Inspection on 20/12/05 for York House (York Way)

This inspection was carried out on 20th December 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

York House (York Way) 05/06/07

York House (York Way) 09/01/07

York House (York Way) 14/06/05

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) York House 180-182 York Way Watford Hertfordshire WD2 4RX Lead Inspector Tom Cooper Unannounced Inspection 20th December 2005 2:40 York House (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 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 (York Way) DS0000019632.V266073.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 Adults 18-65. 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 (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service York House (York Way) Address York House 180-182 York Way Watford Hertfordshire WD2 4RX 01923 676611 01923 676611 kilcullenhomes@fsmail.net 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) Miss Caroline Dunne Mr Michael Dunne Miss Caroline Dunne Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) York House (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The category MD(E) only applies while the named service user remains at the home. 14th June 2005 Date of last inspection 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. The home is made up of 2 ordinary looking adjoining semi-detached properties at 180 and 182 York Way. which are linked internally by a double staircase through an opening on the first floor landing. It is situated in Garston, close to local shops and public transport routes. All the homes bedrooms are singles with en-suite facilities. Each house has a bathroom, dining room, lounge, kitchen, and there is a staff sleeping-in room. House 182 also contains the managers office and the main laundry room. A room previously used as a smoking room in 182 has been converted into a games room. There is a large, easily accessible, well maintained garden to the rear of the building and ample car parking space to the front. York House (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection for the current inspection year and took place on a weekday in the late afternoon and evening. The main focus of the inspection was to check compliance with the statutory requirements and any action taken in respect of the recommendations made at the last inspection as well as evaluating the service users’ experience of living in the home. Discussions were held with the assistant manager, other staff on duty and most of the service users in residence. Documentation checked included four service users’ personal files including their care plans, risk assessments, fire alarm system tests and drill records, medication records, the complaints procedure. A tour was made of the premises and two service users showed the inspector their bedrooms. The staff and residents were very friendly and welcoming. The home looked quite festive with numerous Christmas decorations put up by staff. The inspection indicated that the home was running well with the service users expressing reasonable satisfaction with their lives in the home and enjoying positive relationships with staff. Statutory requirements have been made in respect of care plan reviews, bedding, minor premises defects and the availability for inspection of staff records. Recommendations have been made in respect of décor, staff training in abuse awareness, staff supervision and the fire alarm system. What the service does well: Service users reported general satisfaction with the home, praising the caring and constructive attitudes of staff, the food provided and the arrangements for medication. Two service users were unhappy with their low incomes but this was exacerbated by their smoking habits. All those spoken with felt they were able to exercise a fair degree of personal autonomy. Good assessment information was held in service users’ personal files examined, with clear details of the personal circumstances of each individual, the current agreed approach to be taken and good progress notes. Members of staff spoken with were very positive about working in the home and rated communications and teamwork as strong. They felt they had good access to relevant training opportunities, although were unable to recall whether they had received abuse awareness training as recommended in the last inspection report. No staff files were available for inspection therefore it was impossible to verify this. The home has a detailed medication policy and sound procedures are operated for the obtaining, storage, administration and recording of medication. The premises are safe, comfortable and mostly well maintained and provide a suitable environment for the service users, although the bedrooms are small York House (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 Page 6 and three service users commented on this. Equipment provided such as fire extinguishers is serviced regularly. The kitchens are modern and well equipped, the living rooms are comfortable and there are adequate bathroom and toilet facilities. The large enclosed garden provides an excellent extra space to use in fair weather. A good standard of cleanliness was found in all areas inspected. What has improved since the last inspection? What they could do better: One service user pointed out several holes in his mattress and the overhead light in his bedroom had no lampshade. The mattress must be replaced and a lightshade fitted. As indicated above the overhead strip lights in the lounge of house 180 are not suitable for a domestic living room and should be replaced with more attractive items. A defective extractor fan in the bathroom of House 180 must be repaired. The home is quite well furnished and decorated but all the rooms seen were painted off-white, including the service users’ bedrooms. This may be easy to maintain but as with the strip lighting in one lounge the uniformity creates a slightly institutional rather than a homely look that is in contrast to most modern care homes, where variety of colour and promotion of individuality are prioritised. The proprietors should consider the potential benefits of a more varied colour scheme when next planning to redecorate. The fire alarm system should be checked and adjusted to reduce the length of time the high-pitched feedback-style note is sounded after the alarm has been triggered and reset. This noise is irritating and not conducive to a peaceful atmosphere and several service users complained about it. The registered manager/proprietor was away on the day of the inspection and none of the staff had access to the staff records, which were locked away in the manager’s office. The Regulations specify that these records must be kept York House (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 Page 7 in the home at all times available for inspection; therefore a requirement has been made. 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) DS0000019632.V266073.R01.S.doc Version 5.0 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection York House (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 1, 2, 3, 4, 5 Adequate information about the philosophy of care and operation of the home is available to prospective and current residents. Admissions are made on the basis of detailed assessments of the individuals’ needs and aspirations so that it is clear that the home can provide a suitable service. The home also has good arrangements to enable new residents to familiarise themselves with the home prior to moving in. EVIDENCE: The home has a suitable Statement of Purpose and Service User’s Guide. Copies are given to each service user. All admissions are made subject to the home’s pre-admission process, involving an assessment carried out by a senior member of staff. Very detailed supporting information was in personal files seen, provided by the involved social workers and the Community Mental Health Team as well as letters from the consultant psychiatrist involved. Contracts of occupancy outlining the terms and conditions of the placements were also on files seen. Initial placements are made on a three month trial basis after which a review is held and the placement confirmed if appropriate. York House (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 6, 7, 8, 9, 10 Comprehensive assessments are in place for each service user detailing their individual status and needs as well as risk assessments. Regular reviews are carried out although care must be taken to ensure that this is done in every case to ensure that the information recorded is up to date in respect of each person. Good interaction between staff and service users was noted. Staff consult service users about their lives and support them to make decisions and choices, including taking responsible risks. This enables them to maintain a good degree of independence in a safe environment. Confidential information is handled appropriately. EVIDENCE: Four personal files were examined, all containing considerable assessment information about the needs of the service user, both from external agencies and materials produced in the home. In combination these documents conveyed an excellent overview of the status and care plan for each individual and the varying levels of support needed from York House (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 Page 11 staff with respect to personal and healthcare as well as emotional needs and medication programmes. Service users are involved in the development of their care plans and sign the finished document to signify their agreement to the contents. Daily progress notes are made. In accordance with the standard, the home’s policy is to review each plan at least every six months and that had been done in three of the four examples selected but not the fourth, for which there was only an undated and incomplete service user plan document which a senior member of staff said was in an obsolete format. Therefore a requirement has been made in the report that all care plans must be reviewed regularly and this must be recorded. Service users said that staff were vigilant in monitoring their daily well-being. The home operates a keyworker system that service users said was effective and appreciated. In some cases keyworkers act as advocates for the residents with relatives otherwise fulfilling this role under the Care Programme Approach (CPA). There is a good system for the management of service users’ money. Most of the service users control their benefit books and manage their own money, although arrangements vary depending on individual circumstances and capabilities. Money is always an issue where service users are on benefits and smoke and staff are aware of the need for sensible strategies to control individual expenditure. Service users spoken with confirmed that staff consulted them over the running of the home, and there were regular house meetings that provide a forum for expressing views. For each service user there is a comprehensive risk assessment with appropriate control measures identified under the CPA. This enables individuals to lead their lives as they choose within a sensible framework that minimises risk. The home has a formal missing person procedure that staff follow consistently as required. Staff are also familiar with the home’s confidentiality policy, discussing service users’ needs in private at handovers and keeping all personal documentation securely. Because of the complexity and variability of the service users’ mental illnesses, information has to be shared frequently with outside health professionals and other agencies but this is done on a need-to-know basis. York House (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 12, 13, 14, 15, 16, 17 Service users are supported and encouraged by staff to lead the lifestyles they choose. They live as part of the local community and engage in social and leisure activities that suit them, using public services and amenities in the ordinary way. Staff ensure that service users can exercise their human rights and encourage the recognition and taking on of appropriate individual responsibilities. EVIDENCE: Service users consulted confirmed that they were supported to lead their lives as independently as possible, maintaining and developing relevant life skills. Evidence of this was also found in care plans seen. All service users have a programme for daily tasks and with staff assistance help they keep their rooms reasonably clean and tidy, do their own laundry and help with meal preparation in the kitchens. They visit local shops frequently to make normal purchases such as cigarettes, sweets, clothes etc. Some attend the local church. Several residents attend day centres during the week, either Northwick in South Oxhey or Henry Smith in Watford. Some maintain external social networks, visiting friends and relatives, coming and going as they choose. York House (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 Page 13 In the evenings residents follow their own patterns, spending time alone in their rooms, or watching television, playing pool or darts in the games room, smoking in the smoking room or garden, or going out to the shops or pub. Several residents had plans for the forthcoming Christmas period. Thus the lifestyle arrangements are highly individual and related to the particular needs and desires of each person. Visitors can be received at any reasonable time and entertained in the communal areas or the service user’s bedroom. Staff are aware of the vulnerability of some residents to visitors and would carefully monitor the situation as judged necessary. The home has a policy on handling unwanted visitors. However this is applied within the context of the home’s duty of care and service users are not prevented from developing personal and sexual relationships if they wish. Residents said that staff respected their privacy and were seen to knock on bedroom doors and wait for an invitation to enter. All the bedroom doors have locks and the service users have keys to theirs. All the residents spoken with said the food provided was good. They plan the menus each week with staff, who then do the shopping. Staff cook the meals with help from the residents in accordance with their individual programmes. The kitchens are open to the residents for drinks and snacks at any time day or night and one resident commented that this was a major benefit of living in the home. One service user has diet-controlled diabetes and staff discreetly monitor her eating habits to ensure this remains under control. Another has frequent weight fluctuations, and his weight had been regularly recorded in his care plan file. York House (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 18, 19, 20 Staff treat service users with respect and dignity. They encourage service users to attend to their personal care and maintain a reasonable standard of physical presentation. Service users’ physical and emotional healthcare needs are well documented in their personal files. The home operates sound procedures for the safe handling of medication that protect service users’ interests. EVIDENCE: The service users’ foremost care needs are to do with managing their mental health problems. The varying levels of support required for each individual are well documented in their care plans. Some service users are able to cope with daily life quite well and need little support whereas others are less resilient and staff have to intervene more. All the programmes in the home are geared to helping the service users develop confidence and independence towards achieving rehabilitation and maximum independence within the limits of their particular conditions and illnesses. Therefore they are all expected and encouraged to take part in household activities, although there are few rigid rules such as strict bedtimes and rising times. Service users all wear appropriate clothes. Regular reviews take place as part of the CPA and the keyworkers and other staff carefully monitor individuals’ progress, using the various communication York House (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 Page 15 tools available such as handovers between shifts and the message book to ensure consistency of care from shift to shift. Care plans inspected showed that changes in service users’ condition had been closely monitored and referrals made as necessary to the appropriate specialists. All service users are registered with local GPs and visit the surgery with staff as and when needed. The medication cabinet has been moved to a new, cooler location in a cupboard under the stairs, following concerns about the storage temperatures for drugs in its previous location. The Boots MDS blister pack system is operated. Only trained staff handle medication and the records are doublechecked every day. Storage, administration and recording were all satisfactory. Staff clearly knew how to follow the home’s medication policy, which has been expanded since the last inspection to include a procedure for when residents go on short-term leave. York House (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 Page 16 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 the following standard(s): 22, 23 Residents are encouraged and enabled to make their views and concerns known. They are aware of the complaint procedure. Policies and procedures are in place to ensure that service users are protected from abuse and neglect. However staff should be given relevant training in abuse awareness and adult protection. EVIDENCE: Service users asked said that they knew how to go about making a complaint although they expressed mixed views as to whether their views would be taken seriously by the manager. The home has a complaint procedure that contains all the elements to meet the standard. No complaints had been recorded in the complaints file since the last inspection. The home has a copy of the Hertfordshire County Council inter-agency adult protection procedure in the office and staff spoken with were aware of the home’s whistle blowing policy. They said they would report any allegations or suspicions of abuse to the manager. However they were unable to recall whether they had received any training in this area and no staff training records were available for inspection to verify this. Suitable training should be provided to enhance service users’ protection. One service user’s finances are subject to power of attorney and several others are subject to guardianship orders. The remaining service users keep their money, benefit and building society saving books in their bedrooms locked in digital safes. York House (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 Page 17 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 the following standard(s): 24, 25, 26, 27, 28, 29, 30 The home provides a safe, comfortable and generally well-maintained environment. However care should be taken to monitor the condition of mattresses, fixtures and fittings to ensure they remain serviceable. The single bedrooms are small but adequate for individual needs and privacy. The shared spaces are well appointed and roomy. Bathrooms and toilets are adequate. However the uniform wall colour scheme and overhead strip lights in one lounge detract from the otherwise homely presentation of the home. A good standard of cleanliness and hygiene is maintained throughout. EVIDENCE: The two houses are generally well appointed and maintained to a satisfactory standard. Furnishings are domestic in style with carpets in good condition and comfortable seating. The service users spoken with said they liked the home, although three said that their rooms were rather small, albeit with useful ensuite facilities. The bedrooms seen contained personal items. The games room (with a pool table) and the designated smoking room are popular with the residents and provide really useful facilities. The kitchens are well designed and equipped in domestic styles. The large enclosed rear gardens are safe, accessible and attractive, providing a valuable extra space for residents to use. All areas inspected were clean and reasonably tidy. York House (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 Page 18 Three issues requiring attention were noticed on touring the premises. In one bedroom the service user pointed out that the mattress on the bed was worn out and holed in several places. This must be replaced immediately. There was also no shade on the overhead light which made the room look stark. In the bathroom of House 182 the extractor fan was not working. This must be repaired or replaced. See requirements. In addition to these matters it was noticed that new fluorescent overhead strip lights had been fitted in the lounge of House 180. Staff said that this was because the previously used spotlights kept blowing bulbs. The new lights were undeniably effective but several residents said they did not like the harsh light produced and in the opinion of the inspector such lights are rather institutional, are not in keeping with a modern domestic living room or the rest of the facilities in the home and should be replaced by items that produce a softer light to create a gentler ambience. The uniform wall colour used throughout the building, including the bedrooms, is similarly rather institutional and therefore the proprietor should consider a more varied colour scheme to increase the homely presentation of the premises. During the inspection the fire alarm was activated and following the all-clear a piercing, high pitched sound was produced for over an hour that was apparently unnecessary and potentially disturbing, especially to service users with mental health problems. The alarm system should be checked and adjusted if possible to reduce this intrusive sound. See recommendations. The laundry room is situated in House 182 and is well equipped with large commercial machines capable of dealing with the workload from thirteen residents. Each resident has a laundry basket and does washing on an allocated day, assisted by staff if necessary. York House (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 Page 19 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 32, 34 and 35 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, 34, 35, 36 Staffing numbers from day to day are adequate to meet the needs of the current group of service users. Staff are confident and knowledgeable about service users’ individual needs and agreed programmes and relate well to them, providing support and guidance. No staff records were available for inspection therefore it was impossible to verify that service users’ interests are protected by robust recruitment, induction and ongoing training policies. EVIDENCE: The staff rotas showed that three staff were on duty during the day shifts to care for the eleven service users in residence, with two staff sleeping in at night. These levels are adequate to meet the needs of the current group. Staff spoken with rated teamwork, communications and mutual support as good. They had a good understanding of the aims of the home and the policies and procedures designed to deliver the service outlined in the statement of purpose. Excellent relationships were observed between staff and residents with calm interactions evident at all times. This was reinforced by the objective notes made in personal files and the communication book. No staff records were available to provide evidence of sound recruitment procedures, induction of new staff or ongoing relevant training provided. York House (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 Page 20 It has previously been established that all new staff undertake a structured induction programme and in conversation staff confirmed that they had good access to training courses but there was no documentary evidence as the staff records were locked in the manager’s office. The manager was away and the staff in charge of the home had no access to her office. The Care Homes Regulations 2001 specify that identity records, references and other records to demonstrate the fitness of all people working at the home must be available for inspection at all times therefore a requirement has been made. One member of staff said that although she felt well supported by senior colleagues she had not received regular individual supervision. This should be provided at least six times a year to meet the standard. York House (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 Page 21 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 40, 41, 42 The home has adequate policies and procedures in place to ensure the rights and best interests of service users are safeguarded and the aims of the home are met in accordance with the statement of purpose. The home’s record keeping procedures inspected were of generally high quality but no staff records were available for inspection. The home is a safe place in which to live and work. EVIDENCE: The home’s policies and procedures are available to staff and those spoken with had a good understanding of them and were observed putting them into practice to the benefit of the service users. Care plan records seen had been well compiled apart from one missing a recent review. The complaints procedure was widely available in the home. York House (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 Page 22 Medication records were flawless. However as indicated above no staff records were available for inspection. Equipment checked such as the fire extinguishers had been serviced within the last year and all kitchen and laundry equipment was in good order. The gardens were safe and accessible and all floor coverings seen were secure and safe. The smoking room was reasonably clean. No hazardous items or features were noted on the premises, which were relatively uncluttered and tidy. The bathrooms were suitable for the residents as they do not have mobility problems. York House (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 Page 23 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 3 3 3 3 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 1 2 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 York House (York Way) Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score X X X 3 2 3 x DS0000019632.V266073.R01.S.doc Version 5.0 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 YA6 Regulation 15(2)(b) Requirement Timescale for action 31/01/06 2. 3. 4. 5. YA24 YA24 YA24 YA34 7. YA41 All service users’ plans must be regularly reviewed at least every six months and this must be recorded. 12(4)(a) & A new mattress must be 16(2)(c) provided for the bed in room 8. 12(4) & A shade must be provided for 16(2)(c) the overhead light in room 8. 16(2)(j)&(k) The extractor fan in the bathroom of House 180 must be repaired or replaced. 19(1) All employees must have individual files with records of past employment including references, CRB checks etc. [Outstanding from inspection report dated 14/06/05] 17(2)&(3) The staff records listed in Schedule 4 of the Care Homes Regulations 2001 must be kept in the home at all times available for inspection. 31/01/06 31/01/06 31/01/06 20/12/05 20/12/05 York House (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 Page 25 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. 2. 3. 4. Refer to Standard YA23 YA24 YA24 YA24 YA36 Good Practice Recommendations All staff should be given adult abuse awareness training. More subtle overhead lights should be provided in the lounge of House 180. The fire system should be checked and adjusted if possible to reduce the length of time the piercing post-alarm warning noise sounds. The manager should consider adding some variety of wall colour to make the premises more homely. All staff should receive individual supervision at least six times a year. York House (York Way) DS0000019632.V266073.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire 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) DS0000019632.V266073.R01.S.doc Version 5.0 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!