Inspection on 07/11/05 for York House

This inspection was carried out on 7th November 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 26/01/09

York House 06/03/07

York House 20/06/06

York House 30/01/06

York House 12/10/04

York House 17/05/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE York House Old Bank Road Dewsbury West Yorkshire WF12 7AH Lead Inspector Tracey South Unannounced Inspection 09:30 7 November 2005 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 DS0000026300.V254071.R01.S.doc Version 5.0 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.V254071.R01.S.doc Version 5.0 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.V254071.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th October 2004 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.V254071.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over 5 hours. Not all of the core standards were assessed on this occasion. The remaining standards will be assessed as part of the next inspection, which is due to take place before the end of February 2006. The home is registered for up to 36 older people and there were 35 residents living at the home on the day of the inspection, leaving one vacancy. The home is currently fully staffed. Documentation examined during the inspection included, complaints log, policies and procedures, staff personnel files, training records, accident books, staff rotas and quality monitoring records. A tour of the building was carried out where a small number of bedrooms were seen. Staff and residents were spoken to as part of the inspection and their comments have been included in this report. What the service does well: The home provides a comfortable and homely environment for residents. Residents looked happy, content and well cared for. Staff were observed supporting residents in a sensitive and caring manner. The home ensures that all lifting equipment, including bath hoists, are checked every 3 months. There are enough staff on duty to make sure residents are cared for properly. Care staff are well supported by cooks and domestic assistants. York House DS0000026300.V254071.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. York House DS0000026300.V254071.R01.S.doc Version 5.0 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.V254071.R01.S.doc Version 5.0 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): None of these standards were assessed on this occasion. EVIDENCE: York House DS0000026300.V254071.R01.S.doc Version 5.0 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): None of these standards were assessed on this occasion. EVIDENCE: York House DS0000026300.V254071.R01.S.doc Version 5.0 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): None of these standards were assessed on this occasion. EVIDENCE: York House DS0000026300.V254071.R01.S.doc Version 5.0 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): 16, 18 The home takes complaints seriously. Residents are protected from abuse. EVIDENCE: There have been no complaints received at the home since the last inspection in October 2004. Staff keep a record of informal complaints which include the nature of the complaint and any action that may have been taken. The complaints procedure is displayed in various parts of the home although it was noted that the procedure does not include the timescale of when the complaint will be responded by. The procedure should be amended to include a timescale of 28 days. Those residents spoken to said they would go to the manager if they had any complaints or concerns. Nine staff have undertaken adult protection training, provided by external agencies. Further staff have completed adult protection questionnaires as part of in-house training. All potential employees are checked against the Protection of Vulnerable Adults register. York House DS0000026300.V254071.R01.S.doc Version 5.0 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): 19, 26. The standard of the environment is good, providing residents with an attractive and homely place to live. EVIDENCE: The standard of décor, throughout the home, remains of a good standard. The home was found to be clean and tidy. There was an unpleasant odour present in one of the communal lounges. The manager made arrangements to ensure it was dealt with immediately. The grounds of the home are well maintained and there are plenty of areas where residents are able to sit out during the warmer months of the year. The fire safety officer visited the home in August 2005 as a follow up from his original visit in March 2005. There are items of fire safety work still outstanding. The organisation must provide the CSCI with an action plan of when the work will be completed. The environmental health officer last visited the home in November 2004. The recommendations made have been York House DS0000026300.V254071.R01.S.doc Version 5.0 Page 13 addressed. The kitchen staff are reminded to calibrate the probe, used for testing hot and cold food items, as this has not been done for quite some time. The laundry facilities consist of 2 industrial washers and dryers. Infection control policies and procedures are adhered to. Cleaning products were observed on the shelves in the laundry. The manager did remove them immediately. It is recommended that the laundry door is kept shut when staff are not present. The staff explained how they are expected to carry out laundry duties as part of their shift. The home would benefit from having its own designated laundry person, as this would enable care staff to spend more time with residents. York House DS0000026300.V254071.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 There are enough staff on duty to make sure residents are cared for properly. Good progress has been made with gaining NVQ qualifications amongst staff. Staff are trained and competent to do their jobs. EVIDENCE: A typical day consists of 6 staff on the morning shift and 5 staff on the afternoon shift. Three members of staff work wakeful nights from 10pm until 8am. Care staff are supported by domestic and kitchen staff. The manager explained how staff are rostered to work in accordance with residents needs. For example, there are a number of residents who require support with feeding and staff rotas are worked around this. Very good progress has been made in staff gaining NVQ qualifications. Twenty of the 26 care staff employed at the home have achieved NVQ level 2 in care. Four staff are about to enrol for NVQ level 2 and 5 staff are currently working towards their NVQ level 3 award. One of the deputy managers has achieved NVQ level 4 and the second deputy has recently achieved NVQ level 3. The necessary employment checks are carried out prior to new staff starting work at the home. The manager must evidence any discussions she has with staff regarding declarations made on application forms and unsatisfactory CRB disclosures. York House DS0000026300.V254071.R01.S.doc Version 5.0 Page 15 All new staff undergo induction training. It was noted that one member of staff, who started work in April 2005 has not yet completed her induction. New staff complete mandatory training such as, movement and handling, food hygiene, first aid and fire training. York House DS0000026300.V254071.R01.S.doc Version 5.0 Page 16 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): 33,35, 38 The home is run in the best interests of residents. Residents’ financial interests are safeguarded. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: A new quality audit system has been introduced and the manager is responsible for carrying out monthly audits. The system is based on outcomes in accordance with the National Minimum Standards. There was no evidence in place of how the outcome had been reached. For example, if the standard being assessed is whether or not residents have been included in the care planning process, the Manager needs to be able to demonstrate that she has actually spoken with the residents. York House DS0000026300.V254071.R01.S.doc Version 5.0 Page 17 Small amounts of monies are kept on behalf of service users. Three residents’ monies where checked, all of which were correct. Health and safety systems are in place to promote the health and safety of residents and staff. A sample of service certification was satisfactory. It was noted that the last recorded fire drill was on 5th April 2004. The manager was advised to ensure that a fire drill be arranged in the immediate future. York House DS0000026300.V254071.R01.S.doc Version 5.0 Page 18 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 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 1 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 York House DS0000026300.V254071.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? NA 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 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 Refer to Standard OP16 OP19 OP26 OP26 OP26 OP29 Good Practice Recommendations The complaints procedure should include details of when complaints will be responded to, that is, a maximum of 28 days. The kitchen staff should make sure they calibrate the probe used for testing hot and cold food items. Cleaning materials should not be left out in the laundry area. Staff should follow COSHH procedures and make sure all cleaning materials are stored away correctly. The laundry door should be closed shut when staff are not present. The organisation should consider employing a designated laundry person. The manager should ensure she records, in writing, any DS0000026300.V254071.R01.S.doc Version 5.0 Page 20 York House 7 8 9 OP30 OP33 OP38 discussions held with staff relating to declarations made on their application form or in receipt of an unsatisfactory CRB disclosure. Induction training should take place within the first 6 weeks of employment. The quality audits need to include the source of evidence. If not already done so, the manager should ensure that a fire drill takes place on receipt of this report. York House DS0000026300.V254071.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI York House DS0000026300.V254071.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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