Inspection on 20/06/06 for York House

This inspection was carried out on 20th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

York House 26/01/09

York House 06/03/07

York House 30/01/06

York House 07/11/05

York House 12/10/04

York House 17/05/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE York House Old Bank Road Dewsbury West Yorkshire WF12 7AH Lead Inspector Tracey South Unannounced Inspection 20th June 2006 09:15 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 DS0000026300.V292987.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. York House DS0000026300.V292987.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service York House Address Old Bank Road Dewsbury West Yorkshire WF12 7AH 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) 01924 459574 01924 463332 Tri-Care Limited Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places York House DS0000026300.V292987.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th January 2006 Brief Description of the Service: York House is a private care home owned by Tri-Care Ltd, registered to provide care and accommodation for up to 36 older people. It is situated in a residential area of Dewsbury, in close proximity to Dewsbury town centre and a variety of community facilities. There is parking available in the grounds for visitors and residents can enjoy views across Dewsbury and the Calder Valley from gardens, bedrooms and the main lounge/dining area to the rear of the home. The home has been purpose built and is well designed in relation to meeting the needs of the elderly resident group. The standard of accommodation and facilities remains high. The current charges at the home range from £450.00 to £480.00 per week. Additional charges are made for hairdressing, chiropody, toiletries, newspapers and transport. York House DS0000026300.V292987.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Since the last key inspection on 30th January 2006 a further visit to the home was carried out on 5th May 2006. The purpose of the visit was to establish whether or not the outstanding fire safety work had been completed as the work has been outstanding over 12 months. After the visit on 5th May a meeting took place with the service provider and the Commission for Social Care Inspection and it was agreed that the service provider would submit a risk assessment and an evacuation procedure in respect of the home. These documents are currently being examined in consultation with the local fire service. As part of this key inspection the Commission for Social Care Inspection undertook a site visit to the home. Alongside this, the staff at the home also completed a pre-inspection questionnaire, which was returned to the Commission before the inspection as requested. Information from this questionnaire was also used for this report. Surveys were sent to service users, their relatives, visiting professionals and GPs. Thirty six surveys were sent out to residents, twenty-nine responses were received. Ten surveys were sent out to relatives, eight responses were received. This inspection was carried out to assess the home against a pre-determined selection of the National Minimum Standards for Older People. In writing this report, information and evidence was not only obtained by way of visiting the home, but also from notifications sent to and information obtained by Commission for Social Care Inspection. The last inspection report was also consulted. The inspector spoke to 5 residents, some in the privacy of their own bedrooms and others whilst in the communal areas of the home. Care practice was observed throughout the day. Inspectors spoke to management, care staff and ancillary staff. Records were examined and a tour of the home was also undertaken. York House DS0000026300.V292987.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. York House DS0000026300.V292987.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 York House DS0000026300.V292987.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 & 3. Standard 6 does not apply. Residents receive a written contract at the point of moving into the home. Residents are admitted on the basis that the home is able to meet their needs. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: From the 29 surveys received, 24 residents said they had received a contract. Two said they had not received one, and 3 residents did not answer the question. Twenty-six residents said they received enough information about the home before moving in. Two said they didn’t and one person did not answer the question. All 3 case files examined contained a signed contract. In most cases the contract had been signed by the resident’s next of kin. York House DS0000026300.V292987.R01.S.doc Version 5.2 Page 9 The acting manager explained how prospective residents are encouraged to visit the home prior to them moving in. There was evidence of this within the case files of two newly admitted residents. Staff at the home will go and visit the prospective resident at home or in hospital. As well as receiving a community care assessment by the funding authority, the home also carries out a pre-admission assessment. The assessment gives an outline of the current needs of the resident. By carrying out such an assessment the home is able to reach a decision as to whether or not they are able to meet the person’s needs. The home then writes to the person to confirm that they are able to offer them a place at the home. York House DS0000026300.V292987.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Each resident has a care plan in place which sets out their health and personal care needs. Residents have access to health care services. The medication systems in place are good. Residents said they are treated with respect. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The care documentation being used for the writing up of care plans is still relatively new to the staff and they appear to be adapting to it positively. Each resident has a care profile in place. The profile includes a number of assessments in relation to the residents care needs. For example, the staff complete the following assessments in respect of each resident; personal care and physical well-being, diet and weight, sight, hearing and communication, oral health, foot care, mobility and dexterity, falls history, continence, medication, mental state, social interests and hobbies, personal safety and risk. Depending on the outcome of the assessment a care plan is then York House DS0000026300.V292987.R01.S.doc Version 5.2 Page 11 completed. The care plans examined were of a good standard and it was clear to the reader the level of support the resident required from staff. Although assessments in respect of resident’s social interests and hobbies are being completed there was no evidence in any of the 3 care plans examined that a care plan had been completed. This needs to be addressed. From the surveys returned 25 residents said they felt they received the care and support they needed. Three residents said they usually did and 1 person said they sometimes did. The home ensures that each resident’s plan is reviewed regularly and involves the resident and or their family. Residents are able to access health care services. GP visits are requested as required. There was evidence in the case files examined that GP visits are recorded. Other appointments such as hospital visits were also recorded. The acting manager explained how the home has good links with the district nursing and the community psychiatric teams. Specialist equipment used for the promotion of tissue viability and prevention of pressure sores was seen in both individual bedrooms and communal areas. Twenty-three residents said they received the medical support they needed. Eight said they usually did. One resident spoken to on the day of the inspection said “the staff are very good at calling the doctor if you are unwell”. The home has a good medication system in place. Medical records examined were well maintained and easy to follow. All stocks of medication were correct in accordance with the records kept. All medication is accounted for when it is received in the home and stocks of surplus medication is recorded and returned to the chemist. The home has obtained a new medication fridge since the last inspection. Residents, who are able to do so, are encouraged to be responsible for their own medication. For those residents wishing to administer their own medication, safe lockable storage is available to them. Those residents spoken to on the day of the inspection said the staff treated them with dignity and respect. Residents explained that staff were sensitive towards them when dealing with personal care tasks. When asked if staff always knock before entering the resident’s room or when in the toilet, one resident said “some staff knock on the door, others don’t”. Another resident spoken to indicated the same. As part of the residents survey they are asked if the staff listen and act on what they say, 13 said staff always listen whilst 15 said they usually did and 2 residents said they sometimes did. York House DS0000026300.V292987.R01.S.doc Version 5.2 Page 12 Induction training covers privacy and dignity and those staff who undertake NVQ level 2 in care will also be expected to demonstrate their competency in this area. The acting manager was advised of the comments received by residents in respect of staff not always knocking on doors before entering the private space of residents. York House DS0000026300.V292987.R01.S.doc Version 5.2 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): 12, 13, 14, 15 Residents are able to take part in organised activities. Residents are able to make their own choices about how they spend their time. Friends and family are made to feel welcome at the home and know that they can visit the home at any time. Residents receive a well balanced diet. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Residents said they were able to make their own choices about how they spend their time. Some residents prefer the privacy of their own rooms whilst others are happy to spend their time in the various communal areas there are available. Residents confirmed that there were no restrictions in place with regards to when they get up and go to bed. From the surveys returned 16 residents said that the staff were available when they were needed. Eleven residents said they usually were and 2 residents said they sometimes were. Other comments made include, “it would be nice to have a little talk now and then like they used to”, “if staff are busy they always come back to you as soon as they can”, “nobody ever has time to spend any 1-1 time with me”. York House DS0000026300.V292987.R01.S.doc Version 5.2 Page 14 The acting manager demonstrates a caring attitude towards the residents and realises the importance of seeking the views of people living at the home. She recently sent out a questionnaire in respect of the new menus recently introduced by the company, Orchard Care Homes Ltd. As a result of the comments made in the questionnaires a residents’ meeting was held in order to give residents the opportunity to air their views. Issues raised in the meeting have been addressed and changes to the menus have been made. The cook was able to demonstrate a good knowledge of resident’s likes and dislikes. She said she was enjoying preparing the new meals that have been introduced. Specialist diets such as diabetic and soft diets are catered for. No cultural diets are currently being requested. There is an activities programme in place whereby residents are able to join in various activities throughout the month. Outside entertainers also visit the home. As part of the survey residents were asked whether the home arranged activities for them to take part in, 13 residents said there were always activities arranged, 9 said they usually were, 8 said sometimes and 3 did not answer the question. Comments made include, “not much variety, not very publicised, I can’t read notice board due to cataracts”. One resident with a sensory impairment felt limited as to what they could take part in. There is an activities log in place in respect of each resident, making it easy to see just what activities, if any, the resident has taken part in. One resident’s log indicated that she had played badminton, attended church service, unloaded the dishwasher, been out for a walk, played bingo and folded the laundry. A programme of activities is displayed in various parts of the home. Residents said they are able to take part in church services at the home. One resident said she receives Holy Communion from the priest each month and also joins in the Church of England service that takes place in the home. Family and friends are able to visit the home at any reasonable time. Relatives confirmed that they are always made to feel welcome visiting the home. One relative said he had been visiting the home for the past 18 months and he has built up good relationships with the staff. Residents are able to see their visitors in the privacy of their own room or in the number of communal areas available in the home. Residents are able to bring personal possessions with them, the extent of which is agreed with prior to admission. Evidence of residents’ personal belongings in place was seen whilst carrying out a tour of the home. New menus were introduced in February 2006 offering a wider choice of variety. There are a number of alternatives available at breakfast, lunch, tea York House DS0000026300.V292987.R01.S.doc Version 5.2 Page 15 and supper. Slight amendments have been made to the Spring/Summer menus, as residents did not like some of the options available. The surveys asked residents if they liked their meals, 19 said they always did, 7 said they usually did and 3 said they sometimes did. Comments also include, “since the name was changed meals terrible…..”, “menu has changed – not as good”, “ the food is cooked well and is always tasty”, “very good meals”. All residents spoken to on the day of the inspection said they enjoyed their meals and that there is a good variety available. A mealtime was observed, dining tables were nicely set with the appropriate cutlery and crockery, napkins were available, as were condiments such as salt pepper, milk and sugar. The meal was well presented and residents appeared to enjoy their choice of either lamb or fish. Residents confirmed that regular drinks are available and staff will always make a cup of tea at any time when asked. York House DS0000026300.V292987.R01.S.doc Version 5.2 Page 16 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 home has a complaints procedure that is up to date, very clearly written, and is easy to understand. Residents know how to make a complaint. Residents are protected from abuse. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home has a complaints procedure that is up to date, very clearly written, and is easy to understand. The complaints procedure is displayed in the foyer of the home and a copy is included in the home’s statement of purpose and service user guide. Surveys returned from relatives indicated that 2 out of 8 people were not aware of the home’s complaints procedure. The residents spoken to on the day of the inspection knew who they should approach if they were unhappy about something. As part of the survey residents were asked if they knew who to speak to if they were not happy, 22 residents said they knew who to speak to 4 people were less sure. The home has not received any complaints within the last 12 months. Informal concerns are logged including the action taken to resolve the matter. The policies and procedures regarding protection of residents are in place. Twenty-two of the staff have received adult protection training. The remaining staff must receive this training within the next 3 months. Those staff spoken to had a good understanding of their responsibilities in reporting bad practice York House DS0000026300.V292987.R01.S.doc Version 5.2 Page 17 and incidents of abuse. Residents themselves said they felt safe at the home and well looked after by the staff employed there. York House DS0000026300.V292987.R01.S.doc Version 5.2 Page 18 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 Residents live in a well-maintained environment. The home is clean, pleasant and hygienic. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home is generally well maintained although there are some signs of wear and tear in relation to the décor. The acting manager is well aware of this and has already requested that the first floor lounge be decorated. New armchairs are to be purchased. A number of skirting boards require repainting due to damage made by wheelchairs. The carpet on the staircase is threadbare on the top step and will require attention before it becomes a tripping hazard. The home does not fully comply with the requirements of the local fire service. This has resulted in the overall quality rating in this outcome area being judged as poor. York House DS0000026300.V292987.R01.S.doc Version 5.2 Page 19 The home received a visit from the environmental health officer in March 2006. No recommendations were made, the visit was said to be a very positive one. Twenty-five surveys indicated that the home is always fresh and clean, 3 residents felt it usually was. One comment made was “York House is very very clean and well kept”. As the company does not employ a designated laundry person the care staff and management staff are expected to undertake laundry duties. A recommendation to employ a laundry person has featured in many previous reports in the hope that the service provider would be encouraged to take this on board. It is disappointing to note that this has not happened and staff continue to undertake laundry duties when they could spend more time with residents. York House DS0000026300.V292987.R01.S.doc Version 5.2 Page 20 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, 29 & 30 There are adequate numbers of staff employed at the home to meet the needs of the residents. The home’s recruitment procedures are robust. Staff receiving the training they need to carry out their jobs. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Relative surveys asked if there were always sufficient staff on duty. Eight relatives said yes, one said no. A typical days consists of 4 care staff, the manager and or the deputy manager on the morning shift, 5 care staff on the afternoon staff and 3 wakeful night staff. Care staff are supported by domestic and kitchen staff. There are currently no staff vacancies at this present time. Agency staff are very rarely used. 73 of the care staff have achieved a NVQ qualification at level 2 or above. All prospective staff undergo employment checks prior to them starting work at the home. The staffing files examined contained the relevant documentation such as an application form, two written references, a POVA first check and a satisfactory criminal records bureau disclosure. York House DS0000026300.V292987.R01.S.doc Version 5.2 Page 21 Information provided within the questionnaire completed by staff, indicates that the following training sessions have taken place, fire, NVQ, moving and handling, food awareness, medication, adult protection, health and safety and first aid. The acting manager explained how the company have recently introduced an induction manual for all new employees. The document itself is very detailed and contains good information for new starters about the principles of providing quality care as well as employment matters. However it does not lend itself to enable the member of staff and their line manager to evidence that the person is considered as competent in all aspects of care. Relative surveys indicated that all 9 of those returned were satisfied with the overall care provided at the home. One relative comments read, “I am very satisfied with the overall level of care. Staff are to be commended on their professional attitude towards the residents”. Other comments include, “The home is first class and the staff treat my father with care and respect”. “My mother is well looked after”, “well run home with excellent staff”, “staff are friendly and extremely caring”. York House DS0000026300.V292987.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 The home is well managed and is run in the best interest of the residents who live there. Residents’ financial interests are safeguarded. There are good health and safety systems in place. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The registered manager for York House retired in February 2006, since then the home as employed an acting manager. The acting manager has 13 years experience of working with older people in a residential setting and has worked at York House since it opened. She is qualified to NVQ level 4 in care management and is also a manual handling facilitator. The acting manager is resident focused and is proactive in seeking the views and opinions of residents York House DS0000026300.V292987.R01.S.doc Version 5.2 Page 23 and their families. Both residents and relatives spoke highly of the acting manager, acknowledging that she is an approachable and caring person. The company sent out satisfaction questionnaires to residents in January 2006 and a summary of the findings was produced in February 2006. When examining the summary it was difficult to ascertain the exact level of satisfaction as there was no indication as to how many questionnaires were sent out and how many were received. The Area Manager is responsible for carrying out visits to the home to form an opinion of the standard of care provided. A report is then produced a copy of which is sent to the Commission for Social Care Inspection. Records of residents’ monies held in the home are kept and receipts for any purchases made on the residents’ behalf are available. Three residents’ monies were checked against the records kept, all of which were correct. Residents are provided with facilities to ensure that their valuables and money are safe. There are health and safety systems in place and regular checks such as fire alarm tests, fire drills, gas safety checks and the servicing of equipment are carried out. The evacuation procedure recently submitted to the Commission for Social Care Inspection must include more specific details about how an evacuation in the home will be managed. The document submitted is generic and does not include any management issues the staff may need to consider when evacuating residents. York House DS0000026300.V292987.R01.S.doc Version 5.2 Page 24 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 3 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 2 1 X X X X X X 3 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 2 York House DS0000026300.V292987.R01.S.doc Version 5.2 Page 25 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 OP19 Regulation 23 Requirement Schedule 1. No. 1. An acceptable evacuation policy for the premises must be in place. No. 4. The final exit doors must be accessible in the event of fire. No. 5. Evidence must be obtained that the roof void and lift shaft are covered by smoke detection. Schedule 2 No. 1. Fire doors to sub divide the bedroom compartments must be fitted. No. 3 & 4. Confirmation that the home meets the fire alarm and emergency lighting standards must be obtained. The care plan must include the social care needs of the residents. All staff must receive adult protection training within the next 3 months. Timescale for action 30/08/06 2 3 OP7 OP18 15 13 30/07/06 30/09/06 York House DS0000026300.V292987.R01.S.doc Version 5.2 Page 26 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 3 Refer to Standard OP10 OP26 OP30 Good Practice Recommendations Staff should ensure they knock before entering the private space of residents, whether in their own rooms or in toilet and bathroom areas. The company should consider employing a laundry assistant to enable care staff to spend more time with residents. The induction manual needs to show evidence that the new member of staff is considered as competent in aspects of care. York House DS0000026300.V292987.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 DS0000026300.V292987.R01.S.doc Version 5.2 Page 28 - 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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