omissions from the medicine records, where staff had not signed to confirm whether a medicine had been given or not. A requirement was made about this. Since then the manager has reminded staff about this, and commenced a weekly audit of the medicines records. Two staff had also completed a 12 week safe handling of medicines course, and the manager had purchased some in-house training materials. The standard of record keeping in relation to medicines had improved and the requirement was satisfactorily met. Through discussion with staff it was evident that they were aware of the need to protect residents privacy and dignity. Personal care was provided in bedrooms or bathrooms, and door locks or engaged signs were used. Residents were addressed by their preferred name, and this was recorded in Yanwath Care Home DS0000061530.V284171.R01.S.doc Version 5.1 Page 10 their care plan. Residents wore their own clothes, which were laundered on site, and pressed nicely. Hair care had been attended to, and residents were properly dressed with socks/stockings and footwear as they wished. Staff said the best way to care for the more challenging residents, was through a polite and respectful approach, to build up residents’ trust, and help them feel safe. All staff, not only the carers and nurses, were observed speaking kindly and politely to residents. Staff spent time with residents, and promoted a calm and unhurried atmosphere. Care plans were generally good at the last inspection, although there was some weakness in the recording of wound care, and a recommendation was made. At this time there were no residents with wound care needs, so the homes’ progress with this could not be assessed, and will be reviewed next time. There was a mock up of a new care planning system available, which had been devised using a care pathways approach. This looked a very good layout, and was to be introduced following some staff training. Yanwath Care Home DS0000061530.V284171.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 14 Yanwath provided a stimulating environment with a range of suitable activities on offer. Links with friends and family were encouraged, and residents had opportunity to get out of the home with staff, into the local community. Staff respected residents choices and decisions, and tried to work with residents to provide their care. EVIDENCE: Yanwath employed three social activities organisers, who covered the week, including some evenings, between them. Each week there was a mini bus outing, and staff ensured that different people had the opportunity to go on this. Today seven residents went to a tearoom by the railway level crossing. The residents who went liked to watch the trains and the crossing barriers working. Other weekly trips went to different cafés, either at the shops or at local garden centres. There was also a good varied programme of in-house activities and entertainment. The home operated an open visiting policy, which meant residents could receive visitors at any time they liked. Visitors were mostly well known by staff, and there was good rapport between them. The home was secure, with the front door having a coded keypad. Entry and exit for visitors was gained Yanwath Care Home DS0000061530.V284171.R01.S.doc Version 5.1 Page 12 only through the staff. This was to ensure that residents were not accidentally let out through the front door without the staffs’ knowledge. Residents were limited by their dementia in exercising full choice and control over their lives. However, small choices in day to day living were clearly being offered and respected. Staff were seen to offer residents choices at meal and drink times, and whether to join in activities or not. It was evident that when a resident declined to participate in any activity, be it a social or care activity, staff respected this, left the resident and offered the care at a later time. Staff said that residents were able to express their choices about their personal care through their body language if not verbally. With the help of relatives, staff built up a picture of what each resident liked, but were alert to this changing. Residents were able to wander freely around the home and have access to a secure garden. Yanwath Care Home DS0000061530.V284171.R01.S.doc Version 5.1 Page 13 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 the following standard(s): EVIDENCE: These standards were not fully inspected on this occasion. The manager took any complaints seriously and offered meet with complainants to try and resolve their concerns. The home kept a record of any complaints made. One complaint had been made recently, and was in relation to a period of very heavy snow, which prevented some staff getting into the home one day. Yanwath Care Home DS0000061530.V284171.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 19 and 26 Yanwath provides a comfortable, clean and safe environment for residents, although the building is need of some decorative upgrade and equipment replacement. EVIDENCE: Further to the last inspection, the home is in need of some refurbishment, with new carpets, furniture and re-decoration needed. There was also damage to some bath panels. The owners are currently considering a substantial amount of re-building work. This is not certain to happen, and if it does not take place, a refurbishment plan will be needed. The manager has completed a list of works for the owners’ consideration. Meanwhile Yanwath continues to offer and comfortable and safe environment for residents. When bedrooms became vacant, the handyman redecorates and does any minor repairs. The home has previously been recommended to provide a lockable storage facility in each bedroom. The manager said this was on hold pending the possible building/refurbishment work. The recommendation remains. Yanwath Care Home DS0000061530.V284171.R01.S.doc Version 5.1 Page 15 The laundry is sited externally to the home, and is staffed for 5 or 6 six days a week. Bedding and towels go out to a contract laundry service, leaving staff to do residents clothing and personal duvet covers. The access to the laundry is unfortunately through the dining room. However, staff operate a system of laundry bags being brought through during the night or early morning, when the room is not in use. The laundry staff had access to adequate equipment, including gloves, aprons and facility to wash their hands. Red laundry bags that go straight into the washing machine were used for foul laundry, to reduce handling. The laundry floor was painted concrete, and where the paint had worn, the floor was not impermeable or easily cleaned. This needs to be rectified. The standard of cleaning throughout the home was good, with 3 or 4 cleaners on duty each day. Carpets and curtains were cleaned regularly. Domestic staff knew to take extra care with cleaning products and cables when residents were around. Yanwath Care Home DS0000061530.V284171.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 29 Staffing levels were good and ensured residents’ needs were met consistently. The recruitment procedures were sound and protected residents from having unsuitable persons working in the home. EVIDENCE: Staffing levels reflected the high needs of the residents. On duty were, two nurses and 7 care staff, plus social activity, kitchen, maintenance, laundry, domestic and administrative staff. The manager was additional to the two nurses on duty. A high percentage of care staff held care qualifications, either an NVQ in care, or an overseas nursing qualification. The home had thorough recruitment procedures in place, and a review of staff files showed these had been adhered to. There were references and other checks in place, along with evidence of any training attended. The recruitment procedures prevented unsuitable persons being employed and the induction and ongoing training ensured staff understood their roles. New staff did not work unsupervised until they were deemed competent. The home had employed some overseas nurses and care staff in recent months. These workers had been recruited via an agency, which carried out full personnel checks. These workers had also completed a Standard English language test as part of the selection procedure. Yanwath Care Home DS0000061530.V284171.R01.S.doc Version 5.1 Page 17 There had been an occasion recently where the home had been understaffed due to heavy snowfall. This had been unavoidable and the staff on duty had rallied round to ensure residents were cared for appropriately. Yanwath Care Home DS0000061530.V284171.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 38 The home was being run in the best interest of residents, and quality checks were in place. Residents’ money was safeguarded, and the building was maintained to promote the health and safety of residents and staff. EVIDENCE: The manager operated a quality assurance system, which included in-house audits and satisfaction surveys. Audits looked at the quality of care plans, medicines records, cleaning and meals. Satisfaction surveys had been sent out recently to relatives and professional visitors. The results of these had not been fully analysed, but the manager was aware of only two negative comments. One of these related to dental care and as a result, a British Dental Association assessment tool was being trialled in the home. This demonstrated that the manager and staff took notice of, and acted on peoples’ comments. Yanwath Care Home DS0000061530.V284171.R01.S.doc Version 5.1 Page 19 The manager also received feedback from the relatives support group. This group met every three months, and was made up of 10 to 15 people. The home did hold spending money for safe keeping on behalf of some residents. The individual monies and records of this were held securely. A sample of three residents’ records and money was inspected, and correct. There were receipts to confirm any spending, and the accounts had been checked and signed after each transaction. Inspection of the maintenance records showed that all services were up to date. These included checks on the fire equipment, the boiler, gas and electrical safety, hoists and lifts. The home had a contract for the disposal of clinical waste, and a satisfactory environmental health report. Since the last inspection some recommended improvement works to fire doors had been carried out to the fire officers satisfaction. Staff had received training in fire safety, safe moving and handling, and food hygiene. There were two qualified fire wardens, and the home had a fire risk assessment in place. Yanwath Care Home DS0000061530.V284171.R01.S.doc Version 5.1 Page 20 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 3 Yanwath Care Home DS0000061530.V284171.R01.S.doc Version 5.1 Page 21 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 OP19 Regulation 23(2) Requirement There must be time scaled plan for upgrading the standard of decoration and furnishings. (Previous timescale of 01/3/06 not met) 2. OP26 23(2) The laundry floor must be impermeable and easy to wash. 01/06/06 Timescale for action 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP8 OP24 Good Practice Recommendations Records about wound care, prevention, descriptions and treatments should be clear and accurate. The rolling programme of providing lockable storage space for residents should continue. Yanwath Care Home DS0000061530.V284171.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Yanwath Care Home DS0000061530.V284171.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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