Inspection on 05/06/07 for York House (York Way)

This inspection was carried out on 5th June 2007.

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 (York Way) 09/01/07

York House (York Way) 20/12/05

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 Pat House Key Unannounced Inspection 5th June 2007 12:30 York House (York Way) DS0000019632.V342382.R01.S.doc Version 5.2 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.V342382.R01.S.doc Version 5.2 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.V342382.R01.S.doc Version 5.2 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 FP 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.V342382.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The category MD(E) only applies while the named service user remains at the home. 9th January 2007 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 adjoining semi-detached properties at 180 and 182 York Way, which are linked internally. The home has recently been renovated and now contains one communal lounge, dining room, kitchen and smoking room. All the homes bedrooms are singles with en-suite facilities. Each house has a bathroom and a staff sleeping-in room. House 182 also contains the Managers office and the main laundry room and staff have an office in house 180. 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 is situated in Garston, near to bus routes and local shops and residents have easy access to the town of Watford, which has numerous facilities and good transport links. The home’s Statement of Purpose, Service User’s Guide and the last CSCI inspection report are kept in the office and are available on request. The current fee for the home is £507.96. York House (York Way) DS0000019632.V342382.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one afternoon with one inspector. Residents and staff were spoken with and a selection of records was checked. All areas of the home and garden were visited briefly. The manager was present for part of the inspection and other staff also assisted, showing how medication is administered and providing information. What the service does well: What has improved since the last inspection? What they could do better: No requirements have been made as a result of this inspection. York House (York Way) DS0000019632.V342382.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. York House (York Way) DS0000019632.V342382.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection York House (York Way) DS0000019632.V342382.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Up to date information is provided for all potential residents and detailed assessments are also completed. This ensures that all parties can be sure that individual needs can be fully met by services provided at the home. EVIDENCE: The manager is currently updating the home’s Statement of Purpose and Service User’s Guide. When completed, copies will be given to all residents and a copy will be sent to the CSCI. A selection of records was checked and showed that care summaries are obtained for all potential residents and that care staff complete their own, detailed assessments for all new residents. One new resident was recently admitted to the home and on-going assessments are still underway to ensure the home is the correct place for them to live. York House (York Way) DS0000019632.V342382.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures followed in the home ensure that residents have their needs fully documented and are supported by staff to make their own decisions and take appropriate risks. EVIDENCE: Three care plans were checked during the inspection and these were detailed and well documented. Appropriate risk assessments were in place although one needed to be signed and dated. One resident had been involved in plans to maintain their safety when they were out and had signed agreement to carry a tracking device when they left the home. There was evidence that residents were involved in all their care planning and reviews were up to date in the plans checked. York House (York Way) DS0000019632.V342382.R01.S.doc Version 5.2 Page 10 Those residents who spoke with the inspector confirmed that staff supported them to make decisions about their daily lives and were supported to manage their finances where possible. York House (York Way) DS0000019632.V342382.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures followed in the home ensure that all residents are able to spend their days as they wish, are supported to maintain family and community links and are treated with respect by staff. Residents enjoy a balanced diet, which helps to promote their well-being. EVIDENCE: All residents are able to make independent trips out of the home and several went in and out during the inspection. Residents spoken with confirmed that staff accompany where appropriate, such as for hospital visits. Staff said that residents attend day centres on various days of the week, but that the current residents were unable to take up training courses or paid employment. Staff spoken with said that on two evenings each week residents go out to a local pub and monthly trips are made to the cinema. Two residents now have bus passes and use these to make regular trips out. Those spoken with also York House (York Way) DS0000019632.V342382.R01.S.doc Version 5.2 Page 12 confirmed that relatives were welcomed to make visits at any time and that some residents had regular visits from their families. All current residents manage their own personal care. Residents spoken with said they kept their own rooms clean and took turns to help with general household tasks. Rotas for domestic chores were seen displayed around the home and one resident had cleaned a bathroom just before the inspection began. All bedrooms have locks on the doors and some rooms were locked during the inspection. Each bedroom also has a lockable safe for any personal valuables. All residents spoken with confirmed that staff treated them with respect and said they were able to be as private as they wanted. They also said they enjoyed the food in the home. A menu was displayed in the dining room and some residents made themselves drinks during the inspection. All staff spoken with had completed Food Hygiene training and records of fridge and freezer temperature checks were being regularly recorded. As noted at previous inspections, a large bowl of fruit was available in the dining room and service users said they could help themselves this. Drinking water was available from a dispenser in the lounge. York House (York Way) DS0000019632.V342382.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The system for administering medication in the home is sound and helps to protect the residents whose health needs are also met in ways they choose. EVIDENCE: Residents spoken with said they were happy with all the support provided by staff and were generally independent regarding personal care. Records showed that appropriate referrals and appointments were made for residents to see Health professionals. A Local Authority review was taking place with one resident during the inspection. The system for storing and administering medication was checked and no shortfalls were found. Almost all medication is provided in blister packs and no Controlled Drugs are prescribed at present. Only senior staff are responsible for giving medication and all have completed accredited training courses. York House (York Way) DS0000019632.V342382.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures in the home ensure that any concerns residents have are listened to and that residents are protected from abuse. EVIDENCE: Written policies on making a complaint and on Safeguarding Adults (Adult Protection) and Whistle Blowing are in place, which staff were aware of. Staff have received training in Adult Protection. Details about making a complaint were displayed in the home although the CSCI contact details needed updating. Residents spoken with confirmed they would tell a member of staff if they had any concerns about living in the home. York House (York Way) DS0000019632.V342382.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a home which is hygienic and well maintained. EVIDENCE: The home generally looked clean and well maintained during the visit and residents were using the garden and the smoking room as well as the lounge. Residents have modern audio and visual equipment in the lounge and those spoken with said they choose their own colour bedroom colour schemes and have their own possessions in place in their rooms. The bathrooms were clean and had paper towels and liquid soap in place. The home has a written policy on Infection Control and has links with the Health Protection Unit in the area. York House (York Way) DS0000019632.V342382.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the thorough recruitment practices in the home and have their needs met by well trained staff. EVIDENCE: There have been no new staff appointed since the last inspection. The manager has introduced new recruitment procedures and new documents to record the process. The system for recruiting staff is now streamlined and the records examined had evidence of appropriate recruitment checks and a checklist to show what had been completed. Induction training had all been signed off and certificates for completed courses were seen on staff files. A lot of training courses have been provided for staff and more are planned so that all mandatory and specialist training will be completed in the near future. Up dates for Moving and Handling training for all staff are also planned. Two senior staff in the home have completed the Certificate in Mental Health training course, at level 2 and one has level 3. The York House (York Way) DS0000019632.V342382.R01.S.doc Version 5.2 Page 17 Manager is searching for an appropriate professional course for support workers, as NVQ training is felt to be unsuitable for staff in the home. York House (York Way) DS0000019632.V342382.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,36,39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are content with their daily lives and benefit from living in a well run home, where their views are listened to and where the health and safety of residents and staff is promoted. EVIDENCE: The Registered Manager has completed the NVQ 4 Registered Manager’s award and the deputy has also applied to do this training. Those spoken with said the home was well managed and all said their views were listened to. There is a written Quality Assurance policy and annual questionnaires are due to be sent out in a few months. York House (York Way) DS0000019632.V342382.R01.S.doc Version 5.2 Page 19 Formal supervision has been started for all staff and a chart is in operation containing the year’s supervision dates. Records of supervision and appraisals are completed and kept locked in the office. Fire equipment had been recently serviced and residents confirmed that regular fire drills and tests take place in the home. Accident and incident recording was being properly documented and any resulting issues were followed up and details were recorded. No fire doors were being wedged open. York House (York Way) DS0000019632.V342382.R01.S.doc Version 5.2 Page 20 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 Standard No Score 1 3 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x York House (York Way) DS0000019632.V342382.R01.S.doc Version 5.2 Page 21 No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations York House (York Way) DS0000019632.V342382.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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