CARE HOMES FOR OLDER PEOPLE
Yohden Dene Care Home Hesleden Road Blackhall Hartlepool Cleveland TS27 4LH Lead Inspector
Mrs Sue Lowther Unannounced Inspection 7th November 2007 09:30 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 Yohden Dene Care Home DS0000070329.V354534.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 Dene Care Home DS0000070329.V354534.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Yohden Dene Care Home Address Hesleden Road Blackhall Hartlepool Cleveland TS27 4LH 0191 5862284 0191 5862284 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 Jayne Golightly Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Yohden Dene Care Home DS0000070329.V354534.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 only - code PC To service users of the following gender: Either Whose primary care need on admission to the home are within the following category: Old Age, not falling within any other category - Code OP, maximum number of places 36 The maximum number of service users who can be accommodated is 36 N/A 2. Date of last inspection Brief Description of the Service: Yohden Dene is a purpose built care home situated in a quiet residential area of Blackhall, which is a village close to Peterlee. The home provides residential care for up to thirty six people. All of the rooms have en suite toilet facilities and there are additional bathing facilities provided throughout the home. Some of the bathrooms have specialist bathing facilities to support those people who are less able. There is a communal lounge and dining area, plus a smoking lounge and separate coffee shop. People have access to a secure and very attractive garden area. Fees range from £411.00 to £450:00 per week; this does not include hairdressing or chiropody. Yohden Dene Care Home DS0000070329.V354534.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 7th November 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 selfassessment, 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. 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 home should continue to update the care plan documentation and transfer it to the company format to ensure a consistent approach. The treatment room is very small. Staff sometimes need to move medication trolleys out when they Yohden Dene Care Home DS0000070329.V354534.R01.S.doc Version 5.2 Page 6 need to access some of the cupboards. The company should consider relocating the treatment room to a more appropriate area. 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 Dene Care Home DS0000070329.V354534.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 Dene Care Home DS0000070329.V354534.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. One person who responded to the survey said that they felt people should not be charged for hairdressing, toiletries and chiropody. However the home do state this in their contract and make people aware of these charges before they are admitted.
Yohden Dene Care Home DS0000070329.V354534.R01.S.doc Version 5.2 Page 9 People are only admitted after a full assessment of need is carried out by an appropriately trained person. This is usually the registered manager. This is to 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 Dene Care Home DS0000070329.V354534.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: 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. At the time of this inspection staff were busy transferring this information to the format required by the new company and therefore some were not fully completed. However those seen which were completed were of a good standard. There was evidence within some of the plans to confirm that people had been consulted with regard to their care. Yohden Dene Care Home DS0000070329.V354534.R01.S.doc Version 5.2 Page 11 Records examined showed that people receive visits from other healthcare professionals. These include district nurses, doctors, and care managers. One visitor said, “The staff keep me well informed about my relatives health and well being”. Another said, “The staff treat people like their own parents. They ring me straight away about any changes”. Medication is administered by senior care staff who have been trained. The home has a comprehensive medication policy. Accurate records of all medicines received, administered and those leaving the home are maintained. The drug fridge was checked and found to be in order. However the treatment room is very small. Staff sometimes need to move medication trolleys out when they need to access some of the cupboards. The company should consider relocating the treatment room to a more appropriate area. People spoken to said that staff always treat them with dignity and respect. One of the relatives said “The care home staff are caring and friendly to both clients and relatives. The staff really make it like the person is in their own home and treat everyone with dignity and respect”. Yohden Dene Care Home DS0000070329.V354534.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 good 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 an activities coordinator. Routines of daily living and activities are flexible and varied to suit individual expectations, preferences and capabilities. Personal choice is promoted at all times. People’s interests are recorded, there is a daily activity programme which is flexible. The activities organiser said that she tends to work with people in small groups or on a one to one basis. The range of activities includes board games, armchair exercises, bingo, skittles, outings and pie and peas suppers”. Yohden Dene Care Home DS0000070329.V354534.R01.S.doc Version 5.2 Page 13 People can have visitors at any time and private visiting areas are available. 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 good. We get a choice and there is definitely plenty. I have put on weight since I came to live here. This is my home now”. Yohden Dene Care Home DS0000070329.V354534.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. There were no complaints recorded at the time of the inspection. 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. I know she would put things right as soon as she could”. Staff said that if they have a problem they feel that they can approach the manager and she tries her best to sort it out. 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 whistle blowing (telling someone) if there was a problem. Yohden Dene Care Home DS0000070329.V354534.R01.S.doc Version 5.2 Page 15 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 excellent 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 and furnished and decorated to an excellent standard. EVIDENCE: The communal areas were bright, spacious and nicely decorated. 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 ornaments. One person wrote, “I am very lucky to be living in such a nice pleasant home”. Another said, “The atmosphere in the building is warm and the staff make it feel as though you are entering your own home. The building is maintained to
Yohden Dene Care Home DS0000070329.V354534.R01.S.doc Version 5.2 Page 16 a high standard and is always immaculately clean and tidy. This includes individual rooms, lounges and dining areas”. The gardens at the home were pleasant and well kept. One of the people who lives in the home had recently had a bird table put up outside the bedroom window. 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 Dene Care Home DS0000070329.V354534.R01.S.doc Version 5.2 Page 17 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 good 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 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 needs of the people who were using the service. People said that staff were always around and answered the call bells quickly. 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. One person commented on the survey that the home should employ more male staff. The manager said that she considers all applicants equally when recruiting regardless of race or gender. 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 NVQ level 2. Certificates to confirm this were seen in staff files. Staff confirmed that there is plenty of training available.
Yohden Dene Care Home DS0000070329.V354534.R01.S.doc Version 5.2 Page 18 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 manager has several years experience in working with older people. Staff, the people who live in the home and visitors were extremely complimentary about the manager. One member of staff said “The manager is very approachable and has a good rapport with staff and the people who live in the home”. One relative said “The manager has been very helpful since my relative moved into the home”. One visiting professional said “The manager is always
Yohden Dene Care Home DS0000070329.V354534.R01.S.doc Version 5.2 Page 19 professsional, approachable, friendly and is knowledgable about all of her clients”. 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 Dene Care Home DS0000070329.V354534.R01.S.doc Version 5.2 Page 20 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 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 Dene Care Home DS0000070329.V354534.R01.S.doc Version 5.2 Page 21 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. Standard Regulation Requirement Timescale for action 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 OP7 OP9 Good Practice Recommendations The home should continue to update the care plan documentation and transfer it to the company format to ensure a consistent approach. The company should consider relocating the treatment room to a more appropriate area. Yohden Dene Care Home DS0000070329.V354534.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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
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