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Inspection on 16/06/08 for Yaxley House Residential Home

Also see our care home review for Yaxley House Residential Home for more information

This inspection was carried out on 16th June 2008.

CSCI found this care home to be providing an Adequate service.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

The home had met the two requirements made at the last inspection. A lock at the exit of the special needs unit had been replaced. The new lock gave instructions for how to use it that could be simply understood by those able to use it. The washing machine had been replaced.

What the care home could do better:

A period of unplanned absence by the manager at the time when major building works were coming to completion has been unfortunate, and arrangements for management cover in the manager`s absence have not been underpinned by additional staff time for care being in place. During the last few months care plans have not been completed in a timely way or full reviews undertaken. Records of monies held on behalf of residents were not accurate, so residents cannot be assured their finances are fully safeguarded. The current work to provide additional places for people with dementia has caused some disruption and some hazards in the environment. Some of these matters were addressed on he day, but should have been identified and picked up on an ongoing basis. The home must ensure that senior staff covering management duties are fully aware of the proper reporting procedures for safeguarding referrals, to ensure residents are fully protected. The home has a proper recruitment process but in one case two references were not on file for a member of staff. All staff must have full documentation, as required by regulation in place before they commence work at the home, to ensure that they are properly suitable and equipped for the work they are to perform.

CARE HOMES FOR OLDER PEOPLE Yaxley House Residential Home Church Lane Yaxley Eye Suffolk IP23 8BU Lead Inspector Mary Jeffries Unannounced Inspection 16th June 2008 17:00 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 Yaxley House Residential Home DS0000066076.V366463.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. Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Yaxley House Residential Home Address Church Lane Yaxley Eye Suffolk IP23 8BU 01379 783230 01379 783743 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) Providence Health Care Limited Mrs Carole Jeanette Wilson-Godber Care Home 25 Category(ies) of Dementia - over 65 years of age (9), Old age, registration, with number not falling within any other category (16) of places Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th August 2006 Brief Description of the Service: The current owner purchased the home in December 2005. A new manager, Mrs Wilson-Godber was appointed at the same time and has been registered by the Commission for Social Care Inspection. The home was registered to provide care to up to 16 older people. In February 2007 the home completed an extension and became registered for 9 older people with dementia. The new extension has 9 single rooms all with private en-suite facilities. The original part of the home has 12 single and 2 shared bedrooms, with bedroom accommodation on both the ground floor and the first floor. A shaft lift gives easy access to the upper floor for those unable to manage the stairs. At the time of the inspection further building work was in progress with a view to the home submitting an application for the registration to be varied to allow the home to provide for a further nine residents. This will, when submitted, be the second variation application of a scheduled improvement plan for the home, and increase the total number to 34. The home is set in attractive gardens close to the church in the village of Yaxley. Ramps and handrails are provided at the front entrance. There is parking to the front of the house. Fees for this home range from £450 to £700.00 per week. Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection was unannounced and took place over four hours on a weekday. This was a key inspection, which focused on the core standards relating to older people. The report has been written using accumulated evidence gathered prior to and during the inspection. This included a completed Annual Quality Assurance Assessment (AQAA). The inspection was facilitated by a senior carer who, along with another named colleague, was responsible for management of the home during a period of absence by the manager. Twenty-four residents were in the home at the time of the inspection. Four residents completed a survey questionnaire on the day of the inspection; these and another two were spoken with in depth in privacy. A group of residents were spoken with in a sitting room. A number of records were inspected including those relating to residents care plans, residents finances, complaints, staff personnel and training, medication, quality assurance and polices and procedures. What the service does well: The home provides a good standard of accommodation, with a new unit for people with dementia that is built to a very good standard and updated décor and refurbishment throughout most of the mainstream unit. Residents are well satisfied with the home, there is a friendly atmosphere in the home and residents are able to exercise choice in their daily lives. A good range of activities are provided and residents participation in activities is monitored. Ongoing training updates are provided for staff, so maintain and develop their skills. Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 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 Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service can be sure that there is information available about the home and they can also expect to have their needs assessed and therefore feel confident that the home can meet their needs, before they move in. EVIDENCE: A Statement of Purpose and Service User Guides were available in the home. The Service User Guide in each resident’s room did not contain the current fees; these were included on the Service User Guide dated April 2008 that had yet to be distributed to current residents. Information about the home explains the trial periods available. Three sets of records were examined. The manager had completed assessments on residents before they moved in and sought information from the placing authority and relatives where appropriate. Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 9 The home does not provide intermediate treatment. Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 10 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 &10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst residents can expect their medication will be properly and carefully administered, they cannot be assured that all of their care needs will be identified. EVIDENCE: All four of the residents who completed a survey on the day of the inspection advised that they felt well cared for, were treated well by staff and that their privacy was respected. This was confirmed by observation during the inspection, when staff were seen entering rooms, assisting residents, and anticipating and responding to their needs. One resident said that they felt that the managers respected their intelligence. Another advised that staff were very good to them, and very helpful. All of the three residents tracked had care plans, which were comprehensive, however two of these who had been admitted in 2008 did not have their care plans completed until several weeks after admission. One had a basic plan done on admission, but had no nutritional assessment until a month after Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 11 admission, a bathing assessment was completed four months after admission and they had had no night care plan. Another recently admitted resident did not have a care plan completed until three months after admission, when a moving and handling assessment, nutritional assessment, waterlow tissue viability assessment and a falls risk assessment were completed. These two plans had been completed less than a month before the inspection, and therefore were not required to have been reviewed. The plan for the resident admitted in 2007 had been completed in a timely way, but had not been fully reviewed. The manual handling assessment had been reviewed once, at approximately twelve months after admission, and the falls risk assessment had last been reviewed ten months before the inspection. This resident had, as they explained, and as was supported by the accident book and the care record, fallen two weeks prior to the inspection when they had cut their head, there was no evidence that the risk assessment had been reviewed after the incident, and they had fallen again the night before the inspection. Records showed the appropriate involvement of the G.P., chiropody and district nurses. Three residents were assessed on an ongoing basis by the Warfarin clinic. Residents spoken with said they had access, if they needed, to the doctor. A district nurse visits the home daily to do insulin injections for one resident. A senior member of staff was observed completing the teatime drug round. Each medication administration record had a photograph of the resident to ensure correct identification for administration. Records included specimen signatures of staff to audit those who had administered medication. The security of medicines was appropriate with the keys being held by the senior person on duty and drug trolley was chained to the wall. The room in which medicines were kept was locked each time the senior carer left the room. The Medicine Administration Record sheets were properly completed with no gaps in signatures. Amounts administered tallied with the stock remaining in the drug trolley. No controlled drugs were held at the time of the inspection. The member of staff was observed to sign that medication was administered after taking the medicine to the resident. The member of staff confirmed that they had received medication training, at this home from the manager within the last year and previously from Boots. Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 12 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 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to enjoy a homely environment where in they are free to make choices about where they spend their time and what they do, and to have a range of activities available for them to participate in. EVIDENCE: A group of residents were spoken with in the lounge in the mainstream unit. All but one were happy to participate and chatted freely and happily about life at the home. All but one said that they liked living at the home; one resident said that they would like to be in their own home, rather than being cared for, so couldn’t really say that they liked it. Residents were able to spend time in their rooms or communal areas as they wished. A number of residents retired to their rooms early on the day of the inspection. One resident spoken with advised that they didn’t like getting up early, and that they might go downstairs at 11.30 am if they felt like it. They spoke of having freedom to do what they wanted to do in the home. Daily menus were available and displayed in the home, however there were no picture menus to assist those with dementia make their choices. A good range Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 13 of home cooked food and fresh vegetables was available to residents. The four residents who completed a survey during the inspection all stated that they liked the food in the home. One said, that they had “ beautiful” food. A resident spoken with advised that the staff come round and give them a choice of what they would like to eat. Residents ate in either of the two dining areas or in their rooms if they preferred. One resident spoken with advised that they always took their meals in their room and preferred to do so. The kitchen is new with modern equipment and good food stocks were seen. Although the home had employed an activities worker, they had recently left and a carer was covering their duties. A resident who chooses to spend most of their time in their own room advised that staff were “very constructive” in assisting them, and had offered to get talking books for them. They advised, “If you want help with anything you could have it.” Most of the residents spoken with said that there were suitable activities in the home, one advised that it was sometimes hard to get the other residents to join in but that a group of five of six had played bingo earlier that day. The records of the residents tracked included a record of their participation in activities. These included board games, bingo, and flower arranging. The records also showed that one of the residents had attended Holy Communion, which is held at the home once a month. One resident said that whist there were activities, they found the time between 6pm and 9 pm a “waiting time”. They explained that they couldn’t see well enough to enjoy TV, and they found themselves waiting for their tablets and then waiting for bedtime. One resident advised that although there were activities available, they didn’t join in because they had so many visitors. The visitor’s book showed that relatives regularly attend the home at a variety of times. Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 14 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 & 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to have access to a proper complaints policy and to feel able to raise concerns or complaints within the home and be listened to. They cannot be assured, however, that they will be fully protected by adult safeguarding procedures. EVIDENCE: The four residents who completed a survey during the inspection had varied responses to the enquiry,“If you are unhappy do you know who to speak to?” One resident spoken with advised that they could speak to any of the carers if they felt unhappy about any aspect of their care. Another indicated that they sometimes knew who to speak to, one stated that hadn’t needed to, and the fourth stated that they would always speak to their friend, a visitor in the first place. A complaints procedure is in place and this forms part of the Service Users Guide and Statement of Purpose. A copy of this was also on display at the home. The records relating to the recording of complaints was examined. This contained information regarding all complaints including more minor concerns. Two concerns were noted regarding nails in the car park during the building work, within a few days of each other. This indicates that although action was noted after the first of these, it was not initially effective. Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 15 A policy and procedure is in place relating to the protection of vulnerable adults, and a copy of the local policy and procedure for dealing with matters that arise for safeguarding adults (the protection of vulnerable adults) was available in the home. Staff records showed that in house safeguarding training had been provided recently. The senior carer covering management duties was asked how they world deal with a safeguarding concern. Although they had a good understanding of the issues, they did not have any knowledge of Customer First, which must be the first point of referral in Suffolk. They advised that they had received training initially in another County. If staff covering management duties are not aware of the proper agreed reporting procedures, there is a risk that any safeguarding concerns will not be properly reported and responded to and residents are therefore not fully protected. No safeguarding referrals have been made. Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 16 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, 22 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service can expect to enjoy a clean, comfortable and homely standard of accommodation, but this may be disrupted by building works. EVIDENCE: The home is secure, the front door has a bell that visitors are expected to ring. The entrance porch, hall and stairs of the home were well decorated and attractive. A tour of all communal areas and some bedrooms was undertaken. At the time of the inspection significant building work was taking place in the home. The home was planning to increase the number of residents with dementia that it could provide care for. In addition to the planned new wing, the home had a refurbishment action plan, which included redecoration and recarpeting to existing rooms, as well as developing the laundry facilities and creating a new bathroom in the main part of the home. The majority of the Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 17 redecoration/ refurbishment planned had been carried out, with the exception of three bedrooms and those parts of the scheme that were part of the changes that supported the new wing. The wing which currently accommodates people with dementia was recently built, it has nine single en-suite bedrooms, and a lounge dinner and two new assisted bathrooms and two toilets able to accommodate disabled people. This area has its own enclosed garden with paths and lawn area. The closure at the exit of the dementia unit had been changed since the last inspection, and there was a notice advising residents to push a button to open the door. The residents on this unit do have access to the enclosed outside space; the purpose of the closure is to prevent residents without dementia being disturbed in their sitting room by residents with dementia who have, in the past, wandered through unintentionally. On the special needs unit two doors clearly marked “keep locked” were not locked, one was to a sluice room and one was to a laundry cupboard. These were locked when brought to the attention of the senior carer, however, they stated that they did not know the cupboard had to be kept locked. It was evident that the building work for the new wing had caused some disruption. A room that was being used for keeping medication was sited off a main sitting room. We were told that this was not the place where medicine was usually stored. The room was safely locked each time it was left unattended. One resident said that they didn’t like having to be sitting next to a room kept under lock and key. A carer explained to them in a gentle manner why this was happening, and that it was a temporary measure during the alterations that were occurring. We were advised that residents were not using the building as they normally do during this time, with some choosing to spend more time in their individual rooms. The complaints log evidenced that several complaints had been made about disruptions or annoyances associated with the building work, an obstructed view, nails in the car park and temporary lack of hot water. Two bathrooms were out of use at the time of the inspection. The new bathroom and refurbished laundry had not been completed to the timescale previously provided to the CSCI; all of the work was due to be finished within the next few weeks. There was a new industrial washing machine with sluice facilities in the laundry, but the laundry walls were not impermeable or easily cleanable. A rack of clean laundry was airing, the rack was hanging from a work surface which had dirty washing on it; this posed an infection control risk as the clean clothing could be contaminated by the dirty laundry. The rack was moved when this was pointed out. The planned new laundry has separate parts for clean and dirty washing, and separate doors to each part. The home was otherwise clean and hygienic, and no lingering odours were detected. Protective clothing was available for staff throughout the home. Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 18 All but three of the bedrooms on the older part of the home have now been redecorated. Two of the bedrooms where we spoke with residents were clean and properly equipped. One of these was a double room. The screen in the room did not provide for one of the residents to be washed in privacy, given where the washbasin was placed in the room. However, the resident spoken with advised that they and the other occupant of the room – were both washed in bed and therefore this arrangement shortfall did not affect their privacy. The AQAA states that the home is able to borrow equipment from the local multidisciplinary team. During the year one complaint was made to the home from a relative who was concerned, amongst other matters that their relatives mattress had been put on the floor. Social Care services looked into the complaint and found that care had been given in accordance with the care plan. It was, however, confirmed that after the resident returned from hospital the mattress had been put on the floor because of the residents’ risk of falling out of bed, as an offer to loan a low bed had not materialised. Assisting a person occupying a mattress on the floor would have presented a risk to the health and safety of staff. The majority of the beds in the home have recently been replaced, but the home does not have rise and fall beds. The home must ensure that it can fully and safely meet the needs of residents before admitting them or accepting them back from hospital. Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to be looked after by caring and friendly well trained staff group, but cannot be assured that their will be sufficient staff at all times to ensure that the needs of residents are identified and met. EVIDENCE: The four residents who completed a survey during the inspection all stated that staff treat them well. One commented that they “are very good to you, very helpful.” During the inspection staff were seen to have a good manner with residents and to be alert to and responsive to their needs. All of the residents spoken with thought that their needs were met by staff, however the lack of timely care plans for new residents and of a full review for an established resident as described under the Health and Personal Care section of this report evidences that all of residents needs may not have been identified. Several residents spoke of wishing that staff had more time to speak with them, and staff appeared to be busy throughout the inspection. Although they were busy, staff were attentive to residents needs. One resident was seen by a carer about to retire upstairs and was asked to use the lift or wait to be accompanied. A resident with dementia was asking to go home at the end of the day, although they were a permanent resident. This responded to in a kindly and open manner by the carer. Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 20 The senior who was, in part, covering the manager’s duties advised that they had been covering their existing care role, and at times a cooks role, during the manager’s absence. On the day of the inspection there were four carers including this senior on duty during the morning and the evening, and no other manager on duty in the home. This was confirmed by the staffing rotas as being the basic level of staffing. No additional time had been scheduled to account for the fact that two of the senior carers were covering the manager’s role. The senior advised that they were able to cover shifts with existing staff but that staff often did not want to work them. The cook’s position and the activity worker’s position were vacant at the time of the inspection. These roles were being covered by members of the care staff. The personnel files for two staff were examined. One held full recruitment information and identification and criminal record check details. One had most of the required documentation but had only one reference on file. All staff receive an induction programme which included dementia awareness. This was confirmed by a member of staff. The home had documentation for core skills induction that is conducted over 13 weeks. Both of the staff files examined had evidence of moving and handling training. The files and training records of the two staff who were covering the management task were also inspected. They had revived appropriate training updates in key areas including moving and handling, safeguarding adults, medication and fire safety. Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 21 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): 31,33,35,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst residents expect to enjoy an open and homely atmosphere, they cannot be assured that their health and safety or welfare will be fully protected at all times. EVIDENCE: The manager is registered with the Commission, and holds the appropriate qualifications including the Registered Managers Award. The certificate of registration was on display. We were notified at the beginning of May 2008 that the Registered Manager would be away from their post for at least four weeks. CSCI were kept informed of this absence which continued beyond the initial expectation, and of the two named staff members who covered the duties of the post in the Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 22 manager’s absence. The manager had not returned to their post at the time of the inspection. The senior carer who facilitated the inspection confirmed that the owner of the home had been attending the home regularly and providing management support. As noted under the staffing section, additional care time had not been put in place to support the senior carers cover the management role. The impact of the building work had not been managed as tightly as it should have been during this period. Regulation 26 reports of monthly visits undertaken by the owner were available in the home. The report for May 2008 was inspected; this covered all the necessary areas. The AQAA stated that a residents and relatives survey had been undertaken in 2007 and the senior carer confirmed this. Regular staff meetings were held and staff files showed that regular supervision of staff was taking place. Financial matters are dealt with by the individuals, their family or in one case Social Services, but small amounts of cash are kept securely in the home for some residents. The records and amounts kept for three residents were checked. Two staff signatures supported each transaction and receipts and running records were kept. In two of the three cases inspected the amounts held did not tally with the record; one had one pound less than the total recorded, one had thirty pounds more than the amount recorded. Various maintenance records and servicing records were examined and found to be in order. The home was introducing the ‘Safer Food better Business’ quality monitoring pack recommended by environmental health, and there was a fire risk assessment in place. There was a comprehensive set of policies in the home, which were reviewed annually and are accessible to care staff. On the day of the inspection it was found that in one of the walls of the special needs unit there was a temporary opening to the outside that had not been properly boarded up. The temporary cover had been put up from the other side. It was not solid and there was a gap between the cover and the flooring on the inside of the home which presented a risk to residents with dementia. Some other health and safety matters were identified as requiring attention, which are detailed in the environment section of this report. Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 23 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 X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 2 2 X X 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 2 X X 2 Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 OP18 Regulation 13(6) Requirement Timescale for action 31/08/08 2. OP19 OP38 3. OP29 5. OP35 All staff must be aware of Local agreements for reporting safeguarding matters so that residents are fully protected from abuse. 13(4)(a)(c The building must be risk ) assessed and maintained to a safe standard during adaptations 23 (1)(a) to the structure so that the risk (2)(b) of harm to residents is minimised. 19(1)(a) All of the necessary schedule documentation listed in the 2 schedule must be available before a member of staff starts work at the home, and available in the home. This is to ensure full appropriate checks have been made. 17(2) Records of monies held on behalf schedule of residents must accurately 4 reflect amounts held so that residents can be assured that their assets are safeguarded. 16/06/08 20/08/08 20/06/08 Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 25 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 OP14 Good Practice Recommendations Residents with dementia would benefit from having picture menus available to them. Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. Extracts may not be used or reproduced without the express permission of CSCI Yaxley House Residential Home DS0000066076.V366463.R01.S.doc Version 5.2 Page 27 - 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. 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