Inspection on 24/01/06 for Yaxley House Residential Home

This inspection was carried out on 24th January 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 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

Yaxley House Residential Home 27/10/09

Yaxley House Residential Home 03/06/09

Yaxley House Residential Home 16/06/08

Yaxley House Residential Home 07/08/06

Yaxley House Residential Home 30/03/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Yaxley House Residential Home Church Lane Yaxley Eye Suffolk IP23 8BU Lead Inspector John Goodship Unannounced Inspection 24th January 2006 02:30 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 Yaxley House Residential Home DS0000066076.V279995.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Yaxley House Residential Home DS0000066076.V279995.R01.S.doc Version 5.1 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 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Yaxley House Residential Home DS0000066076.V279995.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13 July 2005 Brief Description of the Service: The home was purchased by the current owner 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 is registered to provide care to up to 16 older people. 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. The home is set in 4 acres of land close to the church in the village of Yaxley. The gardens are attractively planted. Ramps and handrails are provided at the front entrance, with level access from the lounge into the garden. There is parking to the front of the house. Yaxley House Residential Home DS0000066076.V279995.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was the second one in the current inspection year. It took place four weeks after the purchase of the home by Providence Health Care Ltd, who appointed a new manager, Mrs WilsonGodber from the same date. The owner intends to build an extension to care for people with dementia. At the same time, a programme of refurbishment and upgrading will be undertaken in the main house. Although a number of environmental deficiencies were observed during the inspection, it is accepted that there is a plan to remedy them. The deputy manager was in charge on the inspector’s arrival. The manager and the owner returned to the home during the inspection from visiting the other home owned by the company. The visit took place in the late afternoon, and the inspector was able to talk to several residents in the lounge, and later on in the dining room as they assembled for tea. A tour of the building was also undertaken. What the service does well: What has improved since the last inspection? Yaxley House Residential Home DS0000066076.V279995.R01.S.doc Version 5.1 Page 6 The security of medicines and fire safety have improved. The temperature of the hot water outlets is now at a safe level. The residents have been offered more choice at meals, which they have appreciated. 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. Yaxley House Residential Home DS0000066076.V279995.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Yaxley House Residential Home DS0000066076.V279995.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2. Prospective residents will receive up-to-date information about the home. All residents have been issued with contracts. EVIDENCE: The previous Statement of Purpose and Service Users’ Guide were now out-ofdate following the sale to the new owner. The owner was aware that information on the new company and the new manager must be added. There were also out-of-date references to the NCSC, the Commission’s predecessor. Contracts with residents would also need updating. Yaxley House Residential Home DS0000066076.V279995.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8,10. Residents can expect their health care needs to be regularly monitored and action taken as necessary. Residents can expect to maintain their privacy at all times. EVIDENCE: The residents whose particular problem with eating, and the taking of medication, was discussed in the last report was still causing concern although there was evidence of occasional improvements. All relevant professionals were in regular contact with the person. Anxiety about another resident who was prone to falls had been referred to the doctor, who had reviewed their medication. This had solved the problem. Although the home encouraged residents to eat in the dining room, and join in activities in the lounge, they were free to choose to stay in their rooms whenever they wished. The medicine cupboard had been fitted with a new lock as required. Yaxley House Residential Home DS0000066076.V279995.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Residents will in future be offered a more varied range of activities which should provide for the different interests of each resident. Residents are now able to exercise more control and choice over aspects of the catering arrangements. EVIDENCE: A new cook had been in post for two weeks prior to the inspection. Additional cover was being recruited. The cook was learning the likes and dislike of the residents. Their main choice was for traditional English dishes, but the cook was planning to gradually introduce variations to see how they went. Fresh vegetables were supplied locally, and meat was supplied by a local butcher. The cook was delighted that it was planned to refurbish the kitchen as it was cramped, and not easy to keep clean. The main oven was also past its best. The food store had an uneven brick floor. All these matters would be addressed in the upgrade, which would also provide sufficient facilities for the planned extension. The manager stated that she had tried to encourage as many residents as possible to come to the dining-room for breakfast. There had not been a choice previously as all breakfasts had been served in the rooms. Residents could still have that choice, but most of them chose to eat in the dining-room. One consequence had been that residents could now choose from a wider range of Yaxley House Residential Home DS0000066076.V279995.R01.S.doc Version 5.1 Page 11 items on the menu, rather than always having the same things taken to their rooms. It had been recommended in the previous report that more effort be made to develop activities for residents. Independently of this, the new manager had identified a member of the care staff to take responsibility as activities coordinator. This person was currently receiving training at another care home to enable her to take up this role. The manager commented that during a heating problem over Christmas, more residents had had to come into the lounge. It had created a good atmosphere as some group activities were undertaken with residents who normally stayed in their rooms. She hoped to keep this level of activity going as it proved popular. Contact with relatives is covered under the section ‘Management and Administration’. All residents bar two have contact with relatives and friends. Yaxley House Residential Home DS0000066076.V279995.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. The policy for handling complaints will give residents confidence that their concerns will be treated seriously. EVIDENCE: The complaints procedure was displayed on the noticeboard and was included in the Statement of purpose and service users’ guide. It had not been updated for the new ownership, nor for the new name of the Commission for Social Care Inspection. There had no complaints since the previous inspection. Yaxley House Residential Home DS0000066076.V279995.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21,25,26. Until the home has implemented its planned programme of refurbishment and upgrading, residents will not be living in a completely safe and hygienic environment. EVIDENCE: The home only did the personal laundry for residents. Other major items were sent to a commercial laundry. The laundry work was done by care staff. Some of the bathrooms and toilets were in need of re-decoration. The downstairs bathroom floor and skirting board were damaged behind the WC. The shower tray in the upstairs bathroom was discoloured as was the mat. There was a notice above the bath stating: “Caution – very hot water.” However the temperature of the hot water was 41°C which was within the safety parameter. All other hot water outlets which were tested were within safe limits. Yaxley House Residential Home DS0000066076.V279995.R01.S.doc Version 5.1 Page 14 Pipes in one of the WCs were black with some peeling of the wallpaper. The other WC at the end of the corridor had a discoloured bowl. Bedroom 9 had some stains on the carpet by the bed, and had no bedside table, although there was a bedside lamp on the floor. The owner stated that there were plans to replace the call bell system, to upgrade the heating system and the fire precautions, and to remove the steps and ramp on the first floor to level it out. The home had suffered a major loss of heating over Christmas when an oil delivery failed to turn up. The manager took appropriate emergency action which meant that no resident suffered harm. Indeed the manager felt that a certain camaraderie had developed to overcome the inconveniences. The home is awaiting approval for its plans to build an extension for residents with dementia. Yaxley House Residential Home DS0000066076.V279995.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30. Residents can expect to have staff available in sufficient numbers to meet their needs. Residents can expect to be cared for by a staff team who are appropriately qualified. EVIDENCE: One carer was due to start the week after the inspection, but this was dependent on receipt of two references and the POVAFirst clearance. Interviews for another carer and a domestic vacancy were being held during the inspection. There were four carers on duty in the morning, two in the afternoon, and two in the evening. The manager was considering increasing the latter to three. In addition there were two staff on at night with either the manager or deputy manager on call. The manager was undertaking an audit of the training completed by staff to identify any gaps and the need for refresher training. Numerous certificates were available although some were out-of-date. However, the manager was a qualified Moving and Handling trainer and also a trained fire marshal. She had already started training sessions on fire procedures and would be programming other sessions. Yaxley House Residential Home DS0000066076.V279995.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36. Residents are benefiting from the new leadership and management of the home through improved choices and a wider range of activities. Residents’ financial interests are safeguarded through audited cash handling arrangements. Staff supervision sessions have started, to ensure that residents are cared for by properly trained staff. EVIDENCE: It was recognised that the new manager had only been in charge for under four weeks. She listed several things she wanted to improve but they could not all be done at once. She was doing a review of all records and policies. Staff who were spoken to were happy with the way the home was being managed. No member of staff had left because of the change, and recruitment seemed to be improving. Yaxley House Residential Home DS0000066076.V279995.R01.S.doc Version 5.1 Page 17 One resident said that the new manager “was getting round to things”. Another said: “It’s better now. You must give them time.” The manager had completed her Registered Manager Award, and was a qualified Moving and Handling trainer and a fire marshal. The new Certificate of Registration showing the new registered provider and the new registered manager was displayed in the hall. The insurance certificate was shown to the inspector. Comment cards were available in the hall for visitors and residents. A meeting for residents and relatives had been held at the beginning of the month to introduce the new owner and manager, and to answer questions about any changes planned. The minutes of this meeting were pinned up on a notice board, and it was well attended by half the residents and many relatives. A meeting for all staff was also held for the same reasons, and the minutes of this meeting were also displayed. Both meetings emphasised that there would be no change in fees or procedures, and no changes in staff terms. The manager had instituted a new system for the keeping and handling of residents’ petty cash for everyday purchases. Previously residents were dependent on money being handed over by relatives as purchases were needed. There were now running cash floats for each of them. Most residents’ financial affairs were handled by their relatives. In two cases, the manager was seeking alternatives to the home being responsible. This was being discussed through the residents’ social workers. The manager stated that five supervision sessions had been held so far with the remainder planned. None had yet been written up. The bolts had been removed from two fire doors as required at the last inspection. Fire notices had also been revised as required. The new manager had given fire procedures instruction to nine staff last week, and a review of the need to cover other staff was in hand. Yaxley House Residential Home DS0000066076.V279995.R01.S.doc Version 5.1 Page 18 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 2 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 X 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 X 2 X 2 X X X 2 2 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X X Yaxley House Residential Home DS0000066076.V279995.R01.S.doc Version 5.1 Page 19 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 OP1 Regulation 4 and 5 Requirement Timescale for action 24/01/06 2 OP16 22 The registered person must make an up-to-date statement of purpose and service users’ guide available to current and prospective residents. The registered person must 24/01/06 ensure that the contents of the home’s complaints policy and procedure are up-to-date and correct. 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 OP19 Good Practice Recommendations The planned programme for the upgrading of the fabric of the building should be set out for residents to see as soon as possible. Yaxley House Residential Home DS0000066076.V279995.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Yaxley House Residential Home DS0000066076.V279995.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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