Inspection on 28/11/07 for Yohden Care Complex

This inspection was carried out on 28th November 2007.

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

Yohden Care Complex 16/08/10

Yohden Care Complex 04/06/10

Yohden Care Complex 04/01/10

Similar services:

22 Sandown Road

The Highlands

Turret Villa Retirement Home

Dilston College Of Further Education

West View House

Moor House

Blenheim House

Prince Bishop Court

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

CARE HOMES FOR OLDER PEOPLE Yohden Care Complex Hesleden Road Blackhall Hartlepool Cleveland TS27 4LH Lead Inspector Mrs Sue Lowther Unannounced Inspection 09:30 28 November & 5 December 2007 th th 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 Yohden Care Complex DS0000070331.V354430.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. Yohden Care Complex DS0000070331.V354430.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Yohden Care Complex Address Hesleden Road Blackhall Hartlepool Cleveland TS27 4LH 0191 5860294 0191 5862868 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) Southern Cross OPCO Ltd Mrs Dorothy Lowther Care Home 77 Category(ies) of Dementia (29), Learning disability (10), Old age, registration, with number not falling within any other category (48), of places Physical disability (15) Yohden Care Complex DS0000070331.V354430.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP, maximum number of places 48 Dementia - Code DE, maximum number of places 29 Physical Disability - Code PD, maximum number of places 15 2. Learning Disability - Code LD, maximum number of places 10 The maximum number of service users who can be accommodated is 77 N/A Date of last inspection Brief Description of the Service: Yohden Care Complex is a seventy seven bedded home situated in a quiet residential area of Blackhall, which is a village close to Peterlee. The home provides residential and nursing care. There is a separate unit for people with dementia who have been assessed as needing residential care. The home is split over two floors with lift access. Some of the bedrooms have en suite toilets with sufficient additional facilities located throughout the home. Communal bathing facilities are located throughout the home. These have specialised bathing equipment to support people who are less able. The home has a large central dining and lounge area as well as small lounge and dining areas within each unit. Fees range from £419:50p and £450 weekly, which does not include the free nursing care element. Additional charges are made for hairdressing, chiropody and personal newspapers. Yohden Care Complex DS0000070331.V354430.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 28th November and 5th December 2007. Southern Cross OPOC Ltd has recently purchased the home. During the inspection time was spent talking to people using the service, staff, relatives and management. A number of records were looked at and the grounds and building itself were inspected. The home was also asked to complete a self-assessment, which provided the inspector with information prior to the site visit. Several of the people who live in the home, staff and visitors returned questionnaires about the home. A second inspector, Belinda Parker, spent time in the unit for people with dementia to observe the interaction between the staff and the people who live there. Information gathered throughout the inspection may be included within the inspection report. The inspection focussed on key standard outcomes for people who live in the home. What the service does well: What has improved since the last inspection? What they could do better: The manager should reinforce the complaints procedure so that everyone is aware of the process to follow when they are unhappy. Staffing levels must be reviewed in the dementia unit to make sure sufficient staff are available for social interaction. The lounge in the dementia unit could be improved so that people are able to interact more easily. The current shape makes this very difficult for staff, the people who live in the home and relatives to Yohden Care Complex DS0000070331.V354430.R01.S.doc Version 5.2 Page 6 communicate with each other. The acting manager must apply to be registered with the CSCI. The home must continue to maintain and to build upon the good service it gives to the people who live there. 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. Yohden Care Complex DS0000070331.V354430.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 Yohden Care Complex DS0000070331.V354430.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): 3. The home does not provide intermediate care. Therefore assessment of standard 6 is not required. ‘People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. Admissions are well managed and people are provided with information about the home before moving in. EVIDENCE: The home provides a statement of purpose and service user guide, setting out its aims and objectives, the range of facilities and services it offers to people. This enables people to make fully informed choices about whether the home can meet their indivdual needs. People are only admitted after a full assessment of need is carried out by an appropriately trained person. This is usually the acting manager. This is to Yohden Care Complex DS0000070331.V354430.R01.S.doc Version 5.2 Page 9 make sure that the home can meet the care needs of the people who go to live there. The family of one person who had recently gone to live in the home confirmed that they had looked around the home and had been supplied with all of the information they needed to make a decision about whether or not their relative would like to live there. Yohden Care Complex DS0000070331.V354430.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, and 10. ‘People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. People’s health care needs are well managed by the home. Systems to administer medication are safe and people living at the home say that they are treated well and that the standard of care is good. EVIDENCE: The acting manager said that all of the people who live in the home have care plans so that staff know how to look after people on an individual basis. Seven were looked at and were found to be of a good standard. There was evidence within some of the plans to confirm that people had been consulted with regard to their care. Eight people spoken to during the inspection and two people who returned surveys said that they were happy with the care received and the level of information given. However one person who returned the survey anonymously felt that they are not given sufficient information about their relative unless they ask. The acting manager agreed to discuss this at the Yohden Care Complex DS0000070331.V354430.R01.S.doc Version 5.2 Page 11 next meeting and to encourage people to use the complaints procedure available within the home if they are unhappy with the level of care provided. Records examined showed that people receive visits from other healthcare professionals. These include district nurses, doctors, and care managers. One person who lives in the home said, “The staff know when I am not well and get the doctor straight away. I am well looked after and all of the staff are excellent”. Medication is administered by qualified nurses. The home has a comprehensive medication policy. Accurate records of all medicines received, administered and those leaving the home are maintained. People spoken to said that staff always treat them with dignity and respect. One of the relatives said “ The staff are really good. Everyone is treated with dignity and respect, including visitors”. Yohden Care Complex DS0000070331.V354430.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 and 15. ‘People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. The home provides a range of activities with input from the people that live there. Relatives are made welcome and encouraged to visit the home. People living at the home said that they were able to make choices within all aspects of daily living. There is a varied menu and people likes and dislikes are well catered for. EVIDENCE: The home have recently appointed an activities coordinator, who was present on the day of inspection although had not as yet taken up the role. Routines of daily living and activities are flexible, however some comments received suggested that these are sometimes limited especially in the unit which caters for people with dementia. The inspector who spent some time in the unit saw that although staff were kind and treated people with respect, there was little time for any interaction other that to attend to the health and personal needs of the people. Staff tended to talk to them in the corridor whilst carry out other tasks. The activities organiser said that she intends to work with people in small groups or on a one to one basis to find out the likes and dislikes on an Yohden Care Complex DS0000070331.V354430.R01.S.doc Version 5.2 Page 13 individual basis. People can have visitors at any time and private visiting areas are available. One person suggested on the survey that it would be nice to have a coffee area where people could spend time with their relatives. The acting manager said that she would consider this suggestion. People’s spiritual needs are respected. People are encouraged to make choices and decisions wherever possible and this was observed throughout the day. One person said “I can get up and go to bed when I want. I can also have a bath or shower when I want”. Meals are varied, appealing, nutritious and based on individuals choice. The choice of menu is recorded daily but remains flexible. Special dietary needs are catered for and people are assisted to eat if necessary. One person who lives in the home said “The food is excellent. We get a choice and there is definitely plenty”. Yohden Care Complex DS0000070331.V354430.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 and 18. ‘People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. Complaints and adult protection matters are supported by clear guidance and training. EVIDENCE: The home has a complaints procedure in place, which is displayed throughout the home. Some of the people who live in the home said that they would know how to make a complaint. One person said, “I have never had any problems but if I did I would ask to see the manager”. One relative who returned a survey anonymously said that a complaint had been made to the administrator and this had not been followed up. The acting manager was informed and agreed to investigate this. She should reinforce the complaints procedure so that everyone is aware of the process to follow when they are unhappy. There were four complaints recorded within the home which have been investigated using company procedures. Records were available to confirm this. Staff are trained to recognise and prevent abuse of the people who live in the home. The home has a clear adult protection procedure which links with the local authority procedure for safeguarding adults. The home also has an active whistleblowing policy. All staff spoken with said that they would have no hesitation in telling someone if there was a problem. One member of staff said Yohden Care Complex DS0000070331.V354430.R01.S.doc Version 5.2 Page 15 “I would speak to the manager straight away. If she were not available or if it involved her I would speak to the area manager”. Yohden Care Complex DS0000070331.V354430.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 and 26. ‘People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. The home is clean, well maintained, furnished and decorated to a good standard. EVIDENCE: The communal areas were bright and nicely decorated. Although they are mostly spacious, the lounge in the dementia unit could be improved so that people are able to interact more easily. The current shape makes this very difficult for staff, the people who live in the home and relatives to communicate with each other. Many of the rooms are decorated to the person’s own taste and there was evidence to confirm that people can take in some personal items when they go to live there. This includes pieces of furniture as well as photographs and Yohden Care Complex DS0000070331.V354430.R01.S.doc Version 5.2 Page 17 ornaments. One person wrote, “I love my bedroom. All of the bedding now matches and makes me feel that I am living at home”. The gardens at the home were pleasant and well kept. The premises were clean, hygenic and free from any odours. Policies for the control of infection are in place and adequate handwashing facilities are available. Yohden Care Complex DS0000070331.V354430.R01.S.doc Version 5.2 Page 18 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 and 30. ‘People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. Staffing numbers support people’s health needs. The home has a commitment to staff training and recruitment practices protect people living in the home. EVIDENCE: From the rota supplied at the inspection there was sufficient care staff on duty to meet the assessed care needs of the people who were using the service. People said that staff were always around and answered the call bells quickly. However as previously stated from observation on the day and comments received the dementia unit would benefit from a staffing review to make sure that there are sufficient staff to meet the social needs of the people who live there. The home had staff files in place, which provided evidence that the appointment of new members of staff is made through proper recruitment processes. This includes the vetting of staff through the use of Criminal Record Bureau (CRB) checks, Protection of Vulnerable Adult checks (POVA) and written references. Training has recently taken place in fire safety, safe handling of medicines, moving and handling and first aid. A large number of care staff are trained to Yohden Care Complex DS0000070331.V354430.R01.S.doc Version 5.2 Page 19 NVQ level 2 and have recently completed a dementia awareness course. Certificates to confirm this were seen in staff files. Staff confirmed that there is plenty of training available. Yohden Care Complex DS0000070331.V354430.R01.S.doc Version 5.2 Page 20 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 and 38. ‘People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. The home is well managed and relatives and people using the service are regularly consulted about the service they receive. Financial arrangements are good and health and safety systems and practices protect people. EVIDENCE: The previous registered manager has left the home. An acting manager has been appointed. She is a qualified nurse and has several years experience in working with older people. However she must apply to be registered with the CSCI. Staff, the people who live in the home and visitors were extremely complimentary about the acting manager. One member of staff said “The manager is very approachable and I would not hesitate to approach her if I Yohden Care Complex DS0000070331.V354430.R01.S.doc Version 5.2 Page 21 had a problem”. A relative said “The manager has been very supportive to me and my family. My relative is very happy here”. There are clear lines of accountability within the home. Staff, relatives and those living at the home are actively involved in the decision making process of the home. The home has an annual plan for quality assurance which includes, meetings with people using the service, relatives and staff. These are held monthly and information from these are included in quality monitoring. The manager also makes herself available one evening a month. However if a relative wished to see her on an alternative evening or during a weekend she is very flexible and will arrange a meeting at a suitable time. The area manager completes a regulation 26 visit monthly. This is an audit which covers all aspects of the environment and the care delivered. The manager said that during this audit the area manager speaks to staff, the people who live in the home and visitors about their views. Any suggestions made are considered and improvements made where possible. The administrator is responsible for the record keeping with regard to people’s financial interests. Personal finances are kept in the home for people who request this. Two signatures are obtained and receipts are kept to ensure peoples’ financial interests are safeguarded. The company carry out an audit on a regular basis. Health and safety systems were looked at. Safe working practices are maintained in line with current regulations and appropriate risk assessments are available. All safety checks for maintenance are carried out by external contractors as designated by law. All accidents are recorded and reported appropriately. Yohden Care Complex DS0000070331.V354430.R01.S.doc Version 5.2 Page 22 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Yohden Care Complex DS0000070331.V354430.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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 OP27 Regulation 18 Requirement Staffing levels must be reviewed in the dementia unit to make sure sufficient staff are available for social interaction. The acting manager must apply to be registered with the CSCI. Timescale for action 31/01/08 2. OP31 9 31/01/08 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. 2. Refer to Standard OP16 OP19 Good Practice Recommendations The manager should reinforce the complaints procedure so that everyone is aware of the process to follow when they are unhappy. The lounge in the dementia unit could be improved so that people are able to interact more easily. Yohden Care Complex DS0000070331.V354430.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection St Nicholas Building St Nicholas Street Newcastle upon Tyne NE1 1NB 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 Yohden Care Complex DS0000070331.V354430.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!