Inspection on 25/07/05 for York House

This inspection was carried out on 25th July 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 15/12/05

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 Chris Handley Announced 25 July 2005 9.30am 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 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 I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service York House Address 47 Norwich Road Dereham Norfolk NR20 3AS 01362 697134 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Black Swan International Limited Celia Joy Hart Care Home 31 Category(ies) of Old age (31) registration, with number of places York House I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Thirty-one (31) older people may be accommodated. Date of last inspection 11 January 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 I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out as part of the annual inspection programme. Preparatory work had previous undertaken. A total of 3 comment cards had been received from residents. On the morning of the inspection there were 27 residents in the home, five of whom were interviewed and were supplied with information cards which detail the role of the CSCI. There were 10 staff on duty 6 of whom were interviewed. The Manager Mrs Hart, and the Director Mr Clive Hill were present for the inspection, and accompanied the Inspector on a brief tour of the home. Four visitors were briefly spoken to. What the service does well: What has improved since the last inspection? This is the first inspection by this inspector, so improvements are hard to identify. York House I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 Page 6 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 I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection York House I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 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 standard(s) 1,2,&3. The home provides prospective residents with information which is of a high quality. The terms and condition/contract is clearly set out and contains all the information required. A pre-admission assessment is carried out on all prospective residents. EVIDENCE: The Statement of Purpose and Service Users Guide was seen and briefly read by the Inspector It contains all the information required. A large print copy of this document is available if needed. All residents are supplied with a contract, and relatives are frequently involved in this matter. If needed staff assist residents in their understanding of this document. Some residents have retained their contract others have passed them to their relatives The office retains a signed copy of this document. York House I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 Page 9 A pre-admission assessment is carried out on all prospective residents by the Manager or Senior Carer. The Manager showed the Inspector the Identity card which she carries on these occasion. This contains all the information required and would protect the Manager and Company. Having read the assessment the Inspector recommends that Depression which is not uncommon in the elderly, is added to the mental health assessment part of the document. York House I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 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 standard(s) 7, 8 & 9 Al residents have an individual care plan. The health care needs of residents are met. The medication system is safe and effective. EVIDENCE: Three sets of care plans were read by the Inspector. The plans are contained in individual A4 folders with the residents name and “This file is Confidential” written clearly on the outside. Each file is separated with dividers and there is a numbered index at the front. The management of these documents is good. The entries in many parts of the care plans are typed. Where hand written the writing is neat and legible. There is an assessment plan, implementation and review. The residents and relatives are involved in the review process. Some residents spoken to by the Inspector were aware that the “Staff have our Records”. A Risk Assessment ,weight record, visits by Doctors/Nurse is maintained. There is also a risk assessment for those who self medicate. The home has the good practice of maintaining a Daily record, these were legible dated and signed, and provided a brief record of the resident day/night. The files are kept in the office which is locked when not in use. York House I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 Page 11 All residents have a G.P. the Manager said. A wide range of personal care is provided in the home. If needed the G.P. would refer residents to other specialist. The District Nurse visits the home on a regular basis, with whom the home enjoys a good working relationship. The Chiropodist visits the home every six weeks, Optical service are provided. The Dietician has visited the home to view the menus. There are 6 residents who have Diabetes, 3 of whom require Insulin and they attend the Diabetic clinic at the local hospital. At present there are no residents who have pressure sores the Manager said. The Inspector advises that staff receive training in the prevention of pressure sores which are very painful and distressing to residents. The Incontinence Advisor visits the home on a regular basis. Staff have received training in this important area of care. The Inspector was shown the medication system by the Manager. The home has a medicine room which is kept locked. As this room is on the ground floor there is a metal grill over the window. The medicines are kept in a locked designated medicine trolley. In order to further enhance the security of this trolley, it is recommended that it be kept locked to the wall when not in use. The contents of this trolley was neat and tidy. The home uses the Boots Monitored Dosage System, which is relatively new to the home and the Manager said that staff were just in the process of getting accustomed to the new system. The Inspector saw neatly initialled records of administration of medicines. Staff who administer medicines have received training for this. There were Controlled Drugs in the home on the day of the Inspection, and one was counted, and found correct against the Controlled Drug Register. If staff had any concerns about the effects of medicines on residents, they would contact the prescribing Doctor. The home enjoys a good working relationship with the supplying pharmacy. There is one resident who self medicates, and there are guideline for this. The home has a detailed medicine procedure which was briefly read by the Inspector. The home has the good practice of having medicines reviewed on a regular basis, and the Inspector recommends that these reviews should be entered on the Daily record. York House I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Visitors are welcomed to this home, and enjoy good relationships with staff. Residents have a wide range of choice in their daily life. The home provides a good catering service. EVIDENCE: The routines of daily living are made as flexible as possible the Manager said and this was confirmed by the residents spoken to. They exercise choice in the times that they get up or retire, the choice of food, and choice of friendships. Representatives of various religious organisations call to the home on a regular basis. Some residents go out to the shops with relatives and one resident goes to the local pub. There are activities provided in the home but the Inspector suggest that the interests of the residents could be broadened by the home arranging to have a member of staff specifically trained in activities for older people, and recommends that this should be done. York House I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 Page 13 Visitors are welcomed at any reasonable time the Manager said, late night visiting can be done be arrangement. Residents are able to choose who they see or don’t see, the Manager said. Residents may receive their visitors in private and on the day of the inspection some visitors were seen in residents rooms and others saw their relatives in one of the lounges. Based on his observation the Inspector got a strong impression that staff have a close working relationship with visitors and appreciate their importance to the residents. The Inspector introduced himself to several visitors, who all spoke well of the staff and the care they provide. The visitors are warmly welcomed and by residents who obviously enjoy their presence and there was laughter and good humour in one of the lounges, between the residents and their visitors. Other visitors to the home include representative of religious organisation. Residents have a choice in many areas of their life. They choose when they get up or retire the Manager said they have a choice as to whom they see or mix with. Residents handle their own money where ever possible, some with the assistance of their relative. If needed advocacy services would be contacted. Residents bring in items of furniture, and many of these were seen by the Inspector. Residents told the Inspector who the people were on some of the family photographs seen. Residents told the Inspector that they have many choices, what to wear, when to have their hair done, and other personal and important features in their daily life. Residents do have access to their records which are kept safely in the office which is locked when not in use. The menus were seen by the Inspector they were nutritious, interesting, and varied. The Menu is displayed in the sitting rooms so that residents can see in advance for is for the next meal. Special Diets are provided and this is recorded on the Menu. The home maintains a list of likes and dislikes, and if the meal of the day is one that the individual does not like they are provided with a choice. The Inspector recommends a comprehensive choice is offered, i.e two menus possibly on the previous day from which the residents can choose, this would provide clear choice for the individual, and not just a “Replacement“ as it were. If needed the Dietician advice is sought. Residents spoke very highly of the meals provided, and said that they were very nice, always hot, and there that there was always enough. Mealtime are unhurried and the Inspector discreetly observed residents taking their mid day meal. York House I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17,&18 Residents are aware of how to make a complaint. The legal rights of residents are protected. Staff are aware of the importance of Adult Abuse awareness. EVIDENCE: The home has a complaints procedure which was seen by the Inspector. Residents interviewed knew how to make a complaint if they needed to. There have been no complaints since the last inspection. In order to make this important document more available within the home the Inspector recommends that a copy of this document be displayed in both lounges in the home. The legal rights of residents are protected. The Manager would facilitate legal advice if this were required, Residents choose to exercise their legal rights and the Inspector was informed that approximately three quarters of them voted at the last election some using postal votes others going to the polling station, the Inspector was informed. York House I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 Page 15 There have been no case of Adult Abuse the Manager said. The staff interviewed were aware of the importance of preventing abuse and knew what steps to take if they thought it was taking place. They were also aware that these matters were not always obvious and that this meant that they must be alert to the possibility that it may occur. Staff have received certificated training in this matter, and since then they told the Inspector that they were more alert to the possibility of this taking place. The home has a detailed and comprehensive policy on this matter, which was seen by the Inspector. York House I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 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 standard(s) 19,25 The location and layout of the home is suitable for its purpose. EVIDENCE: The home is located adjacent to the centre of Dereham with its shops and facilities, and is on a bus route. There is car parking in the grounds. It location makes it easy for visitors to get to the home. There is a programme of routine maintenance of the fabric which was seen by the Inspector and there is also a Handy man’s message book in which minor repairs are recorded for the attention of the handyman. The Inspector undertook a tour of the home with the Manager and noticed that whilst the internal environment was of a good standard there was signs of wheel chair damage on the corridor walls and doors ,and recommends that this be repaired/redecorated. The Inspector also saw a hospital type screen in a double rooms and recommends that this be replaced with curtains for safety reasons. York House I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 Page 17 The Inspector visited a room which it is intended to bring into use. There is still a good deal of work to be done on this room, and it not ready to be registered. The Director undertook to contact the Inspector when the work had been completed, and the room was ready for use, the Inspector would then revisit the home to inspect the room with a view to registering it. York House I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29, & 30 The residents needs are met by the numbers and skills of the staff. The home has an NVQ training programme in place. The home provides a wide range of training. EVIDENCE: There are 4 care staff, 2 domestic staff, 1 house keeper, 1 cook and 1 Kitchen Assistant on the morning shift 7am – 2pm. There are 3 care staff on the afternoon shift. The Manager works across shifts 8 – 5pm. There are 2 staff the night shift, and the Manager is on call. The Inspector spoke to eight staff during the day, including the handyman. They outlined the training which they had received whilst being employed in the home. All the staff interviewed expressed their love of caring for the residents. The comment cards spoke well of the staff as did the residents. “Nothing is too much for them” said one. During the process of the inspection the Inspector frequently saw staff dealing with residents and it is clear based on these observations that they do have a close relationship with each other. The visitors to the home also spoke very well of the staff. York House I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 Page 19 The home has an NVQ training programme in place. The figures provided by the Manager were 4 taking NVQ II, and 6 have taken NVQ III. On this basis there are currently 8 members of staff who have NVQ training this represents 66.7 of the care staff. On this basis this means that the home has achieved the target required 50 , and are commended for this and are urged to continue with this training. When staff have completed their NVQ, they are paid a bonus the Inspector was informed. The staff and the Company are commended for this training programme as it bodes well for the quality of care provided. When interviewing staff they told the Inspector that they were very pleased to have undertaken this training. The home operates through a recruitment procedure based on equal opportunities and the protection of the residents. The home’s detailed recruitment procedure ,which is of a high quality, and was seen by the Inspector. Police and POVA checks are undertaken. Two references are obtained. An application form is completed. Staff are provided with a copy of 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. At present interviews are carried out by one person and the Inspector recommends that there should always be at least two persons involved in interviewing. The home has Induction and Foundation training programmes which meet the NTO training targets. Other training provided includes Basic First Aid, Basic Food Hygiene, Moving and Handling, Fire Safety, Adult Abuse – Basic Awareness, Health and Safety, Medication, Infection Control, and Diabetes Awareness. The Inspector recommended that Catering staff, Domestic staff and the Maintenance man undertake Fist Aid training, because of the potential dangers of their job, and also of the possibility of finding residents who may have fallen in their room. York House I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35,36,37, & 38 The home holds records securely. The home has all the documentation required by Standard 38. EVIDENCE: The home has a quality assurance system in place. Audits are taken on a regular basis and the results of these are passed to Headquarters and it can than be seen where services meet/or do not meet the standard required. This ongoing process then continues to ensure that the quality of service continually improves. York House I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 Page 21 The home holds money on behalf of residents. The money is kept in separate containers, which are kept in the safe, the key of which is held by the Manager. The content of one of the containers was counted and found to be correct against the record. The record of these monies is detailed and the recordings are very neat. The Manager explained how the system works and the home has a written procedure for this. At present when monies are handed in a receipt is not provided, and the Inspector recommends that a numbered receipt be provided when money is handed in. All staff receive supervision which covers practice, philosophy of care, and career development needs. A wide range of records required by regulation were seen during the process of this inspection. The records are held secure. The Inspector and Manager carefully went through all the elements of Standard 38, and the home has them all. All accidents injuries and incidents are reported. Staff receive induction and foundation training which meets TOPPS specification. York House I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x 3 x STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 x 3 x 3 3 3 3 York House I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 Page 23 None Are there any outstanding requirements from the last inspection? 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Refer to Standard 3 8 9 16 29 30 35 19 19 15 Good Practice Recommendations It is recommended that Depression be added to the Mental Health Assessment of the pre-admission document. 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 record is made in the Daily Record when medicines are reviewed. It is recommended that a copy of the complaints procedure is displayed in both lounges. That there are two persons conducting interiews. It is recommended that catering staff, domestic staff and the maintenace man are provided with First Aid training. It is recommended that numbered reciepts are provided when monies are handed in. It is recommended that the wheel chair damage on the walls and corridors is repaired. It is recommended that the bed screens are replaced with curtains. A more comprehensive system of choic of menus is developed, and implemented. I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 Page 24 York House York House I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection 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 I55 S55141 York House V233493 250705 Stage 4.doc Version 1.30 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. 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