Inspection on 15/12/05 for York House

This inspection was carried out on 15th December 2005.

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

York House 20/03/07

York House 25/07/05

York House 11/01/05

York House 13/04/04

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 York House 47 Norwich Road Dereham Norfolk NR20 3AS Lead Inspector Unannounced Inspection 15th December 2005 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 York House DS0000055141.V272475.R01.S.doc Version 5.0 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. York House DS0000055141.V272475.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service York House Address 47 Norwich Road Dereham Norfolk NR20 3AS 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) 01362 697134 Black Swan International Limited Celia Joy Hart Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places York House DS0000055141.V272475.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th July 2005 Brief Description of the Service: York House is a home accommodating thirty one older people, situated about half a mile from the centre of the town of Dereham. It was first opened in 1982 and was purchased by the company Black Swan International Limited approximately two years ago. The front of York House is an older two storey building with a passenger shaft lift to reach the upper floor. At the back of the building is a single storey. The town of Dereham has a reasonable range of amenities including shops, public houses and churches. There is public transport available. York House DS0000055141.V272475.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was unannounced inspection, part of the annual inspection programme. There were 29 residents in the home on the day of the inspection. The inspection commenced at 9.30, and was completed at 2.30. As part of the inspection 4 members of staff, 4 residents, and 5 relatives, were interviewed. The Inspector made a tour of the home. A wide range of documents were examined by the Inspector. The Manager, Mrs Hart was present throughout the inspection. One of the Directors of the Company, Mr Brett Burton, was present during the later part of the inspection. His visit was one of his normal bi-weekly visits. What the service does well: What has improved since the last inspection? What they could do better: • • • Improve the environment of some of the corridors. Continue with the NVQ training programme. Remove the bed screens in double rooms, and replace them with curtains. York House DS0000055141.V272475.R01.S.doc Version 5.0 Page 6 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. York House DS0000055141.V272475.R01.S.doc Version 5.0 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 York House DS0000055141.V272475.R01.S.doc Version 5.0 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): 3&5 The home has good assessment documentation. Pre-admission visits are encouraged. EVIDENCE: In the inspection dated 25/7/05 it was recommended that the pre-admission assessment of mental health be improved to include depression, because of the relatively high incidence of depression in elderly people. This has since been done and it was seen by the Inspector. This small but significant change will enhance the assessment in this vital area of care. The Manager described the arrangements which take place when an prospective residents come to make a pre-admission visit to the home. These visits are positively welcomed the Manager said, as they give the prospective resident, and their relatives, the opportunity to see the home, talk to residents, and staff. They make a tour of the home if they wish, and often a question and answer session follows. Refreshments are often provided. York House DS0000055141.V272475.R01.S.doc Version 5.0 Page 9 Relatives interviewed, told the Inspector that they had visited the home with their relatives, before being admitted to the home and said that this provided an opportunity to find out about the home, as they fully appreciated that moving into a home presents a big change to prospective residents. Staff spoken to by the Inspector were also aware of these visits, and why they took place. York House DS0000055141.V272475.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 All residents have an individual care plan. Residents health care needs are met. Medicines are managed safely and effectively. Residents and relatives said that they are treated with respect. EVIDENCE: All residents have an individual care plan three of which were read by the Inspector. The plans are kept in an A4 ring binder folder and are clearly marked with the residents name and “Confidential.” There are file dividers in each file which helps in the finding of particular pieces of information. The writing in these documents is clearly written. In each care plan there is the essential elements of care planning namely, an assessment, plan, implementation, and review. York House DS0000055141.V272475.R01.S.doc Version 5.0 Page 11 There is also a record of weight, of doctors/nurse visits and a risk assessment. The home maintains a daily record, these were legible dated and signed. Following a discussion with the Manager and the Director the Inspector recommended that some simple guidelines for staff be drawn up for staff so that the essential element of the daily record, e.g. a residents go out of the home, it is recorded. The Inspector is not suggesting that this record become over long but provides a brief succinct record of the residents days/night. A wide range of personal care is provided in the home. All residents have a GP. The Manager said, and they would refer residents to consultants if this were needed. Dental, optical and chiropody services are provided. The dietician visits the home on a regular basis. There are 6 of residents who have diabetes and they have appointments at the local hospital on a regular basis. The incontinence advisor visit the home on a regular basis to provide advice on this very important area of personal care , staff have received training in continence care. There is one resident who has a pressure sore the Manager said, and the district nurse visits to treat this. In the Inspection dated 25/7/05 it was recommended that staff should receive training in pressure sore prevention. As yet this has not happened and the Inspector repeats this recommendation. The Inspector was shown the medicine system by the Manager. The home has a dedicated medicine room, which is kept locked. The medicines are kept in a dedicated medicine trolley. In the inspection dated 25/7/05 it was recommended that the trolley be kept locked to the wall. As yet this has not happened as the Manager is going to have specialist-fixing bars used for this so as to provide additional security for the trolley. The home uses a Boots Monitored Dosage system which the Manager said works well. The records for this were seen, they are neatly completed and there were no crossing out. There were no loose or unaccounted for medicines. Staff who administer medicines have received training to do so. There were Controlled Drugs in use on the day of the Inspection, one of which was counted and found to be correct against the register. At present there are a number of Controlled Drugs in use, and the home has a comparatively small Controlled Drug Cupboard. The Inspector recommends that larger one is purchased to avoid mistakes being made in this category of medicines. If staff had any concern about the effect of medicines on residents they would contact the prescribing GP. The home enjoys a good working relationship with the supplying pharmacist. The home has a detailed medicine procedure and has guidelines for residents who self medicate. These documents were seen by the Inspector. There is one resident who self medicates the Manager said. York House DS0000055141.V272475.R01.S.doc Version 5.0 Page 12 The home has the good practice, particularly in the care of the elderly of having medicines reviewed on a regular basis ,and this is recorded. The induction of staff includes the provision of privacy and dignity the Manager said. The home has the practice of knocking on doors prior to entry and the Inspector frequently saw this in action during the process of the inspection. If female residents are to be escorted they are asked if they have any objections to a male member of staff undertaking this task. Visit by doctors or others would be conducted in the privacy of the residents room. Residents wear their own clothes at all times. On the morning of the inspection all residents appeared well dressed and cared for. Residents are addressed by their preferred names. Residents have access to a mobile phone, which they use in their own room. Both residents and their relatives told the Inspector that staff always treated them with respect. There are screens in double rooms and in the last inspection the Inspector recommended that these be replaced with dividing curtains, a there is a risk that residents may fall over screens, and the Inspector repeats this recommendation. York House DS0000055141.V272475.R01.S.doc Version 5.0 Page 13 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): 15 The home provides a good catering service, and the residents speak highly of the catering services. EVIDENCE: The menus were seen by the Inspector, they appear nutritious, varied and interesting. Special diets are provided and recorded. There are 6 residents who have diabetes and they receive the appropriate diet. From time to time the Dietician visits the home and advises on all the food provided, but especially the medical diets. The home maintains a list of likes and dislikes The residents and relatives interviewed spoke very highly of the meals provided, they said that they “were varied”, “always tasty” and “always enough”. Comments made by staff supported what had been said on this matter. Residents were discreetly observed enjoying their midday meal. York House DS0000055141.V272475.R01.S.doc Version 5.0 Page 14 The table Menus were seen by the Inspector and they are very neatly set out. There is always a second choice available but this is not written on the menu. In the inspection dated 25/7/05 a recommendation was made that the second choice be printed on the menu so that the resident is enabled to make a direct choice from the menu, as one might in a restaurant. As yet this has not be done and the Inspector repeats this recommendation. York House DS0000055141.V272475.R01.S.doc Version 5.0 Page 15 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 & 18 The residents and their visitors are aware of how to make a complaint. Staff are aware of the importance of Adult Abuse prevention. EVIDENCE: There have not been any complaints since the last inspection the Manager said. Residents and their relatives who were interviewed were aware of how to make a complaint and added that they only “had praise for the home and the care provided”. Staff interviewed were aware of how to make a complaint were it needed, but said that in the first instance they would speak to the Manager. In the inspection dated 25/7/05 it was recommended that copies of the complaint procedure be put in the lounges. The Manager and Proprietors have been hesitant over this matter fearing that this may give these sitting rooms an institutional look, but at this inspection have agreed to put a smaller version of the complaints procedure in these rooms. Residents and visitors spend some considerable time in these rooms. The full procedure is displayed in the entrance hall of the home. There have not been any incidents of Adult Abuse since the last inspection the Manager said. Staff interviewed had undertaken certificated training in this matter. They told the Inspector that they are aware that abuse could take place and of the need to be conscious of this. They all said that they would not hesitate to inform the Manager if they thought that abuse was taking place. York House DS0000055141.V272475.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 There are areas of the home, which require maintenance work to be carried out. The home was net clean and tidy on the morning of the inspection. EVIDENCE: The home is located adjacent to the centre of Dereham with its shops and facilities, and it is on a bus route. There is car parking in the grounds the home has a programme of routine maintenance, and a message book for the handyman. The home was neat clean and odour free on the morning of the inspection. The Inspector made a tour of the home and saw that the wheel chair damage which was observed in the inspection dated 25/7/05 remains. Initial work has commenced on this, and the Inspector was informed that because of the likelihood of it being damaged again, in some busy areas protective plastic plates are to be installed. The Inspector recommends that this work commence as soon as is practical. York House DS0000055141.V272475.R01.S.doc Version 5.0 Page 17 In the inspection dated 25/7/05 a recommendation was made that bed screens should be replaced with curtains , because of the potential danger of tripping over them. As yet this work has not been carried out and the Inspector recommends that it should be. In the inspection dated 25/7/05 mention was made of an additional room being prepared to be brought into services. This has since been done and the room has been registered. During the tour of the home the Inspector visited the laundry, which was neat and tidy. Infected linen is not carried through areas where food is prepared. There is a hand sink adjacent to the washing machines, these are commercial type machines. The laundry floor is impermeable, and the walls are washable. The home has polices and procedures for the control of infection and disposal of clinical waste, dealing with spillages provision of protective clothing and hand washing. There is a sluice facility incorporated in the washing machine Foul laundry is washed at the appropriate temperature. The washing machine has specified programming to meet disinfection standards. The Manager is unsure if the services and facilities comply with the Water Supply (Water Fittings) Regulations 1999, and the Inspector makes it a requirement that information on this matter be sought. The director, Mr Burton, is familiar with this requirement, as it has arisen in other homes of the Company. York House DS0000055141.V272475.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 30 Residents needs are met by the numbers of skilled staff in the home. Residents are protected by the home’s recruitment practice. Staff are trained to carry out their jobs, in a safe and courteous manner. EVIDENCE: The staff on duty at the time of the inspection were 5 care staff, 2 kitchen staff, 3 domestic Staff, and the Manager. There are 3 care staff on the afternoon shift. There are 2 staff on the night and the Manager is on call. These figures agreed with the rota. If needed the Manager is authorised to call in additional staff. Based on the dependency of residents seen, there were sufficient staff on duty to meet their needs. Latter in the morning Mr Burton, one of the directors of the Company came to the home on one of his bi-weekly visits. Staff spoken to told the Inspector that they enjoyed caring for the residents and working in this home. Relatives spoken to said that they thought that the staff were very good, and were always very helpful. York House DS0000055141.V272475.R01.S.doc Version 5.0 Page 19 The home has an NVQ training programme in place. The figures given by the Manager are that there are 5 members of staff who have NVQ level III. The Manager, who has NVQ III, is not included in these figures (Standard 28 28.1) and there are 2 members of staff who have NVQ II. Thus making a total of 7. At present there are 3 members of staff who are undergoing training for NVQ II. There is a total of 14 Care Assistant in the home. Based on these figures the home has 50 who have NVQ training, this is despite the fact that some staff who had NVQ had left the home to work in other homes. The Manager staff and Company are commended for this and are urged to continue this training . When staff completed this training they are paid a bonus for it, and the Company is commended for this incentive. The home has a detailed recruitment practice which is of a high quality. Police and POVA checks are carried out, and two references are obtained. An application form is completed. Staff are provide with the Code of Practice as set by the GSCC. All staff are supplied with Terms and conditions and a job description. There are no volunteers in this home. In the inspection dated 25/7/05 a recommendation was made that there should be two people involved in interviewing. This arrangement is now in practice and the Manager is commended for this, as it helps to make the interviewing process safer. The home has an induction and Foundation training programme which meets NTO specification. Other training includes Basic First Aid, Moving and handling, Food Hygiene, Basic Awareness of Adult Abuse, Health and Safety Medication Training, Infection control, and Diabetes. In the inspection dated 25/7/05 it was recommended that the kitchen staff, domestic staff and handyman undertake First Aid training because of the potential dangers of their jobs. As yet this has not been done and the Inspector repeats this recommendation. York House DS0000055141.V272475.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 & 37 The residents’ financial interest are safeguarded. Residents’ rights, and interests are safeguarded by the homes record keeping, polices and procedures. EVIDENCE: The home holds monies on behalf of residents the Manager said. The money is kept in separate containers and is held in the safe. The monies are neatly kept and neatly recorded. In the inspection dated 25/7/05 a recommendation was made that numbered receipts are provided to people who hand money in. Receipts are now provided and this fulfils the recommendation made. York House DS0000055141.V272475.R01.S.doc Version 5.0 Page 21 Mr Burton said that at present the company is trialling a new money system in one of its homes. If this is successful it is likely that the system will be implemented in all the Company homes. This system includes the provision of numbered receipts. During this inspection a wide range of records were seen. The home has a comprehensive range of procedures which are kept in A4 ring binder folders. Residents may have access to their records if they wish but none have chosen to do so the Manager said. These records are clearly marked Confidential. All records are held secure in the Managers office which is kept locked when not in use. The records are maintained in accordance with the Data Protection Act, and other statutory requirements. The Inspector is pleased to report that the same standard of vigilance in this mater is maintained. York House DS0000055141.V272475.R01.S.doc Version 5.0 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 3 x 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 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x 3 x 3 x York House DS0000055141.V272475.R01.S.doc Version 5.0 Page 23 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 OP2626 Regulation 13(3) Requirement It is required that the Manager take steps to find out if the services and facilities in the laundry comply with the Water Supply (Water Fittings) Regulation 1999. Timescale for action 01/03/06 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 OP7 Good Practice Recommendations It is recommended that the Director and Manager produce guidelines for staff to enable them to write the Daily Record, so that the content is uniform, and contains all the detail needed. It is recommended that staff receive training in the prevention of pressure sores. It is recommended that; a. the medicine trolley be kept locked to the wall when not in use. b. A larger controlled drug Cupboard is installed. It is recommended that the bed screens be replaced with curtains. That wheel chair damage in corridors be made good as DS0000055141.V272475.R01.S.doc Version 5.0 Page 24 2. 3. 4 OP8 OP9 OP19 York House 5 6 7 OP16 OP15 OP30 soon as is possible. It is recommended that a copy of the complaints procedure is displayed in both lounges. It is recommended that both choices of meals available, is be displayed on the menus. It is recommended that catering staff, domestic staff and the maintenance man, are provided with First Aid training. York House DS0000055141.V272475.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 York House DS0000055141.V272475.R01.S.doc Version 5.0 Page 26 - 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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