CARE HOMES FOR OLDER PEOPLE
York House Old Bank Road Dewsbury West Yorkshire WF12 7AH Lead Inspector
Karen Summers Unannounced Inspection 30th January 2006 09:00 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.V254517.R01.S.doc Version 5.1 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.V254517.R01.S.doc Version 5.1 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 Ms Patricia Yarnold Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places York House DS0000026300.V254517.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 7th November 2005 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. York House DS0000026300.V254517.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report refers to an unannounced inspection at the home on the 30th of January 2006, and the duration of the inspection was 4.75 hours. Mrs J Davy & Ms Gill, deputy managers were present at the inspection, and five service users, and a district nurse were also spoken with. The following methods have been used in the production of this report: examination of a sample of documents including care records, and medication. The inspector would like to thank residents and staff for their time and hospitality throughout the inspection. What the service does well: What has improved since the last inspection?
The complaints procedure has been amended and informs people that their complaint will be dealt with within 28 days. The kitchen staff now calibrate the food probe used for testing hot and cold food items. Cleaning materials are stored correctly. Fire drills are taking place on a regular basis to include all staff, and records are been maintained. York House DS0000026300.V254517.R01.S.doc Version 5.1 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 DS0000026300.V254517.R01.S.doc Version 5.1 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.V254517.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&5 No resident moves into the home without having had his/her needs assessed and been assured that those needs will be met. Prospective residents and their relatives have an opportunity to visit and assess the quality, facilities and suitability of the home. EVIDENCE: Wherever possible prospective residents and their relatives are encouraged to visit the home and stay for a meal, before deciding to live there. Residents’ needs are assessed prior to admission, and once the manager is satisfied that they can meet the resident’s needs; they are offered a place at the home. York House DS0000026300.V254517.R01.S.doc Version 5.1 Page 9 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): 9 &10 Residents, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Residents feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Staff are in the process of changing the care documentation onto a new system. The information was comprehensive and will be inspected more fully at the next inspection when the new system has been fully implemented. Medication housekeeping was of a good standard, and the audit carried out was correct. Those residents who wish to self-administer their medication are allowed to due so, and appropriate records are maintained. Staff were seen to respond to residents in a kind and respectful manner. York House DS0000026300.V254517.R01.S.doc Version 5.1 Page 10 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 - 15 Due to insufficient documented evidence it was not possible to make a judgement that service users’ interests and recreational activities are met. A variety of meals are offered that take into account the likes and dislikes of the service users. EVIDENCE: Residents’ interests are recorded, and those spoken with confirmed that they are given opportunities for stimulation through recreational activities. Activities that the resident has been involved in prior to admission are also maintained wherever possible. One resident spoke of how she continues to enjoy going to the weekly social club for the blind. A number of entertainers visit the home each month and include; An aromatherapist, hairdressing twice a week, motivation to music, exercises with Heather, vocalists, bingo, church services, arts & crafts. The organised events i.e. when entertainers visit the home, the resident’s involvement is recorded however, activities that the resident takes part in on a daily basis are not recorded. Staff should provide evidence, on a daily basis, that residents are given opportunities for stimulation through leisure and recreational activities. Menus were inspected and offered variety and choice and residents commented on how lovely the food was.
York House DS0000026300.V254517.R01.S.doc Version 5.1 Page 11 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): The standard were not inspected however, the recommendation from the last inspection was. (Standard 16) EVIDENCE: The complaints procedure now includes the timescales for responding to complaints. York House DS0000026300.V254517.R01.S.doc Version 5.1 Page 12 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): The standards were not inspected however, the recommendations from the last inspection were. (Standards 19 & 26) EVIDENCE: Standard 19 – The registered person is requested to confirm in writing when the outstanding fire safety work will be complete. Failure to comply may lead to further action being taken. - The kitchen staff now calibrate the food probe used for testing hot and cold food items. Standard 26 – Cleaning materials are stored correctly. - The registered person should consider employing a designated laundry person, or allocate a carer to carry out the laundry duties each shift/ day. These hours would be extra to care duties. This recommendation remains outstanding from the last insepction.
York House DS0000026300.V254517.R01.S.doc Version 5.1 Page 13 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): 28 In relation to Staff training, (NVQ’s,) service users are in safe hands at all times. The remaining standards were not inspected however, the recommendations from the last inspection were. (Standards 29 & 30) EVIDENCE: 64 of staff have an NVQ 2 or equivalent. Standard 29 – The deputy manager confirmed that future information relating to CRB declarations would be documented. Standard 30 – A new member of staff is due to commence work and an induction programme has been arranged. York House DS0000026300.V254517.R01.S.doc Version 5.1 Page 14 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 The residents benefit from the management approach of the home and the registered manager ensures so far as is practicable that the health, safety and welfare of service users and staff are protected. The remaining standards were not inspected however, the recommendations from the last inspection were. (Standards 33 & 38) EVIDENCE: Ms P Yarnold, the manager, has many years experience in the care of older people, and has completed an NVQ level 4 in management and care. Standard 33 – Quality audits – An audit had not been carried out since the last inspection however Joanne Davy, deputy manager, is aware of the information that should be included in future audits. York House DS0000026300.V254517.R01.S.doc Version 5.1 Page 15 Standard 38 - Fire drills – are now been recorded and Joanne, the deputy manger confirmed that all staff have had a drill. She is also aware that all staff should have two drills a year. York House DS0000026300.V254517.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 1 X X X X X X 2 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X 3 York House DS0000026300.V254517.R01.S.doc Version 5.1 Page 17 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 The organisation must provide the CSCI with an action plan outlining when the outstanding fire safety work will be completed. Timescale for action: 30/11/05 - Not addressed. You are requested to confirm in writing by 21/02/06 when the work will be completed. Timescale for action 21/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations Standard 12.3 - Staff should provide evidence on a daily basis that service users are given opportunities for stimulation through leisure and recreational activities. - The registered person should consider having a designated carer to carry out activities on a daily basis.
York House DS0000026300.V254517.R01.S.doc Version 5.1 Page 18 2. OP26 The registered person should consider employing a designated laundry person, or allocate a carer to carry out the laundry duties each shift/ day. These hours would be extra to care duties. The quality audits need to include the source of evidence. 3. OP33 York House DS0000026300.V254517.R01.S.doc Version 5.1 Page 19 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
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