Inspection on 08/06/06 for Yatton Hall

This inspection was carried out on 8th June 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

Yatton Hall 05/05/09

Yatton Hall 09/06/08

Yatton Hall 17/01/08

Yatton Hall 11/09/07

Yatton Hall 08/02/07

Yatton Hall 21/11/04

Yatton Hall 06/05/04

Similar services:

2 Perhaver Park

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Poldhu

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Yatton Hall High Street Yatton North Somerset BS49 4DW Lead Inspector Barbara Ludlow Key Unannounced Inspection 8th June 2006 10:00 X10029.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 Yatton Hall DS0000020292.V294149.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 and 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. Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Yatton Hall Address High Street Yatton North Somerset BS49 4DW 01934 833073 01934 877373 yattonhall@fshc.co.uk 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) Grandcross Limited(wholly owned subsidiary of Four Seasons Health Care Ltd) Vacant Care Home 48 Category(ies) of Learning disability over 65 years of age (2), Old registration, with number age, not falling within any other category (35), of places Physical disability (13) Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 8. 9. May accommodate up to 35 persons aged 65 and over, requiring nursing care. Staffing levels laid out in the letter to Louis Smith dated 6th September 2004 are applicable. Manager must be a RN on part 1 or 12 of the NMC register. May accommodate up to 13 persons with Physical disabilities aged 1864. The home may provide nursing care for two named persons with learning disability; until such time that the named persons cease to use the home. One named resident to reside in room 33, this condition will lapse when this resident leaves Yatton Hall. One named resident to reside in room 16, this condition will lapse when this resident leaves Yatton Hall. One named resident to reside in room 12, this condition will lapse when this resident leaves Yatton Hall. One named resident to reside in room 28, this condition will lapse when this resident leaves Yatton Hall. 18th October 2005 Date of last inspection Brief Description of the Service: Yatton Hall provides nursing care for up to 48 people. The first two floors are for older people, the top floor for younger disabled people. The accommodation is provided on three floors, served by a lift. There are 44 single and two double rooms. The accommodation has even, level access throughout and there is level access to the grounds outside. Located in Yatton High St, the home is close to the village shops and facilities. Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors, B Ludlow and K McCluskey for CSCI carried out this unannounced inspection over an 8 hour period. The inspection was well received and the manager, staff and service users supported the inspection with their comment cards and participation throughout the day. Both inspectors found this helpful and a positive contribution to the process and outcome. The home has a new Manager Mrs Lisa Brain who commenced working at the home on 5th June 2006, this report will take this into account and the management National Minimum Standards 31, 32 will not be assessed until the 2nd key inspection of the home. The home has a complex set of variations applied to the registration, this will be reviewed to ensure that the registration is clear and that the numbers of service users in each category can be easily defined and prevent the risk of a regulatory breach of the care home registration and conditions. A tour of the premises was made, on all three floors communal space and facilities and a sample of bedrooms were seen. Service users and their visitors were seen and spoken with. Staff were spoken with and were observed throughout the day. All staff and service user interactions were polite and respectful. Lunch was observed being taken on all three floors. Records were sampled and care plans were read as part of a case tracking methodology. Feedback was given on the following day to enable the inspection to close before 6pm and the site visit be concluded in one day. No immediate requirements were made but there was an unmet requirement from the last inspection. This now requires specialist input to assist the resolution. Written post inspection feedback was also sent to the home for the Managers attention. The inspectors would like to thank all those participated in the inspection process for their comments and assistance. What the service does well: Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 6 The Younger persons unit has developed its facilities for the residents and taken account of their wishes and preferences where able. Examples of these include a pool table in the lounge area and a play station/computer area and regular social trips out are made. What has improved since the last inspection? 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. Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6=N/A (O.P) and 2 (Adults 18-65) The quality of this area is assessed as adequate. There is sufficient information available for prospective service users and their families. Individual service users contracts and the invoices sampled were not clearly explicit about the sums of Registered Nurse Care Contribution paid to the home although it was clear that the RNCC is paid directly to the company. Pre admission assessment is undertaken and service users needs are met at the home. The contracts state that the home offers a four week trial period for all categories of service users. Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 9 EVIDENCE: The home has a wealth of information available about Yatton Hall and the care service offered clearly displayed in the entrance hall, this is for all visitors and prospective/service users. The contracts for older people who are self funding and for whom RNCC is paid to the company, do not state what the full cost of care is and could be deemed ambiguous. The contracts state that the home offers a four week trial period. This period is also the same for younger people unless a public service contract states otherwise. The contract should ideally be tailored to reflect the Adults aged 18 to 65 years National Minimum Standard of three months. The current scale of charges range between £500.00 and £950.00 per week. Five care plans were sampled in detail plus care plans were specifically seen where a pressure sore was identified. The service users whose care was case tracked, were found to have their care needs met. Detailed admission assessments were in place for all these service users. Six feedback forms were returned to CSCI from service users. 4 positive responses were made to the question about of enough information about the home being given before moving in. All respondents had a contract of residence. Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10, (OP) 6,9,16,18,19,20 (Adults 18-65) The quality of this area is assessed as adequate. Care plans were in place for all service users. Service users health care needs are met. Health Promotion could be addressed more clearly for the younger adults. Medication management could be improved. Service users were appropriately addressed and were treated respectfully. The top floor unit for younger people offers a good standard of care. Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 11 Communication and personal attention could be improved on the middle floor of the elderly care unit. EVIDENCE: Care plans were in place for all service users. Service users health care needs are met. Health Promotion was not well documented, this could be addressed more clearly in the care plans in particular for health screening for the younger adults. The home has strong links with the local G.P service and a regular visit is made by the doctor to see patients and review their health care needs and prescribed medications. Medication management was sampled, a large number of hand transcribed entries were not countersigned as verified accurate, by a second person. Creams were seen in service users rooms that had labels damaged/removed and opened on or discard by date. The controlled drug stocks were sampled and were accurate. One bottle of Oromorph was seen in the drug cupboard that was date expired; this was brought to the attention of the Deputy at the time of checking. More care must be taken to ensure that medication management is thorough and in line with the Royal Pharmaceutical guidance for care homes and best practice at all times. Service users were heard to be appropriately addressed and were treated respectfully. There was a lack of meaningful communication noticed between staff and service users on the middle floor. This was observed to leave the less able service users reliant upon staff who were not speaking to them very much; the care delivered was not therefore person centred or as attentive as it needed to be, lunch time was also judged to be poorly managed on this floor for this reason. Service users observed on the top and ground floors were seen to experience more interaction and more meaningful communication with staff. Six feedback forms were returned to CSCI from service users. Positive responses were made to questions about care and support and medical care. One respondent indicated that physiotherapy/exercise therapy input was one area where the service could be improved. Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 (OP) 12,13,15,17 (Adults 18-65) The outcome for this group is adequate. The younger persons have activities and opportunities to go out into the community and socialise, they also have more choice and control through the application of a more person centred approach. The activities for the older service users are limited. Service users were seen to be left for long periods of time with little staff interaction. Relatives and friends are welcomed. Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 13 Mealtimes varied from floor to floor. The menu was adequate but the approach to serving and assisting varied and was observed to be poor on the middle elderly care floor. EVIDENCE: At the start of the inspection two service users were seen in the area at the front entrance of the building, access is unrestricted for those able to get out and about. Smoking is only permitted outside the building. Other service users were observed and met with throughout the inspection day; two visitors were seen and spoken with. All service users looked well kempt and those asked confirmed that they are given personal care appropriately and to meet their needs. Personal laundry was confirmed as well managed. Younger Adult service users were seen in the younger persons unit on the top floor of Yatton Hall. A small number of younger service users live within the older persons units on the ground and first floor, these places are subject to particular variations within the registration of the home. The approach by staff and the level of staffing on the top floor unit seemed to promote a more person centred approach to their daily living. The unit had a homely atmosphere and service users expressed their satisfaction with the care they receive at Yatton Hall. The menu and mealtimes were discussed with staff and service users at lunchtime. Lunch was a social occasion and service users choosing to dine together had lunch in the dining room with sufficient staff to provide the support needed. The elderly care units are the ground and first floor, it was noticed that service users who are more dependent had little social stimulation by staff and a small number were seen to spend time sitting with little or no staff interaction other than task orientated contact. This was evident at lunchtime on the first floor, meals were served but assistance and attention could have been better, the social experience of the mealtime was poor. It was noted that drinks with the meal were not offered on the first floor, cups of tea were served after the meal. The menu was varied and alternatives are offered. Drinks were served during the day. Services users asked were unsure what was for lunch, it was suggested that the menu could be displayed in the dining rooms to remind service users of the choices they made the day before. One service user said that the meals at the home had ‘improved’. Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 14 No activities were observed during this inspection for the dependent elderly service users at Yatton Hall. Visitors are welcomed into the home and the feedback from the visitors spoken with was very positive, refreshments are offered and they confirmed that when they visit and they are always made welcome. Six feedback forms were returned to CSCI from service users. Positive responses were made to questions about activities available to service users and the food/ menu offered. One stated that more choice in the menu would be welcomed. Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18, 22 & 23 The outcome for this area is assessed as adequate. All complaints are recorded, the processing of complaints logged since the last inspection was satisfactory. Recruitment practice was discussed and could be improved. EVIDENCE: The company complaints procedure is made available to service users and families and is on the company literature available at the home. The complaints procedure for all complaints made since the last inspection had been followed and was both satisfactory and timely. Staff recruitment files were sampled and examined. The recruitment of overseas staff has been managed by the company’s head office. Individual staff references had been taken up but some were not adequate as they were addressed to ‘whom it may concern’ and followed a very similar set format. All staff recruitment must comply with Schedule two of the Care Home Regulations (2002/03). This matter has been taken up by CSCI with the Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 16 company for resolution at their head office. A requirement is made for all future recruitment practice at the home, see NMS 29. Satisfactory staff CRB checks were seen on file. Six feedback forms were returned to CSCI from service users. Positive responses were made to questions about knowing who to speak to if unhappy and about knowing how to make a complaint. Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 The outcome for this area is assessed as poor. The home requires attention to maintenance and repairs. Doors labelled as fire doors were being wedged and a review of the environment fire risk assessment is required. Infection control measures could be improved. Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 18 EVIDENCE: A tour of the premises was made. At Yatton Hall the accommodation is arranged over three floors. Access to all floors is gained either by the stairwells or a passenger lift. The resident’s private accommodation is that of 44 single and 2 double rooms. Every room has access to the call bell system. Hallways had low temperature radiator covers and hand grab rails to assist with mobility. Since the last inspection two carpets have been replaced and some decoration has been undertaken. CSCI were informed that repairs had been undertaken on the showers, one was again seen to be out of order at this inspection. The inspectors were informed that this had only just occurred and repairs were planned. The home has pleasant gardens towards the rear of the home with various seating areas and pathways. The garden is laid out to lawn with shrub and flowerbeds. The Young Persons Unit is situated on the top floor. This has an open plan lounge area with comfortable seating, a pool table, music centre and a small bookcase. There is a pleasant dining room with one side housing a kitchenette. The staff room is also based on this floor. The quiet room has been changed to accommodate the nurse’s station. The middle floor has an open plan lounge area at its centre. There is a locked pharmacy and treatment store room. The ground floor has a large open plan lounge area at its centre with a separate dining room on the opposite side of the hallway. Residents who choose to smoke have a designated smoking area outside the home. Attention to minor repairs and maintenance were noted, for example, a broken bed table was seen and a wheelchair that was reported to be hard to push, had soft tyres. One bathroom had a broken door handle and one toilet cistern, no lid. One toilet was seen that is being used as a store for wheelchairs, the designated wheelchair store opposite was being used to store linen and pads. The home must have all its stated facilities in working order. Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 19 Liquid soap and paper towels, many had ‘run out’, these stock items were replenished during the inspection. One sluice was seen that contained a faeces smeared vase, this was brought to the attention of the manager at the time of the inspection. A number of bedroom doors labelled as fire doors were wedged open, others had been fitted with fire alarm activated hold open devices. This mixed practice has been noted at previous inspection visits. A reassessment of the premises from a fire risk perspective is now required. Any risks within the premises that are identified must have action taken to manage them in the safest and most appropriate way. It may be necessary for the home to seek advice from the local fire service safety officer. Bedrooms can be personalised and it was evident that service users are encouraged to do so. Individual risk assessments must be made where possessions are stored that are potentially hazardous and require special cleaning or attention to secure them safely to reduce the risk of accident or any harm coming to others with access. This is especially relevant where such bedroom accommodation is left unlocked with the doors propped open when unoccupied. Six feedback forms were returned to CSCI from service users. Positive responses were made to questions about the home always being clean and fresh. Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30,34,35 The outcome for this area is assessed as adequate. Care and nurse staffing levels were adequate. Staff training is available, with a range of mandatory and relevant topics. The recruitment of overseas staff must be improved regarding references. All staff must be able to communicate and deliver care that is person centred. EVIDENCE: The home has sufficient care and nursing staff numbers. The inspectors were informed that staff from other Four Seasons homes supplement the staff team when required in preference to agency staff being deployed. Service users said that there are sufficient staff on duty to provide their care. Visitors also were complimentary about the staff and confirmed their impression that there are sufficient staff on duty. Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 21 Trips out and individual activities were confirmed on the Younger Adults unit, care staff there were more involved with activities as part of their role with the care delivery. There were no activities seen on the elderly care units during this inspection. This should be addressed in either care staff numbers with dedicated activity hours or with staff dedicated to social care provision only. The pre inspection information indicated that the home has 10 registered nurses, 23 care staff and 13 ancillary staff. Only four care staff have an NVQ Level 2 or above equating to 15 . The NMS indicated that the home should achieve 50 of care staff with NVQ Level 2. The homes new manager is keen to improve this statistic and has the pre requisite knowledge and qualification to support staff undertaking NVQ training. Recruitment was sampled and the inspectors saw references presented as ‘to whom it may concern’. These references were also very similar; it is essential that references be taken up which are addressed to the company and verified to support such applications. This matter has been taken up by CSCI with the recruitment department at Four Seasons head office. Six feedback forms were returned to CSCI from service users. Positive responses were made to questions about staff numbers, one service user felt that there are usually enough staff on duty but not always enough staff available at night. Other comment included that staff are ‘always cheerful and helpful’. Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (OP) 34,35,37,38, and (Adults 18-65) 37,39,42 The quality outcome for this area is adequate. A new home Manager Mrs Lisa Brain has just taken up her post at Yatton Hall. Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 23 All financial records seen were well managed and appropriately stored. Service users finances were managed safely. Health and safety matters were highlighted for attention. EVIDENCE: Mrs L Brain the homes newly appointed Manager is an experienced Registered Nurse. Mrs Brain had only just begun working at the home at the time of the inspection and is in the process of applying to CSCI for Registration. The homes administrator undertakes the management of service user finances held by the home. The process and system was explained and the records were sampled. The management of these monies was clearly recorded, receipted and safely held. The storage and management of records seen at the home was safe and judged satisfactory. The home has a designated maintenance staff to complete the routine home maintenance tasks and safety equipment checks. One bathroom was out of order; one toilet was cluttered with equipment and was therefore out of use. A number of wardrobes were seen that had not been secured to prevent them from toppling forwards, some had personal belongings stored on top of them. One toilet cistern had no top. One bathroom had a broken door handle and one bed table was seen that was in poor repair. Attention must be paid to the safety and routine maintenance around the home. Fire safety and the use of wedges to hold bedroom doors open must be addressed and is raised under NMS 19 as an identified need to fully reassess the premises fire risk assessment and take action to address any identified shortfalls or changes required. Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 24 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 X 2 2 3 3 4 3 5 3 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 1 20 3 21 2 22 3 23 3 24 3 25 3 26 1 STAFFING Standard No Score 27 3 28 1 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 X 32 X 33 X 34 3 35 3 36 3 37 3 38 1 Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 25 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 OP9 Regulation 13(2) Requirement Hand transcribed entries must be countersigned as verified accurate, by a second person. Creams in use must not have prescription labels torn or removed, opened on dates or discard by dates must be added. Date expired medication no longer in use must not be held in stock and must be appropriately disposed with. 18(1)(c)(i) Staff must offer service users appropriate assistance at mealtimes to support their eating and their independence. 23(2)(b)(j) One shower facility was out of order and must be repaired. Other minor repair work was identified and must be completed. Cluttered toilet facilities should be cleared for use. 23 (4) (a) and (c)(v) Fire doors were seen to be wedged open. The homes fire risk assessment must be redone and action must be taken to DS0000020292.V294149.R01.S.doc Version 5.1 Page 26 Timescale for action 18/07/06 2 OP15 18/07/06 3 OP38OP19 28/08/06 Yatton Hall address all risks identified. A requirement was made at the last inspection for fire door guards to be fitted and wedges not used. By 19.11.05. To reduce the risk of compromising good practice, staff hand washing facilities must be accessible and have liquid soap and paper towels available at all times. Care must be taken to keep sluice rooms hygienic. A requirement was made at the last inspection for improving infection control: hand wash towels and sluice rooms to be more hygienic. By 19.11.05 13(4)(a) Individual room safety risk 18/08/06 assessments must be completed where potentially hazardous belongings are held. 19(4)(c) Recruitment practice for 08/08/06 Schedule 2 overseas staff must demonstrate paragraph references that can be validated 5 as authentic. 4 OP26 13(3) 18/07/06 4 OP24 5 OP29 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 OP2 Good Practice Recommendations Contracts for Nursing care should make the RNCC payment much clearer to privately funded clients. Contracts for Younger Adults should be reviewed to reflect the National Minimum Standard trial period. Care plans should have more detail and be recorded more carefully e.g., Risk assessments such as Waterlow scoring must be accurately assessed, for example taking into account conditions such as diabetes and neurological DS0000020292.V294149.R01.S.doc Version 5.1 Page 27 2 OP7 Yatton Hall 3 OP28 dysfunction. Preventative care planning should be recorded where risks are identified. The home must strive to meet the NMS target for 2005, that 50 of care staff should hold an NVQ Level 2 in care or equivalent. Yatton Hall DS0000020292.V294149.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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. 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