Inspection on 21/08/07 for York House

This inspection was carried out on 21st August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 02/03/10

York House 20/01/10

York House 01/12/08

York House 14/11/06

York House 31/01/06

York House 04/07/05

York House 01/02/05

York House 26/08/04

York House 30/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE York House 8-10 Cauldon Avenue Swanage Dorset BH19 1PQ Lead Inspector Gloria Ashwell Key Unannounced Inspection 10:00 21 August 2007 &13 September 2007 st 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 York House DS0000026895.V348666.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 DS0000026895.V348666.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service York House Address 8-10 Cauldon Avenue Swanage Dorset BH19 1PQ 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) 01929 425588 01929 426572 Mr Richard Graham Wylie Mrs Maxine Valerie Toni Jacqueline Wylie Mrs Margaret Street Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places York House DS0000026895.V348666.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th November 2006 Brief Description of the Service: York House is a large, older style, detached property that overlooks a recreational/garden area and is close to the seafront. The home is approximately a mile from Swanage town centre, which has a G.P surgery, community hospital, shop, banks, a post office and places of worship. Accommodation is provided over three floors, all are serviced by a passenger lift. All communal lounges and dining areas are on the ground floor, also the kitchen and managers office. There are 30 bedrooms in the home; 20 have en suite toilet facilities. Two rooms are registered for use as shared rooms. A maximum of 34 service users can be accommodated in the category OP (older persons). Mr and Mrs Wylie are the registered providers and have owned York House since 1988. The registered manager is Mrs Street, who is supported by a Deputy Manager and a team of care and household staff. The gardens and grounds are well tended with garden furniture available so that residents can sit outside in good weather. There is car parking space at the front of the house for use by visitors. Laundering of clothing and household linen is carried out at the home and arrangements are made for chiropodists, opticians and other health and social care professionals to visit individual residents. The fee range quoted in the service user guide at the time of inspection was £455 to £515 per person per week. Up to date fee information may be obtained from the service. Information regarding the subjects Value for Money and Fair Terms in Contracts can be obtained from the web link: www.oft.gov.uk York House DS0000026895.V348666.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that took place at the home over two days, comprising a total of five and 3/4 hours. Additionally, time was spent in preparation for the visit, looking at previous inspection reports and other relevant documents and preparing a plan for the inspection visit. The inspector arrived on 21 August 2007 and spoke to residents and staff and toured the premises. By arrangement with Mrs Street she returned to the home at 10.00 on 13 September 2007 and assisted by Mrs Street and the deputy manager discussed and examined documentation relating to the care provision and administration of the home. The care records of four people who live at the home were examined in detail. The inspector was able to meet and speak with most of the residents both individually and in small groups in the communal areas. Additional information used to inform the inspection process included the Annual Quality Assurance Assessment completed in advance of the inspection by Mrs Street. During this inspection compliance with all key standards of the National Minimum Standards was assessed. What the service does well: York House provides a comfortable and homely environment for residents. The management and staff are held in high regard by residents who appreciate the kind, cheerful and professional manner in which they undertake their duties. A good working relationship has been established with the local GP Surgery and primary care team; residents have access to the health care resources that they might need. All staff who administer medication have received formal training. There is good contact with the local community and residents are encouraged to remain active, independent and retain control over their own lives. Bedrooms are personalised with resident’s own belongings. Meal times are a social event and all the residents spoken with said that they enjoy their meals, that their likes and dislikes are well known and that they are satisfied with the food provided. York House DS0000026895.V348666.R01.S.doc Version 5.2 Page 6 Staff have received in house training on adult protection issues. Staff informed the inspector that they felt well supported by the management and that they could approach any of the management team for advice and guidance. 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. The summary of this inspection report can be made available in other formats on request. York House DS0000026895.V348666.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 DS0000026895.V348666.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home does not provide Intermediate Care so Standard 6 does not apply. Prospective residents (or their representatives) are provided with information about York House and are encouraged to visit in advance of admission to establish their impressions of life at the home and the standard of available accommodation although the format of the information may not be suitable for service users who have specific needs for example those with impaired sight. Prior to admission, the needs of each proposed resident are assessed and the home then writes to prospective residents confirming the ability to properly care for them. EVIDENCE: The service user guide is made available to all residents and prospective residents. It contains general information about the home but includes York House DS0000026895.V348666.R01.S.doc Version 5.2 Page 9 inaccurate information regarding smoking in the home; it is recommended that it be amended to ensure accuracy and to include reference to the outcomes of the most recent user satisfaction questionnaire. The Statement of Purpose and service user guide are available in a standard format; it is recommended that this information be made available in alternative formats, appropriate to the needs and capacity of individual prospective residents or their representatives who might find the standard format difficult to read and fully understand. The records of a recently admitted resident included details of pre-admission assessment which had been carried out by the registered manager she visited the prospective resident at the previous address. In advance of making the decision to enter the home the prospective resident and her closest relative visited York House to view the premises and meet residents and staff. The inspector spoke to the resident who confirmed satisfaction with the home and observed that it was “Very comfortable…the carers are absolutely marvellous…they are friendly and jolly; so helpful…”. Following pre-admission assessment of the persons needs and circumstances the home writes to them confirming agreement and ability to accommodate and care for them; a copy of the ‘letter of offer’ is kept on file. York House DS0000026895.V348666.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents care needs are well met but lack of clear care planning documentation means that some aspects of their care may be missed. Residents are treated with respect and their rights are upheld. Medicines prescribed by doctors are safely stored and correctly administered by staff trained in this work but aspects of record keeping must be improved to ensure all medicines can be properly accounted for. EVIDENCE: Residents believe they are properly cared for; comments during the inspection included “the carers are absolutely marvellous…they are friendly and jolly; so helpful”. Some residents described particular aspects of care they require and receive, confirming their satisfaction with the standard of care. York House DS0000026895.V348666.R01.S.doc Version 5.2 Page 11 There is a written plan of care for each resident; the samples examined were hard to follow because they did not reliably describe the care needs and/or the ways these were to be met. Care records of 4 residents were examined; risk assessments should form the basis for care plans but few had been recorded; as a minimum, for each resident there should be regularly reviewed and up to date assessments for mobility, skin condition and nutrition. To ensure correct identification of residents, records should contain a recent photograph of each resident. For each resident the home writes daily records; the sample examined was of satisfactory standard. Staff spoken with during the inspection understood the needs of the residents in their care and said that the manager and deputy manager keep them up to date with any changes that arise. In general, care documentation with particular regard to risk assessments and care plans should be improved to ensure that staff have sufficient information upon which to base their care practice. Residents may wish to sign a summary of their care plan to confirm their agreement. Medicines prescribed by doctors are safely stored and carefully administered to residents by staff trained in this work, thereby protecting residents from medicine errors. In general Medication Administration Records (MARs) were properly kept indicating that residents receive prescribed medicines at the correct times and in correct amounts - those wishing to do so can manage their own medicines in accord with a risk assessment process; some of the currently accommodated residents manage their own medicines. This report contains some recommendations for the further improvement of medicine handling standards. When a variable dose is prescribed the Medication Administration Records (MARs) should state the amount administered on each occasion. Handwritten instructions should be signed, dated and countersigned by the author. For each resident the MAR should include the allergy status (e.g. “None known” when this is the circumstance). Prescriptions should be clear and unambiguous. In the presence of staff residents appeared relaxed, confident and at ease; staff interactions with residents were of a friendly and considerate manner and the atmosphere throughout the home was calm and tranquil. York House DS0000026895.V348666.R01.S.doc Version 5.2 Page 12 Residents are treated with respect and their privacy and dignity is protected at all times. Residents spoken with during the inspection said they get on very well with the staff; one commented “they work together wonderfully; they seem to work in twos, which is really excellent, because it’s better for them and better for me”. York House DS0000026895.V348666.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assisted to maintain as much independence as possible. Social and leisure activities are suited to the preference and ability of each resident. Contact with the local community is encouraged and visits by residents’ friends and relatives are welcomed by the home. Meals are appetising and of good quantity and quality. Most residents take meals in the large dining room on the ground floor; others receive them in their bedrooms. EVIDENCE: The inspector spoke briefly to a number of residents and at greater length with six including those who were ‘case tracked’; all expressed satisfaction with the home, including the range of activities, meal provision, staff and premises. Residents were keen to praise all aspects of York House and said, “they’ll always get anything you need” if what is wanted is not on the recently York House DS0000026895.V348666.R01.S.doc Version 5.2 Page 14 introduced ‘shop trolley’ from which residents can purchase a variety of small items including toiletries. Available activities include board and card games, crafts, painting, quizzes, and occasionally a visiting entertainer. Excursion trips are arranged; a resident explained, “They took all of us who wanted to go to the pantomime last Wednesday – we had lovely seats and a special mention from the stage and then went to the bar for a drink. It was great fun…” There is good contact with the local community, for example attendance at coffee mornings. Residents are encouraged to remain active and independent. Some take an interest in knitting and sewing. Residents said they feel free to come and go as they please and during the first visit of this inspection many residents were seen leaving and returning to York House at intervals throughout the afternoon. An interdenominational faith service is held each month and other contact with religious representatives is arranged on an individual basis, in accordance with residents’ wishes. Residents are encouraged to retain control over their own lives. All have a relative or other person who maintains contact and is in a position to assist or advise regarding financial matters. Residents personalise their bedrooms by bringing in items of furniture and pictures, ornaments etc. Meal times are a social event and all the residents spoken with said that they enjoy their meals, that their likes and dislikes are well known and that they are satisfied with the food provided. Snacks and drinks are readily available. Comments included “I think it’s very good”, “There is always a choice of the main meal and there’s always a substitute; today it was delicious – gammon and pineapple with butter beans and cauliflower and a very nice homemade soup beforehand. I like the chicken nuggets we’re having this evening. At breakfast we have our choice …I could always have a cup of tea or coffee; they bring me tea with honey…”. Visitors are welcome at any time and those spoken with during the inspection confirmed they are always made to feel welcome and placed at ease by the staff. York House DS0000026895.V348666.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure provides information on the procedure to follow to persons wishing to make a complaint; all complaints are recorded and investigated and the home has implemented an adult protection procedure and trained staff to ensure they understand how to protect the people in their care. EVIDENCE: To ensure residents and their representatives have access to the complaints procedure it is displayed in the home, included in the service user guide to the home and a copy is provided to each residents’ relative/representative. Residents know how to complain and feel confident that if they had concerns or complaints they will be listened to and taken seriously. Comments received during the inspection included “I would go straight to whoever was on duty and tell them …but I’ve never had cause to”. The home keeps records of all complaints received and investigated. Since the last inspection no complaints against the home have been received or investigated. York House DS0000026895.V348666.R01.S.doc Version 5.2 Page 16 The home has developed and implemented written policies and procedures for the protection of residents from abuse or neglect and provides staff with training in the understanding of abuse and their role in protecting residents from abuse in its many forms, including neglect. Staff spoken with during the inspection confirmed that training in safeguarding adults is provided when they first commence work in the home, and also to staff who have been in the home’s long-term employ. York House DS0000026895.V348666.R01.S.doc Version 5.2 Page 17 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortably and nicely decorated home. The home provides service users with a clean, tidy and hygienic environment to live in. EVIDENCE: Service users bedrooms are pleasantly decorated and furnished reflecting their personal tastes. During the past year a number of improvements have been made including provision of a new dining room carpet, new dining room chairs and new conservatory furniture and conservatory roof, refurbishment of five bedrooms, York House DS0000026895.V348666.R01.S.doc Version 5.2 Page 18 installation of two new showers and redecoration of the main bathroom. Outside there is a new greenhouse, the car park has been cleared of the rubble which was stored there at the time of the previous inspection and the tarmacadam surface has been renewed. There are a variety of hoists and bath aids to assist residents with impaired mobility; a passenger lift provides level access to all floors without the necessity to negotiate steps; during the inspection residents were seen using the lift unaccompanied, thereby retaining freedom to move about the home at will. The programme of ‘boxing in’ of hot water pipes and the guarding of radiators is nearing completion, to protect residents from risks of scalding. York House DS0000026895.V348666.R01.S.doc Version 5.2 Page 19 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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home employs enough staff to meet the needs of residents and to ensure their safety and comfort and maintenance of the good condition of the premises. Recruitment practices ensure the protection of residents from potentially unsuitable staff. Poor record keeping makes it hard for the managers to know which staff have received training in particular subjects, and who still needs to attend the training. EVIDENCE: Staffing levels are provided in accordance with the assessed needs of residents to ensure that at all times sufficient staff are available to properly meet their needs. Staff are enthusiastic about their work and feel they provide a good standard of care to residents and are properly supported by the management and training provision. York House DS0000026895.V348666.R01.S.doc Version 5.2 Page 20 Since the last inspection no new staff have commenced work in York House; the records of a carer who was to be employed following receipt of CRB disclosure were examined and found to contain all essential information including two written references, an interview assessment, health details and evidence of identity. A new induction training process has been recently introduced and will be first used with this ‘soon to commence’ employee. At present most of the care staff currently employed by the home hold a National Vocational Qualification in care; the home thereby meets the standard for at least 50 of the care staff to hold an NVQ in care. Since the last inspection a number of staff have attended training on dementia care; training in other subjects has also been provided but training records were incomplete, being reliant on the availability of attendance certificates because the home has not established a reliable system of record keeping. A training policy and procedure should be established, including for record keeping and guidance on subjects considered essential and the frequency at which training should be attended e.g. moving and handling, infection control at least once a year. The registered manager plans to obtain training on the recently enacted Mental Capacity Act and to thereafter share the relevant information with other staff, to ensure proper and up to date understanding. York House DS0000026895.V348666.R01.S.doc Version 5.2 Page 21 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, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of day-to-day management is generally acceptable but it is weak with regard to many essential aspects of record keeping, quality assurance and risk assessment. In consequence there is insufficient evidence that residents receive the care they need in a safe environment. EVIDENCE: The manager has many years practical experience and has the support of residents and staff; she is hampered by a lack of formal qualifications York House DS0000026895.V348666.R01.S.doc Version 5.2 Page 22 underpinning managerial skills in a care setting and finds it hard to remain up to date with current developments in the care sector. There is very little administrative support or equipment available to the manager; the home does not have a photocopier or computer to enable staff to access up to date ‘best practice guidance’ relating to the management and delivery of care and to assist with general record keeping. This has contributed to the poor standard of record keeping within the home. The home has not developed a quality assurance system designed to ensure that the opinions of service users are obtained and acted upon; since the last inspection questionnaires were issued to residents – some were completed and returned but survey findings have not been gathered and therefore the comments have not been used to inform future practise. The home should introduce an annual audit and development plan identifying aims and outcomes for service users. The home does not act in any formal capacity on behalf of residents who look after their own affairs or have a representative to assist them. Residents are provided with a lockable facility in their room for the safe keeping of valuables. York House does not manage the finances of any resident. The registered manager stated that the registered provider visits the home frequently but during recent months has not recorded formal visits – to ensure compliance with the Care Homes Act a record be made of monthly visits, carried out in accordance with Regulation 26 of the Act. Records are kept of all accidents but the home has not implemented a policy/ procedure for the investigation of accidents and for the reduction of identified risks. The accident policy/procedure should be extended to include investigation of each accident, subsequent review of the care plan and periodic audit to identify any trends e.g. time, place, person, activity, thereby ensuring that the safety of residents is promoted and exposure to known risks is minimised. Tests and checks of fire safety equipment including alarms and emergency lighting were recorded to have taken place at the required frequency. During January 2007 the registered provider recorded a fire risk assessment for the premises; examination of the document indicated that the viability of the assessment relied upon the registered manager carrying out a number of responsibilities including regular checks of flammable items. No written records were available to provide evidence that these responsibilities had been fulfilled and the registered manager confirmed that she had not previously read the document and had therefore been unaware that these tasks had been accorded her. York House DS0000026895.V348666.R01.S.doc Version 5.2 Page 23 Fire safety training is provided to all staff by the registered manager and deputy manager, but it was unclear from where these persons, acting as trainers, have themselves obtained their training and assessment as competent to train others in this specialist field. This report contains a requirement for the proper management of fire safety; there must be reliable evidence of compliance with the control measures stated in the fire risk assessment and the provision of fire safety training to staff by persons who can demonstrate their competency in this regard. A sample of documents were examined to verify safety of equipment; those for the passenger lift, hoists, gas installation and portable electrical appliances were found to be in order. During the inspection records relating to the safety of the electrical installation and water safety (with regard to bacteriological analysis) were not found; they should be obtained and copies provided to the Commission at the earliest opportunity. To protect residents, visitors and staff from risks of accidental injury there should be a thorough and comprehensive risk assessment for the general health and safety and working practices of the home be recorded and thereafter reviewed at least annually. York House DS0000026895.V348666.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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X 2 2 York House DS0000026895.V348666.R01.S.doc Version 5.2 Page 25 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 OP38 Regulation 23(4) Requirement The registered person must comply with the requirements of the Fire Authority and comply with Regulatory Reform (Fire Safety) Order 2005 and the home’s Fire Risk Assessment; there must be reliable evidence of compliance with the control measures stated in the fire risk assessment and the provision of fire safety training to staff by persons who can demonstrate their competency in this regard. Timescale for action 01/11/07 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 OP1 Good Practice Recommendations The service user guide should be made available in alternatives to the standard format and amended to include reference to the outcomes of the most recent user satisfaction questionnaire, and to accurately describe the DS0000026895.V348666.R01.S.doc Version 5.2 Page 26 York House 2. 3. OP7 OP9 4. OP30 5. 6. OP33 OP37 home’s statement regarding residents smoking on the premises. Care plans should be based on the findings of reliable assessments and should be clear and comprehensive. When a variable dose is prescribed the Medication Administration Records (MARs) should state the amount administered on each occasion. Handwritten instructions should be signed, dated and countersigned by the author. For each resident the MAR should include the allergy status (e.g. “None known” when this is the circumstance). Prescriptions should be clear and unambiguous. A training policy and procedure should be established, including clarity of record keeping and guidance on the essential subjects and the frequency at which training should be attended. There should be an annual audit and development plan for the home, reflecting aims and outcomes for service users. To ensure compliance with the Care Homes Act a record should be made of monthly visits, carried out by the registered provider in accordance with Regulation 26 of the Act. The accident policy/procedure should be extended to include investigation of each accident, subsequent review of the care plan and periodic audit to identify any trends. 7. 8. OP38 OP38 Records relating to the safety of the electrical installation and water safety (with regard to bacteriological analysis) should be obtained and copies provided to the Commission at the earliest opportunity. To protect residents, visitors and staff from risks of accidental injury a thorough and comprehensive risk assessment for the general health and safety and working practices of the home should be recorded and thereafter reviewed at least annually. York House DS0000026895.V348666.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 York House DS0000026895.V348666.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. 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!