Inspection on 15/02/07 for Yarborough House Care Home

This inspection was carried out on 15th February 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Yarborough House Care Home 28/01/09

Yarborough House Care Home 29/01/08

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Snydale Care Home

Hawkhills

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Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Yarborough House Care Home 34 Yarborough Road Grimsby North East Lincs DN34 4DG Lead Inspector Mrs Kate Emmerson Key Unannounced Inspection 15th February 2007 09:30 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 Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Yarborough House Care Home Address 34 Yarborough Road Grimsby North East Lincs DN34 4DG 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) 01472 355791 J Care (UK) Ltd Position Vacant Care Home 27 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (27) of places Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Not applicable. New providers. Brief Description of the Service: The home is situated close to the centre of Grimsby and motorway links and it is well served by local bus routes. The accommodation is situated over two floors with passenger lift access to the first floor. The accommodation is provided in both single and double rooms. The home is comfortable and homely with a variety of communal areas. The fees at the home at the time of the inspection were £329 per week. Additional charges were Hairdressing £3 - £10, Chiropody £9, Bingo £1 and variable charges for outings and toiletries. Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over two days in February 2007. To find out how the home was run and if the people who lived there were pleased with the care they got the inspector spent time in the home watching how the care was given and speaking with the service users. Surveys were also sent out and the Commission received completed surveys from 2 service users, six relatives/visitors and nine staff. The inspector spoke to the person who owned the home, the acting manager and staff working in the home at the time of the inspection. Paper work kept in the home was seen to check that staff are safe to work in the home and that they had been trained to their job safely. Records of care people had received were also checked. New providers had taken over the home in June 2006 and had worked hard to improve the environment and gardens. They had also implemented new care plans and purchased new equipment to assist in the care of the service users. What the service does well: The people who live in the home said they were able to decide on their own daily routines. The service users all enjoyed the food provided. They said the food was ‘very nice with plenty of choice’. The home provided a consistent staff group and staffing was arranged to meet the demands of the busiest times of day. Staff were trained to do their job safely and to give care to meet the needs of the people who live in the home. The people who lived in the home said that the staff were ‘excellent’ and ‘look after you very well’. The service users were provided with clear information about the services provided and the complaints procedure. All the service users had care plans where their likes and dislikes were recorded, their personal and health care needs were met. All the service users spoken with stated that their privacy was respected and a service user stated that they ‘always knock on your door and wait to be invited in before entering you bedroom’. Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 6 The home had good systems in place to protect the service users from abuse and all the majority of the staff had received training in this area. The home was well maintained and clean and tidy and there had been a programme of redecoration and improvement. A sensory garden had been completed and this now provided an attractive area for the service users. The home provided a variety of communal areas, which were very homely and enjoyed by the majority of service users. The management had consulted with the service users and people who visited the home about the quality of the care provided and had acted on the information received. The management provided staff training and safety checks of equipment to protect the health and safety of staff and service user. They had provided detailed assessments where service users required assistance with moving and handling and they had provided new equipment to assist in these tasks. What has improved since the last inspection? What they could do better: They must provide more information for service users about the terms and conditions of residency in the home. To make sure that people get the care they need, the care plans must be written down in more detail and up dated when needs change. They must make sure that medication they record all changes to medication in detail. They must make sure that the hot water is at the right temperature so that people are not having baths that are too cold. They should make sure that they get written references for staff they wish to employ one of which should be from the previous employer. They must make sure that new staff have training to work in the home safely. When they have reviewed the quality of the care in the home they must provide a report and make this available to the service users. Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 7 They must make sure that where service users need to assistance to prevent falls from bed full risk assessments are completed before bed rails are used and if they are used they are regularly safety checked. 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. Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 8 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 Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users had most of the information they required to help them make an informed choice about where to live but the new providers had not provided service users with information about the terms and conditions of residency. The home made sure they could meet the service users needs by assessing and recording care needs prior to admission and providing a staff training programme appropriate to the homes registration. EVIDENCE: Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 10 The home provided detailed information for service users relating to the services provided. The statement of purpose and the service users guide were well-developed and provided clear information. The information was made available to the service users by providing a service users guide in each service users bedroom and the statement of purpose and inspection report in the reception area. The manager stated that the information was available in large print on request as the information was printed in the home. One service user stated they had come into the home, as they had been pleased with the care a relative had received there and another said they had come to stay at the home because he had heard good comments about it. The home had developed a contract/statement of terms and conditions but these had not been offered to service users as the provider stated he was still taking legal advice regarding the content of these. The provider stated he was hoping to distribute these in April 2007. A template of a letter welcoming the service users following assessment was also in place but had no evidence this had been used as the provider stated that they had only admitted those requiring short term care and the letter was not provided in these circumstances. There was evidence that all the service users were assessed with regard to their care needs prior to admission to the home even those admitted as an emergency. The manager stated that the first four weeks of admission were considered a trial period so service users could decide if the home was suitable for them and this was described in the service users guide. The home had a policy and procedure to support the assessment and admission to the home. A varied training plan was provided for the staff to assist them to meet the service users needs. Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users needs were set out in an individual care plans and although there were some gaps in care planning an evaluation service users personal and health care needs were met. The home had detailed procedures in place for the safe handling of medication but some of the administration practise could increase the risk of error. Service users felt they were treated with respect and their privacy was upheld. EVIDENCE: A selection of four care plans was examined. Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 12 Overall these were reasonably well developed and some were very detailed. There was evidence that health needs were monitored and professional advice sought where necessary. There were detailed moving and handling assessments and care plans, which also included photos of staff in the hoist slings showing how the hoist slings should be positioned. Staff had been provided with information booklets re pressure area care and these were held in each care plan where there was a risk of pressure damage. The providers had purchased a variety of equipment to assist in appropriate moving and handling including a portable overhead hoist, profile beds and a sheepskin sling to protect a service user with fragile skin. There were some gaps in care planning. Risk assessments were recorded in areas such as nutrition and tissue viability but where care needs were identified these weren’t always translated into care plans or where plans were developed they sometimes lacked specific care instructions. In one case district nurse instructions regarding pressure area care had not been incorporated into the care plan although care had been provided. Evaluations of the care plans were completed regularly but these didn’t always take into account information recorded in monitoring records such as weight charts and dietary intake charts and so care plans had not always been updated where needs had changed. Detailed daily diary records were maintained although the records completed by the night staff did not meet data protection guidance as information was recorded on one sheet for all service users rather than individually. The manager had addressed this issue by the second day of the inspection. There was some use of correction fluid in care records, which is not acceptable. The home had a detailed policy and procedure for the safe handling of medication. Records of receipt, administration and disposal of medication including controlled drugs were maintained. Staff had received training from Boots and had received a half-day training session in drug awareness but there was no evidence that either were an accredited course. Changes to the prescription were not always dated and signed by the person making the change and there was a lack of recording where discussions regarding medication had taken place with GP’s or the hospital. On one medication round the administering staff member had asked other staff on duty to administer medication to service users out of her vision, this practise is not recommended as it could increase the risk of error. Earlier medication rounds had been observed and were completed in an appropriate manner. The service users felt they were well cared for and their privacy and dignity was maintained. Service users likes and dislikes were recorded, as was their preferred term of address. Observation of staff interaction with service users showed them to be polite, respectful and considerate. Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 13 Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users confirmed that they were able to exercise choice and control in the home. The service users were provided with a varied nutritious diet and they enjoyed the food they received. EVIDENCE: Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 15 There was evidence from observation and discussion with service users that the home was conducted to maximise autonomy and choice. Information with regard to advocacy services, data protection and access to records was displayed in the home. The service users confirmed that they were able to exercise choice in their daily routines and always had choices at meal times. The staffing was arranged to ensure that individual’s needs with regard to rising and retiring could be met. The service users spoken with stated that ‘there is always plenty of staff’ and ‘there is choice of when to get up and go to bed’. The homes activities coordinator had left the home just prior to the inspection but adverts had been placed for another member of staff. All the service users had had their needs assessed in this area and records of individuals participation in events was recorded. Although there had been few activities since the activities coordinator had left there were events booked for the following month including a singer, a fashion show, church service and bingo. Church services were held fortnightly and Holy Communion was provided in the home. The home had raised over £5,000 for a sensory garden through a range of activities, which the service users had enjoyed. The sensory garden had been completed and detailed records had been maintained to show how the money had been spent. The service users stated that their visitors were made to feel to welcome and the visitors/relatives commented in surveys that they were made to feel to welcome, were able to see their relative in private and were kept informed about important matters affecting the service user. They generally thought that the standard of care was good in the home and had improved since the new providers had taken over. The home has a three-week rotating menu. There were always at least two choices available at meal times including a hot snack at teatime. Staff were seen to assist service users sensitively and discreetly. Aids were provided to encourage independence. Soft diets were provided for but could be improved by not mixing the whole meal together. For example serving the individual elements of the meal, such as the meat and vegetables, separately so the service users can be offered different textures and flavours throughout a meal. All the service users spoken with enjoyed the food and stated that the food was ‘nice’ and ‘there was plenty of choice’. The kitchen was clean and tidy and appropriate records were maintained. Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 16 Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints were taken seriously and acted upon in appropriate manner. Service users were protected from abuse. EVIDENCE: The home had a detailed policy and procedure for the management of complaints and a copy of the procedure was provided in each bedroom in the service users guide. A copy of the procedure was also displayed on the notice board usually hung in the reception area but this was temporarily out of place due to redecoration of the area. Complaints investigations were detailed and included written staff statements where required. Referrals to the protection of vulnerable adults team were made as appropriate and one referral had been made to the team and was unfounded after investigation. Service users and visitors stated that they knew how to make a compliant but were happy with the services and care at the home. Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 18 The home had policies and procedures to support the protection of vulnerable adults and staff had received external training in this area. Staff showed knowledge and awareness in this area and complaints recorded showed that staff were prepared to raise issues with the management and surveys showed that they felt supported to do this and found the management ‘very wiling to listen and helpful’ The home did not have a policy and procedure with regard to restraint. Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The providers were working to improve the environment for the service users. The home was clean, tidy and comfortable. The garden space was secure and accessible and appropriate to the service users needs. There were sufficient bathing and toilet facilities and specialist equipment to meet the service users needs. Rooms were personalised and suited service users individual needs. There were some areas which could be a risk to service users. EVIDENCE: The home is well situated close to the centre of Grimsby and is on local bus routes. Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 20 The home and gardens are accessible to service users and there has been work to improve accessibility. The home has a sensory garden with raised beds and seating. Internally the home was undergoing a programme of redecoration and improvement. The home had a selection of bathing options over the two floors, which were appropriate to the service users accommodated. There were a number of communal rooms for the service users, which were well decorated and domestic in character. One room was designated as a quiet area for the service users. The dining room was spacious and well furnished. The bedrooms had been personalised by the service users and some had been redecorated and had new carpets fitted since the last inspection. Lockable storage was provided in bedrooms. The providers had purchased new equipment to assist the service users such as an overhead hoist, new slings and profile beds for some rooms. The home was very clean and tidy and free from offensive odours. There were some issues arising from the tour of the building. The hot water in the ground floor bathroom was too cold at only 37°C, a laundry cupboard was not locked and the conservatory was being used to store items. Two freestanding radiators were found in bedrooms that had been used due to the radiators not getting warm enough in these areas. The provider stated that the problem had been rectified and these not now required and they were removed. The radiators were warm on the day of the inspection. The provider was advised that the free standing radiators should only be used following risk assessment as there was a risk of scolds due to uncontrolled surface temperatures and trip hazards due to trailing wires. Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): All the above standards Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing levels were adequate to meet the service users needs. The recruitment processes in the home were adequate to protect service users. The majority of the staff were trained and competent to do their job. There were some deficiencies in training new staff. EVIDENCE: The homes staffing levels must be assessed under the Department of Health guidance from the Residential Forum. There was evidence from records and discussions with staff that this had been completed and staffing implemented to meet the guidance and the needs of the service users. Service users commented that there was ‘always plenty of staff’ and that staff ‘answered call bells promptly’. One service user commented that although there was usually enough staff they ‘sometimes had to wait a long time to be taken to the toilet when in the lounge’. Four staff files were checked; two written references were in place except in one case where the references had been taken verbally and recorded. References in one case hadn’t been obtained from a previous employer. Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 22 Employment had commenced prior to receipt of the full CRB (Criminal Records Bureau) check but following receipt of a POVA first check (Protection of Vulnerable Adults). Records had been maintained to evidence that the staff member had been working under supervision until the CRB had been obtained. Whilst this adequate, staff must not be routinely employed prior to the receipt of a full CRB. Proof of identity had been obtained but a recent photo was not held on file. Provision of induction training was inconsistent with only two of the four staff having completed some induction. There was a training plan in place and records of training provided were maintained. Since June 2006 staff had received mandatory and service specific training including moving and handling, food hygiene, fire safety, first aid, dementia, diabetes, bereavement and protection of vulnerable adults. Eight of the twenty-five care staff had achieved NVQ 2. The manager had achieved NVQ 4 and the deputy manager had achieved NVQ 3. Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An experienced but unregistered manager ran the home The home was run in the best interests of the service users and the management was generally proactive in ensuring that service users health, safety and welfare were protected. Systems of bedrail assessment and maintenance of bedrails were not sufficiently robust. EVIDENCE: Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 24 The manager Marion Bourne had been appointed and had commenced work as acting manager at the home on 20 February 2006. Marion is experienced in the care field and has previously been a Registered Manager of a care home. She stated she has achieved NVQ 4. Marion has yet to submit her application to the Commission to be considered as the Registered Manager of the home. The atmosphere in the home was open and friendly and the manager had an open door policy. The staff and service users alike found the management approachable and helpful. The provider was keen to improve the home and the service provided and had purchased a quality-monitoring tool. They had started to work through the audits provided in the system. The service users, staff and visitors had been surveyed about the quality of the care in the home in October 2006 but they had not published the results although these were very positive. The home had policies and procedures to support most areas of practise and these had been reviewed and updated as required. Although some of these were basic the provider was proactive at improving these. The home assists service users with their finances. Clear records were maintained. Receipts were held for purchases on behalf of the service users. There were also clear records and receipts for the expenditure on the sensory garden. There was some evidence of a supervision programme that had been provided on a regular basis. Staff meetings were also held on a regular basis. Records were generally well maintained. The records of service users death must include the date time and cause of death. The use of correction fluid in care records should be discontinued. The management was proactive in ensuring the health and safety of service users by ensuring that all the equipment was serviced and maintained at appropriate intervals. The staff had received mandatory training including moving and handling and fire safety. The training plan for March 2007 included health and safety training. Detailed fire and environmental risk assessments had been completed. Individual moving and handling assessments had been completed and equipment such as an overhead hoist had been purchased to assist in these tasks. Records of accidents were maintained and these were audited regularly. Although an external company had checked bed rails for correct fitting and safety just prior to the inspection the home did not have a system for completing regular safety checks on the bed rails. The risk assessment process for the use of bed rails did not identify all the options considered and did not specify whether bumpers were to be used. Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 25 Fire records were maintained and showed that checks had been completed at appropriate intervals since January 2007. Prior to this the fire alarm had not always been tested weekly and the manager must monitor this. Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 26 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 3 1 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 X X 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 3 2 2 Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Not applicable 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 OP2 Regulation 5 14(1)(d0 Requirement The registered person must provide to all service users a copy of the homes contract/statement of terms of conditions of residency and confirmation in writing that the home is able to meet the service users needs. The registered person must ensure care plans reflect all identified needs, are specific in the action required to meet needs and are updated as needs change. The registered person must ensure that that the person administering the medication witnesses that this is taken by the service user. The registered person must ensure that clear records of the circumstances of any changes to medication are completed those are signed by the person making changes. The registered person must develop a policy and procedure regarding the use of restraint in the home. DS0000067288.V330244.R01.S.doc Timescale for action 01/05/07 2 OP7 15 01/06/07 3 OP9 13(2) 15/02/07 4 OP9 17(1) 15/02/07 5 OP18 13(8) 01/05/07 Yarborough House Care Home Version 5.2 Page 28 6 7 OP19 OP25 23(2) 23(2) The registered person must clear 01/05/07 the conservatory of stored items. The registered person must ensure that the hot water in the ground floor bathroom is not too cold and is maintained close to but not exceeding 43°C. The registered person must ensure that two written references are obtained in all cases. The registered person must provide evidence that staff complete induction to the Common Induction Standards The registered person must provide a report of the outcome of the review of the quality of care provided in the home and make this available to the service users and the Commission. The registered person must ensure that the date time and cause of a service users death is recorded. The registered person must further develop systems of risk assessment and maintenance for the use of bedrails. 01/04/07 8 OP29 19 15/02/07 9 OP30 18 01/06/07 10 OP33 24 01/06/07 11 OP37 17(1) 15/02/07 12 OP38 13(4) 01/04/07 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 OP7 Good Practice Recommendations The registered person should discontinue the use of correction fluids in care records. DS0000067288.V330244.R01.S.doc Version 5.2 Page 29 Yarborough House Care Home 2 3 OP15 OP29 The registered person should ensure that the presentation of soft diets offers service users different textures and flavours throughout a meal. The registered person should ensure that at least one reference for staff is obtained from the previous employer. Yarborough House Care Home DS0000067288.V330244.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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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