Inspection on 14/06/05 for York House (York Way)

This inspection was carried out on 14th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

York House (York Way) 05/06/07

York House (York Way) 09/01/07

York House (York Way) 20/12/05

York House (York Way) 12/11/04

York House (York Way) 10/06/04

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

CARE HOME ADULTS 18-65 York House (York Way) 180-182 York Way Watford Hertfordshire WD2 4RX Lead Inspector Bijayraj Ramkhelawon Unannounced 11:00 14th June 2005 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 (York Way) I52 s19632 york house (york way) v232950 140605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service York House (York Way) Address 180-182 York Way Watford WD2 4RX 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) 01923 656611 01923 676611 Miss Caroline Dunne Miss Caroline Dunne Care Home 13 Category(ies) of MD Mental Disorder - 13 registration, with number MD(E) Mental Disorder over 65 - 1 of places York House (York Way) I52 s19632 york house (york way) v232950 140605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 12 November 2004 Brief Description of the Service: York House/York Way is a care home providing personal care and accommodation for 13 adults (18-65) with mental disorders but excluding learning disability or dementia. It is privately owned and the registered manager is also the joint registered provider. This home is made up of 2 adjoining semi-detached properties -180 and 182 York Way which are linked internally with an opening at the top of the landing. It is situated in Garston, close to local shops and public transport routes. All the home’s bedrooms are single accommodation with en-suite facilities. Each house has a bathroom, dining room, a lounge, a kitchen, and a staff sleeping-in room. House 182 also comprises of the manager’s office and the main laundry room. A room previously used as a smoking room in this house has been converted into a games room. The home has extensive gardens that are well maintained and easily accessible. There is ample parking space to the front of the premises and large and well-tended gardens to the front and rear. The premises blend in very well with the rest of the properties. York House (York Way) I52 s19632 york house (york way) v232950 140605 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a positive unannounced inspection, feedback received from service users, their relatives and visitors was excellent and the standard of support and practices observed was good. The majority of time was spent talking to residents, visitors and staff. Some time was spent in the office scrutinising care plans, staff files and other records. Discussions were held with the manager to whom the feedback of the inspection was given. The experience of service users was that there was a pleasant and relaxed atmosphere in the home, they were complimentary of the staff, the food and their rooms. A requirement was made for the home to ensure that it must not use ‘Kilcullen Homes’ to identify itself as it is not registered under that organisation. A requirement was repeated from a previous inspection report on the management of medicines. It was also required that the correct address and contact number of the Commission must be included in the complaints procedure and that all staff working in the home must have the required legal documents. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure that the requirements and recommendations identified in previous and this inspection report are complied with. York House (York Way) I52 s19632 york house (york way) v232950 140605 stage 4.doc Version 1.30 Page 6 It must also reinforce its policies and procedures in relation to the management of medicines and ensure that all staff working in the home are facilitated to attend training in Adult Abuse and must have all the required documents. 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 (York Way) I52 s19632 york house (york way) v232950 140605 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection York House (York Way) I52 s19632 york house (york way) v232950 140605 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1-5 Adequate information was available to current and prospective service users and their families. Assessments of needs were carried out to ensure that staff have sufficient information on each person’s needs before they move into the home. That home must not identify itself as ‘Kilcullen Homes’ as it is not registered as such. EVIDENCE: York House has devised the ‘Statement of Purpose’ and ‘Service Users’ Guide’, a copy of which was given to each service user. Service users have an assessment of needs carried out by a senior member of staff and additional information were also provided by the Care Managers and the Community Mental Health Team. However, the home has been using letterhead of ‘Kilcullen Homes’, which was evident in the home. York House (York Way) I52 s19632 york house (york way) v232950 140605 stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6-10 Care plans were detailed and comprehensive. These included information on all support, health care needs and risk assessments carried out with regular reviews undertaken. Good interaction between staff and service users was noted. Service users were treated with respect and assisted to make choices about their lives and to participate in community activities wherever possible. EVIDENCE: Each service user has a detailed care plan setting out how their social, personal and health care needs will be met. A key worker system operates in the home. The senior care staff act as key workers and the care workers support the service users plans. Service users are involved in the compilation of their care plans and sign to state they agree with it. Care plans were reviewed at least six monthly and progress notes were kept up to date on a daily basis. Changes in the service users wellbeing were acted upon immediately. The relatives and in some cases and the key workers for the service users act as their advocates under the Care Programme Approach (CPA) arrangement. York House (York Way) I52 s19632 york house (york way) v232950 140605 stage 4.doc Version 1.30 Page 10 The home has a good system in place for the management of service users’ money. Currently, the majority of the service users maintain their own benefit books and manage their own financial affairs. Service users spoken to confirmed that monthly house meetings were held and they were involved in the day-to-day running of the home and that staff seek their views on an individual basis. Each service user has a comprehensive risk assessment and management under the CPA arrangement that enables them to continue with their lives in their chosen way. The home has a policy and procedures for a missing person so that all staff know what to do if and when required. The home has a policy on confidentiality of information, which is known to all staff. Staff members discuss the needs of service users in private as part of their daily handover and all personal records and care plans were securely kept. Sharing of information with other parties is on a ‘need to know’ basis in view of the complexity of the service users’ mental illnesses that warrant input from other agencies. York House (York Way) I52 s19632 york house (york way) v232950 140605 stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11-17 Service users were encouraged to make choices in relation to their food, clothes and activities to optimise their abilities in developing their skills for independent living. They are able to access and utilise public services and staff ensure that individual rights and responsibilities are recognised and supported. EVIDENCE: Care plans inspected and services users spoken to confirmed that they were fully supported to learn and develop new skills to enable them to move on to independent living. Each service user has a programme of daily living skills and with the assistance of staff they kept their bedrooms tidy, wash their own clothes and help in the kitchen. Services users access the local shops frequently to purchase cigarettes, newspapers, magazines etc. and they also attend the local church. Currently, there were six service users who attended day centres during the week (Northwick in South Oxhey and Henry Smith House in Watford). Some service users have their own social outlets. They visit their friends and families, go about their own activities as they see fit. They also plan evening activities such watching video, playing pool, darts and going out to the local shops. York House (York Way) I52 s19632 york house (york way) v232950 140605 stage 4.doc Version 1.30 Page 12 At present individual holidays are paid by the service users themselves and they also contribute in part towards the cost of staff. This is not in the spirit of the National Minimum Standards. Service users can receive their visitors in their own bedrooms or anywhere in the home they choose to. Staff members were aware of those service users who might be vulnerable and at risk from visitors and they would pay special attention during visiting times. Service users are not restricted from developing and maintaining intimate personal relationship with people of their choice. The home has implemented a policy on unwanted visitors. Staff members are aware to operate a ‘knock and wait’ policy when entering service users’ bedrooms, bathrooms and toilets. All bedroom doors are fitted with locks and each service user has been provided with a key to their room. Interactions between staff members and service users were noted to be appropriate. Service users plan the weekly menu and they choose the time they wish to eat. Staff shop and with the assistance of the service users cook the meals. All the staff have completed the Foundation Certificate in Food Hygiene. Breakfast can be cooked or continental style as service users choose. Drinks and snacks are freely available in both kitchens, which were clean, well maintained and well stocked with food provisions. Each resident’s meal choices are recorded every day, and the amount eaten is monitored if there is any concern about weight loss or healthy eating. York House (York Way) I52 s19632 york house (york way) v232950 140605 stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18-21 Staff encourage service users to attend to their personal care and treat them with sensitivity and respect. There was a good standad of record keeping of service users health care needs. However, there were shortfalls in relation to the management of medicines including relevant policy and procedures, consent to treatment and monitoring of storage temperature. EVIDENCE: Service users’ primary care needs are one of mental health problems. They have different levels of functional and psychological needs; some are more mentally able to deal with everyday eventualities with little support whereas others find it difficult to cope with daily life and need more support. They are all supported to get involved in household activities as part of their rehabilitation programme and to achieve optimum independence within the limitations of their illnesses. There is not a strict regime of bedtime and rising time in the home. All service users were appropriately dressed. Service users are regularly reviewed as part of their CPA. Permanent members of staff, the key worker system, individualised care plans and staff communication books ensure that there is continuity and consistency of support. None of the current service users require personal care but they sometimes require prompting or supervision by staff to undertake these tasks. York House (York Way) I52 s19632 york house (york way) v232950 140605 stage 4.doc Version 1.30 Page 14 Care plans inspected showed that service users health was monitored and potential complications and problems were identified and dealt with including prompt referral to appropriate specialists. All service users are registered with local GPs and visit the surgery with a member of staff as and when needed. The home uses a monitored dosage system for drug administration. All staff who administer medication have received appropriate training. Service users attending day centres have their midday medicines given to them in individual bottles. This system was inspected and records detailing the receipt and storage of medication were found to be satisfactory. However, it was required that the home must develop a written policy and procedures for the safe handling and administration of medicines to service users on short-term leave. It must also ensure that service users’ consent to treatment is obtained and retained on file. There is a need to monitor and record the storage temperature of medicines storage cupboards to ensure a suitable environment exists so that all drugs administered are at an optimum and have not deteriorated due to being stored at to high a temperature. The home has a Policy and Procedures for the ageing and dying. The home has devised a ‘death wishes’ form, which service users have completed. York House (York Way) I52 s19632 york house (york way) v232950 140605 stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22-23 Service users are encouraged and enabled to make their views and concerns known. They were aware of the home complaints procedure. However, the correct address and contact number of the Commission must be included in this procedure. All staff should be facilitated to attend the relevant training in ‘ Adult Abuse/Protection’. EVIDENCE: The home has a complaints procedure, which includes all of the information required by the Care Home Regulations 2001 and this standard. However, it does not include the correct address and contact number of the Commission. Service users stated that they had received a copy of the procedure and that if they had any queries or concerns they would speak to either the manager or their keyworker. Neither the home nor CSCI have received any complaints since the last inspection. The home has adopted the ‘Hertfordshire County Council Adult Protection Procedure’ and the ‘Whistle Blowing’ policy. Copies of these documents were available to staff and those spoken to were aware of these policies. However, they have not had any training in this area. There is one service user who is subject to ‘Power of Attorney’ and four are subject to the ‘Guardianship Order’. Eight service users keep their money, benefit and building society saving books in their own room in a digital lockable safe. York House (York Way) I52 s19632 york house (york way) v232950 140605 stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24-30 The home provides a comfortable and well-maintained environment for the service users. A good standard of cleanliness and hygiene is maintained within the home. EVIDENCE: The home consists of two houses 180 and 182 York Way, which are interconnected and provide accommodation for up to 13 service users. The home was well maintained and there was an ongoing programme of maintenance. The home has well maintained gardens. All bedrooms are single rooms and have en-suite facilities. These were adequately furnished and personalised with service users personal possessions. All bedroom doors are lockable and service users hold a key to their door. Twelve of the bedrooms have carpet and one has laminated flooring. Service users have access to comfortable communal facilities, which meet the requirements of this Standard. Furnishings and fittings in these areas are of good quality and domestic in character. The majority of service users smoke and a designated smoking room is provided in House 180. York House (York Way) I52 s19632 york house (york way) v232950 140605 stage 4.doc Version 1.30 Page 17 The home has a laundry room situated in 182 York House, each service user is provided with a laundry basket and they each have an allocated day when they use the washing machine. If required, staff will assist service users to undertake their laundry duties. York House (York Way) I52 s19632 york house (york way) v232950 140605 stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31-36 There was an adequate number of staff rostered on duty. Staff spoken to were confident of their knowledge of the needs of the service users and feel well supported in their work. The required records and relevant checks completed prior to working at the home were not available to verify that service users are protected by robust recruitment procedures. EVIDENCE: There was a pleasant, calm and harmonious working relationship between staff and service users. Staff members were observed to treat service users with respect for their dignity and privacy, actively encouraging independence as far as possible. Staff appeared motivated and committed. They demonstrated good skills in communicating with, listening to and in understanding a group of service users with enduring and complex mental health care needs. They also have a good professional relationship with the GP surgery and other health care agencies that have an input into the service users’ care. The manager is currently undertaking the Registered Managers Award (RMA) and 2 staff have completed the Community Certificate in Mental Health accredited by Hertfordshire University. York House (York Way) I52 s19632 york house (york way) v232950 140605 stage 4.doc Version 1.30 Page 19 All new staff undertake a structured induction programme and during this period they are supernumerary to the daily staffing levels. A wide range of training courses were facilitated to staff and each member of staff has a training record. However, on the day of the inspection there was a member of staff on duty who did not have any of the necessary documents required by the National Minimum Standards and its accompanying legislations. Staff meetings are held at least once a month and each staff receive individual formal supervision at least six times a year. York House (York Way) I52 s19632 york house (york way) v232950 140605 stage 4.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37-43 The quality assurance system ensures that views of the service users, their relatives and other professionals underpin all self-monitoring, review and development of the home. The management within the home is effective ensuring that the needs of the service users were being met and that the home was meeting its aims and objectives. However, files pertaining to individual staff should be kept secure in accordance with the Data Protection Act 1998. EVIDENCE: The home has developed and implemented a quality assurance system in seeking the views of service users, relatives, GP’s, social workers and other professionals involved in the lives of the service users. Regular service users and staff meetings also provide additional forum where views can be expressed and shared. Staff and service users spoken to said that the manager is approachable and supportive. York House (York Way) I52 s19632 york house (york way) v232950 140605 stage 4.doc Version 1.30 Page 21 The home maintains appropriate records, which were kept up to date and in good order. However, it was recommended that staff files were should be kept under lock and key. The home has a valid insurance cover certificate with Ecclesiatical Insurance which expires on the 15th September 2005. York House (York Way) I52 s19632 york house (york way) v232950 140605 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 Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 1 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 York House (York Way) Score 3 3 1 3 Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 3 3 I52 s19632 york house (york way) v232950 140605 stage 4.doc Version 1.30 Page 23 yes 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. 2. Standard A1 A 20 Regulation 4 13 (2) Requirement The home is not registered as Kilcullen Homes and must use its headed papers. Develop a written policy and procedures for the safe handling and administration of medicines to service users on short -term leave. (Outstanding from last report 31/03/05). Ensure service users consent to treatment is obtained and retained on file. (Outstanding from last report 31/03/05). Monitor and record the storage temperature of medicines storage cupboards. (Outstanding from last report 31/03/05). The correct address of the Commission must be included in the complaints procedure. All employees must have individual files with records of past employment including references, CRB checks etc. Timescale for action 13/06/05 19/08/05 3. A 20 13 (2) 19/08/05 4. A 20 13 (2) 19/08/05 5. 6. A 22 A 34 22 (7) (a) 19 (1) (b) (i) 19/08/05 19/08/05 York House (York Way) I52 s19632 york house (york way) v232950 140605 stage 4.doc Version 1.30 Page 24 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. Refer to Standard A 23 A 37 Good Practice Recommendations All staff should be facilitated to attend the Adult Abuse’ training. Staff files should be kept secured and locked at all times. York House (York Way) I52 s19632 york house (york way) v232950 140605 stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City AL7 3BQ 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 (York Way) I52 s19632 york house (york way) v232950 140605 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. 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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