CARE HOMES FOR OLDER PEOPLE
Yoakley House (Michael Yoakley`s Charity) Yoakley House Via Drapers Close St Peter`s Road Margate Kent CT9 4AJ Lead Inspector
Clair Brown Unannounced Inspection 10th March 2006 11:05 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 Yoakley House (Michael Yoakley`s Charity) DS0000023632.V274631.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. Yoakley House (Michael Yoakley`s Charity) DS0000023632.V274631.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Yoakley House (Michael Yoakley`s Charity) Address Yoakley House Via Drapers Close St Peter`s Road Margate Kent CT9 4AJ 01843 223652 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) Michael Yoakley`s Charity Mrs Gillian Lilley Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Yoakley House (Michael Yoakley`s Charity) DS0000023632.V274631.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. To admit four (4) Services Users, under the category of MD, whose dates of birth are 19/07/1921, 18/05/1914, 18/05/1914 and 09/06/1923. 18th July 2005 Date of last inspection Brief Description of the Service: The Home was purpose built in the 1980s in a semi-rural location. It is a short journey to the local amenities and is situated on a bus route. The local general hospital is situated next to the Home. The Home is registered 26 male & female service users of both genders, aged 65 years plus. The Home is all on one level and all bedrooms are single with en-suite facilities. There are two waking night staff on duty every night and between 2 and 5 care staff on duty during the day. Yoakley House (Michael Yoakley`s Charity) DS0000023632.V274631.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the home’s unannounced inspection, which was conducted by one inspector. The duration of the inspection was 5 hours. The Home representative was the registered manager. Additional time was spent in planning the inspection and report writing. The inspection included assessing the progress being made to meet the previously made requirements and recommendations from the last inspection. Documents and records were examined and service users files were case tracked. What the service does well: What has improved since the last inspection? What they could do better:
The service users care plans should provide clear instructions on how to meet identified needs with daily reports clearly recording care provided and the
Yoakley House (Michael Yoakley`s Charity) DS0000023632.V274631.R01.S.doc Version 5.1 Page 6 events of the day. All service users who are self-medicating need to be provided with the appropriate lockable storage facilities and a procedure introduced to monitor /audit the medication of those who are self-medicating. Medication should be regularly audited. The registered manager should to produce a report of the collated information gathered during the annual quality assurance programme, to include an action plan. The registered person should conduct monthly visits and produce a report. All staff should have formal one to one supervision six times a year. 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. Yoakley House (Michael Yoakley`s Charity) DS0000023632.V274631.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 Yoakley House (Michael Yoakley`s Charity) DS0000023632.V274631.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): 4,6 The home does not ensure prospective service users are within the category of registration prior to admission. The home does not provide intermediate care therefore standard 6 is not applicable. EVIDENCE: Currently there is a service users at the home for respite, the registered manager has requested further assessments as there is some doubt about their mental capacity, with possible dementia needs. The registered manager confirmed the home does not provide intermediate care. Yoakley House (Michael Yoakley`s Charity) DS0000023632.V274631.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 Medication procedures and practices have improved but there needs further improvements in practices. The care planning system does not adequately provide staff with the information they need to satisfactorily meet service users needs. EVIDENCE: Medication facilities and practices have continued to improve. Some selfmedicating service users have been provided with appropriate lockable facilities, however others have not. The policy and procedures have been updated to include homely remedies and self-administrating procedures. However, some errors were found in the records (MAR charts). Two service users files were case-tracked; one provided staff with clear information and instructions about the service users needs. When case tracking and cross referencing information in the second file it did not correspond and did not provide staff with clear instructions on how to meet the individual needs. Care staff have recently taken over the responsibility of writing the care plans. Some daily reports were very detailed especially when there was a significant event such as a health need / doctors visit. However routine days recorded little information about the care provided.
Yoakley House (Michael Yoakley`s Charity) DS0000023632.V274631.R01.S.doc Version 5.1 Page 10 Yoakley House (Michael Yoakley`s Charity) DS0000023632.V274631.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15 The programme of activities satisfies the wishes of the service users. Procedures for food safety have improved and records are now kept. EVIDENCE: A member of the care team has changed their job description to include a set number of hours a week for the development and implementation of an activities programme. The registered manager confirmed that hot food is now temperature probed and records kept. A system has been introduced for the keeping records of meals provided. Yoakley House (Michael Yoakley`s Charity) DS0000023632.V274631.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): EVIDENCE: Yoakley House (Michael Yoakley`s Charity) DS0000023632.V274631.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): 26 The home is clean and has updated its clinical waste and infection control procedures. EVIDENCE: The registered manager confirmed that she had contacted the infection protection agency regarding clinical waste procedures and has implemented their advice. Yoakley House (Michael Yoakley`s Charity) DS0000023632.V274631.R01.S.doc Version 5.1 Page 14 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): 29 A format for the recording of prospective staff interviews has been introduced. EVIDENCE: The registered manager showed the inspector a template for interview records of prospective staff. Due to the low turnover of staff no new staff have been employed since the last inspection, therefore it has not been possible to use the new document. Yoakley House (Michael Yoakley`s Charity) DS0000023632.V274631.R01.S.doc Version 5.1 Page 15 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): 35,36 Service users money is stored securely and recorded. Staff are not receiving sufficient formal supervision. EVIDENCE: The service users money is held in individually with their own records including receipts of expenditure kept. All totals and cash corresponded. However the procedure is a single signature procedure, with records kept in small cashbooks. Staff records and the registered manager confirmed that the staff have had some one to one formal supervision during the last year but not they have not had sufficient quantity of supervision. Yoakley House (Michael Yoakley`s Charity) DS0000023632.V274631.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 2 2 X X Yoakley House (Michael Yoakley`s Charity) DS0000023632.V274631.R01.S.doc Version 5.1 Page 17 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 OP4 Regulation 4,12,14, 18 1012-18 sch 3-4 Requirement Timescale for action 31/03/06 2 OP7OP8OP 37 3 OP9 12-14 16 17 23 sch 3 4 OP33 26 The registered manager must determine if the respite service user requires a variation to the homes registration. 1) The registered manager must 31/07/06 ensure that all service users care plans provide clear instructions on how to meet identified needs, with these being crossreferenced between documents such as risk assessments, health assessments and reviews. 2) Daily reports must clearly record care provided and the events of the day. 1) For all service users who are 30/04/06 self-medicating to be provided with the appropriate lockable storage facilities. 2) To develop a procedure to monitor /audit the medication of those who are self-medicating. 3) Regular medication audits to be conducted, investigating all errors and gaps in the records (MAR charts). 1) The registered manager is 31/07/06 required to produce a report of the collated information gathered
DS0000023632.V274631.R01.S.doc Version 5.1 Yoakley House (Michael Yoakley`s Charity) Page 18 5 OP36 18 during the annual quality assurance programme, to include an action plan. These should be sent to the CSCI office and made available. 2) The registered person to conduct monthly regulation 26 visits and the report to be sent to the CSCI. For all staff to formal one to one supervision six times a year. Previous timescale: 31.01.06 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP35 Good Practice Recommendations To review the procedures for the recording of service users money, to use a 2 signature procedure. Yoakley House (Michael Yoakley`s Charity) DS0000023632.V274631.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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