CARE HOMES FOR OLDER PEOPLE
York House 8-10 Cauldon Avenue Swanage Dorset BH19 1PQ Lead Inspector
Mike Dixon Unannounced Inspection 31st January 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address York House DS0000026895.V280238.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 DS0000026895.V280238.R01.S.doc Version 5.1 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.V280238.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 4th July 2005 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 about one mile from Swanage town centre and the amenities therein, which include a G.P surgery, community hospital, High Street shops and banks, a post office and places of worship. Accommodation is provided over three floors, all of which are serviced by a passenger lift. All communal lounges and dining areas are on the ground floor, along with the kitchen and managers office. There are 30 bedrooms in the home, two of which are currently 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, registered providers, have owned York House since 1988. The home has a registered manager, Mrs Street, who is supported by the Deputy Manager, Mrs Dyke and Assistant Manager, Mrs Parham. York House DS0000026895.V280238.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted as part of the Commission’s regulatory duty to inspect all care homes twice a year. The purpose was to review the home’s progress in implementing the requirements and recommendations from the previous inspection report. The purpose was also to assess the home’s compliance with the remaining key national minimum standards for older persons that had not been considered during the previous inspection visit. In order to obtain a fuller picture of the home the reader should refer to the earlier inspection report dated 4th July 2005. During the visit which lasted six hours the inspector spoke with eight service users, the manager, assistant manager and six staff members. He looked round the accommodation, observed practice and inspected records relating to service users’ care, staffing and medication and other documentation relating to the running of the home. Prior to the inspection, comment cards were sent to the home for distribution to a variety of people who have an association with the home. At the time of publication of the report the Commission had received a total of three responses, one from a service user, one from a GP practice and one from a social care professional. What the service does well:
The home liaises well with the GP surgery and primary care team and ensures that service users receive the health care services that they need. Staff assist service users to keep well and as active as feasible, within the limits of service users’ capabilities. Service users are encouraged to retain control over their lives, pursue their own interests and maintain contact with the local community. There is a varied programme of activities, including board games and periodic outings, and several service users enjoy this provision. Staff respect service users’ privacy and treat them with respect. The inspector observed staff approaching and interacting with service users in a supportive manner. The premises are being maintained in a reasonably good condition. There are plans in place for further refurbishment and upgrading of the passenger lift. The home is warm, clean and free from unpleasant odours and provides a comfortable environment for service users. The laundry provision meets with the approval of service users. The majority of the care staff members have attained a nationally recognised qualification, NVQ level 2. Service users have a high opinion of the staff, as
York House DS0000026895.V280238.R01.S.doc Version 5.1 Page 6 evidenced by the following comments that were made by service users during the course of the inspection: “we’re well looked after”, “the staff are very good” and “I think the staff are wonderful”. The service users and staff have confidence in the management team; there is an “open” style of management at the home and people are happy with the way in which the home is run. There are suitable arrangements in place to assist service users with managing their finances, where such a need arises. What has improved since the last inspection?
The home has fully implemented six of the eight requirements from the previous inspection report and has mainly implemented the remaining two. All five recommendations have received attention. There is a new and comprehensive statement of purpose and service user guide which complies with regulations. The manager informed the inspector that copies were made available to service users and/or their representative. Pre-admission assessments are now carried out and recorded for prospective service users so that the home is able to ascertain that it is in a position to meet people’s care needs. Care plans are reviewed on a regular basis and amended to reflect the changing needs of the service users. In most cases there is now recorded evidence to show that service users and/or their representative have been consulted regarding their care plan. The three recommendations made regarding medication arrangements have been addressed: risk assessments for self-medicating service users have been amended, “carried forward” balances are recorded on the medication administration record for medicines not contained in the blister packs (in order to assist with an audit trail) and a secure cabinet has been suitably fixed to a solid wall for the safe keeping of controlled medication. Service users were consulted about the quality of the meals in a survey conducted in July 2005. During the course of this inspection the majority of people with whom the inspector spoke commented favourably on the topic, although a minority were less than enthusiastic about the food quality or variety. Views expressed by service users ranged from “the food is very good, they always give an alternative” to “the food’s not bad on the whole”. The management has made some adjustment to staff rosters to maximise the amount of time staff spend with service users. During the course of this inspection all service users with whom the inspector spoke confirmed that they received the assistance that they required from staff. Radiator covers have been fitted in the rooms of service users whom the management has assessed as being at high risk. Risk assessments have been
York House DS0000026895.V280238.R01.S.doc Version 5.1 Page 7 recorded with regard to this topic for other service users and these assessments take account of most of the necessary aspects of health and safety. Appropriate measures are now being carried out for the recruitment of new staff, including a police/POVA check via the Criminal Records Bureau and the receipt of two references. What they could do better:
There are ten requirements, eight recommendations and two suggestions arising from this inspection visit. The home must complete the process of consulting service users and/or their representative about the content of their care plan. For new service users this exercise should be completed as soon as practicable following admission. A risk assessment regarding the prevention of falls must be drawn up either prior to the admission of a new service user or as soon as practicable following admission. Regular monitoring of service users’ weight should take place in accordance with service users’ wishes and the findings of the nutritional assessment. Service users should be advised in writing that they may access their personal records within the terms of the Data Protection Act 1998. The adult protection policy/procedure should be amended to inform staff not to commence an investigation until advice has been obtained from Social Care and Health. Staff should attend the training provided by Dorset County Council on the topic of adult protection. Oxygen warning signs must be displayed on doors of rooms where oxygen is stored or used. Risk assessments carried out in respect of unguarded radiators must be expanded to include consideration of radiators accessed by service users in communal areas. Improvements to the documentation of the induction and foundation programme for new staff are required. All staff members must receive emergency first aid training and all who handle food must receive basic food hygiene training. The training needs of each staff member should be assessed periodically at supervision sessions or at an annual appraisal. The registered manager must achieve a qualification in the management of care that is recognised as being equivalent to NVQ level 4 by 30/9/07. She must undertake periodic training in care-related topics in order to evidence that her practice is in keeping with developments in this field. The registered provider must compile a report on the conduct of the home each month and send a copy to the Commission. It is suggested that the option of setting up periodic residents’ meetings is explored with service users, perhaps on the next occasion when a service user
York House DS0000026895.V280238.R01.S.doc Version 5.1 Page 8 survey is conducted. The scope of the annual survey of service users’ views should be broadened to include relatives and friends and visiting professionals. There should be an annual audit and development plan for the home, reflecting aims and outcomes for service users. The home’s policies/procedures should be reviewed at least annually to ensure that the information within them is upto-date and reflects expected practice. Care staff should receive one-to-one supervision on the basis of one session every two months. A copy of staff qualifications and proof of each person’s identity (e.g. birth certificate or passport) must be retained at the home. It is suggested that staff training files are organised in such a way as to make the information more readily accessible. The record of fire instruction to staff must include a note of the content of each session. There should be a qualified first aider on each shift. 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 DS0000026895.V280238.R01.S.doc Version 5.1 Page 9 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.V280238.R01.S.doc Version 5.1 Page 10 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): None of these standards were considered during the inspection. EVIDENCE: York House DS0000026895.V280238.R01.S.doc Version 5.1 Page 11 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 and 10 Care plans are generally comprehensive but they do not yet consistently demonstrate that the content is in accordance with service users’ wishes. Risk assessments need to be conducted promptly and updated following an incident so that staff are fully informed of service users’ circumstances. The home liaises effectively with the primary health care team and ensures that residents’ health care needs are met. Some additional measures are recommended with respect to the monitoring of service users’ weight in order to better safeguard service users. In most respects medication arrangements comply with guidance but an additional safety measure is necessary regarding the storage of oxygen. Staff treat service users with respect and dignity, promoting service users’ feelings of worth as valued members of the household and community EVIDENCE: Each service user has a care plan which is kept under review. The home has made progress in asking service users and/or their representative to sign the care plan or review sheet as evidence of consultation. However, there were a
York House DS0000026895.V280238.R01.S.doc Version 5.1 Page 12 few examples where this had not yet happened. Risk assessments are conducted in relation to a number of areas, including the prevention of falls. In one example looked at by the inspector the assessment had not been carried out until a month after the service user had been admitted to the home, although the pre-admission assessment had indicated that the person in question was prone to falling. Following a subsequent fall the risk assessment had not been “revisited” to ensure that it still accurately reflected the service user’s circumstances. The home enjoys good support from the local GP surgery and primary care team. Some service users go to GP appointments; in most cases home visits are made. The GPs conduct regular reviews of service users’ medication. Any nursing input is provided by the community nurses. Staff assist service users to attend hospital appointments if relatives are not able to do so. In discussion with the inspector service users confirmed that the home called their GP on their behalf, if the need arose. Service users have access to the health care resources that they might need, including hearing and sight tests and dental treatment. Staff assist service users to remain physically active, where feasible, and mentally alert through discussion and participation in an activities programme. A nutritional assessment is conducted on each service user, following admission. The management refer service users to the GP if they are concerned about a service user’s health, e.g. loss of weight. Currently, there is no arrangement in place for the regular weighing of service users and the inspector recommended that this be addressed by conducting a risk assessment which takes into account service users’ wishes. The home has taken action to address the recommendations from the previous report regarding medication. The one aspect that the inspector noted concerned the arrangements for the storage of an oxygen cylinder which a service user self-administers; additional safety precautions are required for this provision. Service users have the choice of where they spend their time, either in their bedroom or in one of the several communal areas. Those who smoke may do so in the front conservatory. There is some flexibility with bathing arrangements for those service users who require assistance. Service users informed the inspector that their privacy was respected, e.g. staff knock on their door before entering, they may lock their door if they choose. Service users may make or receive phone calls in private and they receive their mail unopened. Staff were observed to approach and talk with service users in a respectful manner. York House DS0000026895.V280238.R01.S.doc Version 5.1 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 and 14 The home offers a varied programme of activities, thus providing a stimulating environment for service users. The home encourages service users to pursue their interests and preferred lifestyle where feasible, enabling them to retain some measure of control over their lives. The home makes arrangements which enable service users to have their spiritual needs met. EVIDENCE: The programme of activities includes the following: board and card games, crafts, painting, quizzes, a visiting entertainer every three months and periodic outings to places of local interest by minibus. Views expressed to the inspector regarding the programme during the inspection were generally favourable; service users choose which activity they take part in. Outings, in particular, appear to be popular. Several service users pursue their own interests and make their own social arrangements. There is good contact with the local community, e.g. attendance at coffee mornings. Service users are encouraged to remain active and independent. Some take an interest in knitting and sewing (e.g. carrying out minor repairs to staff uniforms). During the course of the inspection a few service users played a board game with a staff member and others went out for part of the
York House DS0000026895.V280238.R01.S.doc Version 5.1 Page 14 day, making their own arrangements. Service users informed the inspector that they felt free to come and go as they pleased. An interdenominational Holy Communion service is held each month and other contact with clergy is arranged on an individual basis, in accordance with service users’ wishes. Service users 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. Service users are able to personalise their bedroom by bringing in items of furniture or other features of interest. Service users may access their personal records but information on this subject is not included in the written information that is provided to service users. York House DS0000026895.V280238.R01.S.doc Version 5.1 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The measures in place for responding to allegations of abuse do not entirely comply with guidance and therefore do not provide service users with full protection. EVIDENCE: The home has policies/procedures relating to adult protection (prevention of abuse) and “whistleblowing” and a copy of the “No Secrets” guidance from Dorset County Council, all of which documents are available for staff to read. The adult protection policy/procedure is in need of some amendment to ensure that the advice accords with locally agreed procedures. Staff have received inhouse training on this topic and a record of such training has been retained. In discussion with the inspector, there was some lack of clarity by staff about this topic and it is recommended that staff attend a training session that is provided by Dorset County Council. York House DS0000026895.V280238.R01.S.doc Version 5.1 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26 The accommodation is maintained in a reasonably good condition. The rooms and areas that are accessed by service users are warm, clean and odour-free, providing a pleasant and comfortable environment for service users. Laundry facilities are sufficient to provide service users with clean clothing and linen. EVIDENCE: The accommodation is being maintained in a reasonably good condition. Although there is no recorded plan for refurbishment/upgrading there is an ongoing programme which has included the redecoration of the outside of the building and the refurbishment of bedrooms as they become vacant. The woodwork in corridors is showing signs of wear and this aspect is to be addressed this year. Carpets are in a safe condition. In a few places joins are fixed in place by tape; in the dining-room the tape has worked loose in one place. The main project for this year is upgrading the passenger lift, work which is desirable in view of the number of occasions when it fails to operate.
York House DS0000026895.V280238.R01.S.doc Version 5.1 Page 17 Visits have recently been conducted by the environmental health and fire officers. The home has now complied with the majority of requirements/recommendations contained in their reports. There are records in place to evidence the regular servicing of such services and facilities as the hoist, bathing aids, gas boiler, electrical installations, portable electrical appliances and fire precaution system. The home was warm; there is central heating with thermostatic controls on radiators. Service users informed the inspector that the home maintained a comfortable temperature in times of cold weather. The programme of fitting guards to radiators has continued and there are now guards in several bedrooms, including where particular service users are considered to be at high risk. Risk assessments are recorded in respect of each service user and his/her bedroom. The assessments do not take into consideration the location of unguarded radiators in corridors. For example, the corridor radiators in the vicinity of bedrooms 1 and 2 on the ground floor and rooms 27-29 on the top floor were very hot. The home was very clean and there were no unpleasant odours. All service users and the visitor with whom the inspector spoke on the subject said that their rooms were kept clean and that their bed linen was regularly changed. With one exception all service users praised the laundry provision, saying that clothing was quickly and efficiently laundered. The cleaner and laundry assistant on duty informed the inspector that they had all the necessary resources to carry out their work. York House DS0000026895.V280238.R01.S.doc Version 5.1 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 and 30 The home promotes the achievement of nationally recognised care qualifications and has built a staff team that enjoys the confidence of residents. The home encourages staff to receive training but further work is needed to complete the training programme and to evidence the progress made by new staff in the first six months of their employment. EVIDENCE: The manager reported that eleven of the sixteen care staff members had attained a nationally recognised care qualification at NVQ level 2. Certificates were in evidence for some of the people in question. A further three staff members are now preparing for NVQ level 3. From views expressed by service users during the course of the visit it is evident that they hold the staff in high regard. Comments such as “we’re well looked after”, “the staff are very good” and “I think the staff are wonderful” represent the comments made to the inspector. A staff training programme is in place which in the recent past has included manual handling and a session on MRSA and related infection control procedures. There are some shortfalls with the provision. There was no recorded evidence of an induction or foundation programme for three care assistants who had been employed at the home for nearly a year. Some staff members had not received basic first aid or food hygiene training. On the other hand, staff members with whom the inspector spoke, who included two
York House DS0000026895.V280238.R01.S.doc Version 5.1 Page 19 people who had trained as nurses in their country of origin, were confident that they had the necessary knowledge and skills to provide care for the service users who are currently living at the home, many of whom remain relatively independent. The individual training needs of staff members are given some consideration during the course of supervision sessions but some further clarity on this subject would put the home in a better position to demonstrate how it is developing the skills of the staff team. York House DS0000026895.V280238.R01.S.doc Version 5.1 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36, 37 and 38 The manager is experienced and has the support of service users and staff; her lack of formal qualifications limits her ability to evidence attainment of managerial skills in a care setting. There is an open style of management at the home which enables service users and staff members alike to feel confident about raising issues. The lack of a formal quality assurance system limits the extent to which the home is able to demonstrate how it meets the expectations of service users and achieves its stated aims and objectives. The home has the necessary arrangements in place to safeguard service users’ finances. A few shortfalls with the health and safety provision at the home mean that service users’ welfare is not fully safeguarded. York House DS0000026895.V280238.R01.S.doc Version 5.1 Page 21 EVIDENCE: The registered manager has many years experience of running a care home. She does not hold a formal qualification in management or care, qualifications that managers were expected to have attained by 31/12/05. She does not wish to undertake such a commitment at this stage of her career. The deputy manager is currently working towards achieving NVQ level 4 in management and care. The manager keeps abreast of current care practice issues by reading journals. She has a job description which reflects her level of responsibility. She shares the day-to-day management duties with the deputy and assistant managers. The management structure is explained in the home’s statement of purpose. It is a requirement that managers of care services hold a nationally recognised qualification as evidence of their competence of management. It is also a requirement that the registered provider produce a report on the conduct of the home each month and send a copy to the Commission; these reports have lapsed in the past few months. Staff told the inspector that they had the opportunity to raise issues and to share ideas at shift “handover” meetings or during the course of breaks from work. The manager and her colleagues are considered to be “approachable” and to provide good leadership. There are no formal staff meetings but it appears that there is good communication between staff members who work well as a team. Service users also say that they are happy to discuss problems or raise issues with any member of the management team. The underlying ethos of the home is one of informality of relationships at all levels and there are no formal systems in place for service users to participate in decision-making, other than periodically completing a questionnaire. The inspector suggested that service users might be given the option of holding residents’ meetings; such a possibility might be put to service users the next time a survey of views is sought. A comprehensive formal quality assurance system is still some way from fruition, although a survey of service users’ views was conducted in July 2005. Informally, the management discusses issues with relatives, staff and visiting professionals but at present there is no mechanism for the home to receive and record views from these sources, e.g. via a questionnaire. However, views expressed to the inspector from a variety of sources indicated a high level of contentment with the home. The management does not have an annual development plan and policies and procedures are not reviewed routinely on at least an annual basis. The home does not act in any formal capacity on behalf of service users who look after their own affairs or have a representative to assist them. Cash is
York House DS0000026895.V280238.R01.S.doc Version 5.1 Page 22 held in a secure place for a small number of service users. Records are kept of all transactions and receipts are retained, where appropriate. Service users are provided with a lockable facility in their room for the safe keeping of valuables. Staff informed the inspector that they felt well supported by the management and that they could approach any one of the management team for advice and guidance. Staff receive one-to-one supervision and the outcome of each session is recorded. Formal supervision has lapsed in recent months and the manager undertook to address this issue. Some of the records seen by the inspector were to a good standard, e.g. medication records, some aspects of care and fire records. There were a few shortfalls with staff records and not all the relevant information was readily accessible. The management support the staff and service users in maintaining a safe environment. There is equipment to enable staff to transfer service users safely. Staff are provided with protective clothing. Risk assessments are conducted in relation to a range of topics relating to health and safety. Accidents are recorded. Some of the relevant staff training is currently being provided, including fire instruction, although the records are not complete in all area. A few shortfalls with home’s provision and approach to this topic have been identified earlier in the report, in relation to Standards 7, 25 and 30. York House DS0000026895.V280238.R01.S.doc Version 5.1 Page 23 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 x X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 X X X X X 2 3 STAFFING Standard No Score 27 X 28 3 29 x 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 3 2 x 3 2 2 2 York House DS0000026895.V280238.R01.S.doc Version 5.1 Page 24 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 OP7 Regulation 15 Requirement Where practicable consultation with the service user or a representative must take place when preparing and reviewing the care plan. This requirement has been mainly met; previous timescale of 4/9/05 not met. A risk assessment regarding the prevention of falls must be drawn up either prior to the admission of a new service user or as soon as practicable following admission. The assessment must be reviewed in the light of subsequent incidents or accidents. Oxygen warning signs must be displayed on doors of rooms where oxygen is stored or used. Where radiators are not covered nor have low temperature surfaces, risk assessments must be in place to demonstrate that they reflect the needs and capabilities of current service users and that they are regularly reviewed.
DS0000026895.V280238.R01.S.doc Timescale for action 31/03/06 2. OP7 13(4) 15/02/06 3. 4. OP9 OP25 13(4) 13(4) 28/02/06 28/02/06 York House Version 5.1 Page 25 This requirement has been mainly met; previous timescales not met, most recently 4/9/05. 5. OP30 18(1) There must be documented evidence of the induction programme provided to new staff members (in accordance with National Training Organisation specifications). For new staff who do not hold a care qualification such as NVQ level 2, similar documentary evidence must be in place regarding the foundation programme which should be completed within six months of commencing employment. All staff members must receive emergency first aid training and all who handle food must receive basic food hygiene training. The registered manager must achieve a qualification in the management of care that is recognised as being equivalent to NVQ level 4. She must undertake periodic training in care-related topics in order to evidence that her practice is in keeping with developments in this field. The registered provider must compile a report on the conduct of the home each month and send a copy to the Commission. A copy of staff qualifications and proof of each person’s identity (e.g. birth certificate or passport) must be retained at the home and be available for inspection. The record of fire instruction to staff must include a note of the content of each session. 31/03/06 6. OP30 13(4) 16(2) 9(2) 31/05/06 7. OP31 30/09/07 8. OP31 26 28/02/06 9. OP37 19 and sched 2 31/03/06 10. OP38 23(4) 31/03/06 York House DS0000026895.V280238.R01.S.doc Version 5.1 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. Refer to Standard OP8 Good Practice Recommendations Regular monitoring of service users’ weight should take place in accordance with service users’ wishes and the findings of the nutritional assessment. In the event of a service user not wishing to be weighed or the home not having the facility to weigh a service user appropriately, the matter should be kept under review via risk assessment. Service users should be advised in writing that they may access their personal records within the terms of the Data Protection Act 1998. Such information could be contained in the service user guide, terms and conditions of residence, statement of purpose or other documentation. The adult protection policy/procedure should be amended to inform staff not to commence an investigation until advice has been obtained from Social Care and Health. Contact details of both this body and the Commission should be included in the documentation. Staff should attend the training provided by Dorset County Council on the topic of adult protection. The training needs of each staff member should be assessed periodically at supervision sessions or at an annual appraisal. The scope of the annual survey of service users’ views should be broadened to include relatives and friends and visiting professionals. There should be an annual audit and development plan for the home, reflecting aims and outcomes for service users. The home’s policies/procedures should be reviewed at least annually to ensure that the information within them is up-to-date and reflects expected practice. Care staff should receive one-to-one supervision on the basis of one session every two months. There should be a qualified first aider on each shift 2. OP14 3. OP18 4. 5. OP31 OP33 6. 7. 8. OP33 OP36 OP38 York House DS0000026895.V280238.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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