Inspection on 09/01/07 for York House (York Way)

This inspection was carried out on 9th January 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 found no outstanding requirements from the previous inspection report, but made 2 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) 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 Unannounced Inspection 9th January 2007 11:30 York House (York Way) DS0000019632.V326797.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.V326797.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.V326797.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.V326797.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. 20th December 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 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. York House (York Way) DS0000019632.V326797.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 day with one inspector. There were 12 service users living in the home at the time of the visit and several were spoken with, as was some of the staff on duty. A brief tour of the building took place and lunch was observed during the visit. The Manager was present during the second half of the inspection and a selection of records was examined. The process of administering medication was also seen and drug storage and records were checked. The home’s Statement of Purpose and Service User’s Guide are kept in the staff office and are available on request. Currently, fees for the home are £498 per week. What the service does well: What has improved since the last inspection? What they could do better: Staff recruitment files were not examined at the last two inspections but two were checked here. The checks seen were not adequate and, as formal staff supervision has not yet started, this situation could leave service users at risk. Requirements have been made to improve both these areas and the Manager will forward the evidence needed for the two staff records checked, to the York House (York Way) DS0000019632.V326797.R01.S.doc Version 5.2 Page 6 CSCI. Another inspection will be made in due course to examine all the recruitment files in the home. 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.V326797.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.V326797.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): Standard 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user needs are fully assessed prior to entering the home to ensure that all individual needs can be met. EVIDENCE: There had been two new service users admitted to the home since the last inspection. Care plans for these individuals were checked and contained detailed assessments from the referring agencies and assessments completed by staff from the home. York House (York Way) DS0000019632.V326797.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 enable service users to make decisions about their own lives and all residents are supported by staff to take appropriate risks. Detailed information recorded in care plans ensures that staff are aware of the individual needs of service users and can provide appropriate assistance in each case. EVIDENCE: A selection of care plans were checked and these contained detailed information about the service users and their needs and aspirations. Appropriate risk assessments were included and reviews were up to date. The plans recorded individual choices and service users spoken with confirmed that staff supported their wishes, or explained why any restrictions had to be imposed. One resident explained that a solicitor helped him handle his finances and staff at the home assisted in the arrangements made in this case. Service users spoken with said they understood the risks associated with smoking and supported the house rule that they only smoke in the smoking room. York House (York Way) DS0000019632.V326797.R01.S.doc Version 5.2 Page 10 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. Service users are supported to pursue any appropriate leisure activity they choose and are encouraged to maintain links with their families and friends and therefore to continue to feel part of the community. The daily lives of the residents in the home are further improved by staff who support individual choices and who provide wellbalanced and enjoyable food. EVIDENCE: The Manager said that service users attend day centres on various days of the week, but that the current residents were unable to take up training courses or paid employment. One service user is, however, just starting to work for a few hours as a volunteer in a charity shop. All residents are able to make independent trips out of the home and several went in and out during the inspection. Service users confirmed that staff accompany them going out where appropriate, such as for hospital visits. The Manager said that relatives were welcomed to make visits at any time and that some residents had regular visits from their families. All current service users manage their own personal care. Service users said they kept their own rooms clean and took turns to York House (York Way) DS0000019632.V326797.R01.S.doc Version 5.2 Page 11 help with general household tasks. Rotas for domestic chores were seen displayed around the home. All bedrooms have locks on the doors and service users were seen using their own keys to go in and out. 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. The mid-day meal was seen prepared and enjoyed and service users said they enjoyed the food in the home and could say what food they preferred. A menu was displayed in the dining room. Staff spoken with had completed Food Hygiene training and records of fridge and freezer temperature checks were being regularly recorded. There had been a recent Environmental Health Inspection and the report was seen. No requirements had been made as a result of that inspection. 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.V326797.R01.S.doc Version 5.2 Page 12 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. Procedures in the home ensure that all service users’ health needs are met in a manner they prefer and the system for administering medication is thorough and helps to protect service users. EVIDENCE: Service users spoken with said they were happy with all the support provided by staff and were generally independent regarding personal care. One resident had been accompanied by a support worker that morning when he attended a local doctor’s surgery and another resident said staff went with him to have a monthly injection. Records showed that appropriate referrals and appointments were made for residents to see Health professionals. 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. Five senior staff are responsible for giving medication and all have completed accredited training courses. York House (York Way) DS0000019632.V326797.R01.S.doc Version 5.2 Page 13 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 service users are protected from abuse and have their views taken into account. EVIDENCE: The home has written policies on Making a Complaint, Whistle Blowing and Adult Protection and staff were aware of these. Service users spoken with said they would always tell staff if they had a concern or a complaint. There is also a sealed box in the hall where anyone can place a comment, complaint or suggestion. Adult Protection training has been provided for some of the staff and more has been booked so that all support workers and seniors will have received accredited training by the summer. York House (York Way) DS0000019632.V326797.R01.S.doc Version 5.2 Page 14 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): Standard 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a well-maintained and comfortable environment, which is kept clean and hygienic. EVIDENCE: On the day of the visit, staff were cleaning parts of the home and were using protective gloves and clothing. The home generally looked clean and well maintained. Since the last inspection, changes have been made to the buildings and there is now one communal dining room, lounge and kitchen, which staff and service users said was much more “sociable” than the previous arrangements where each house had its own facilities. The kitchen has been newly fitted and there is one large smoking room, which appeared very popular. Lighting in the lounge has been improved and the residents have modern audio and visual equipment. Bedrooms were all very personalised and one resident has a new mattress and light shade, as recommended at the last inspection. The extractor fans were working in the bathrooms and one service user had been involved in choosing a new colour scheme for his bedroom. York House (York Way) DS0000019632.V326797.R01.S.doc Version 5.2 Page 15 Some service users wanted to leave their own toiletries and soap in the communal bathrooms but staff were reminded that this was not good practice and should encourage the residents to keep their own toiletries in their bedrooms, unless there were lockable facilities in the bathrooms. 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.V326797.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, 35 and 36. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users benefit from having care provided by staff that are generally well trained, although not all basic training is up to date. However, recruitment procedures in the home are not thorough and in addition, formal staff supervision does not yet take place. This means that systems in the home do not provide adequate protection for vulnerable service users. EVIDENCE: There were three support workers on duty during the inspection and the Manager arrived during the afternoon. Staff confirmed that two support workers provided “sleeping-in” duties every night. Service users said they felt there were enough staff on duty in the home. The Manager has updated individual staff training profiles but it was recommended that an overview be produced to ensure that all staff training is up to date. A lot of courses have been provided for staff and more are planned so that all mandatory and specialist training should be completed in the near future. Two senior staff in the home have completed the Certificate in Mental Health training course, at level 2 and one has level 3. The Manager is searching for an appropriate professional course for support workers, as NVQ training is felt to be unsuitable York House (York Way) DS0000019632.V326797.R01.S.doc Version 5.2 Page 17 for staff in the home. The Manager has completed an Infection Control course and this will now be provided for other staff in the home. At two previous inspections, staff recruitment files were unavailable and were not checked. Two files were checked at this visit, including that for a new support worker. Both members of staff need to provide evidence of current permission to work in this country and references in both cases were inadequate. POVA clearance and evidence of CRB clearance was in place but the general standard of recruitment procedure was not thorough and did not provide sufficient protection for residents in the home. A Requirement has been made that procedures for recruitment must improve and the Manager must make further checks on the two staff discussed and send copies of the relevant evidence to the CSCI. Recruitment checks on all staff employed will be made at the next inspection. York House (York Way) DS0000019632.V326797.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 37,39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a well run home where their views are listened to and where good health and safety procedures are followed. EVIDENCE: The Registered Manager has completed the NVQ 4 Registered Manager’s award and has also undertaken other training courses since the last inspection. Both staff and service users felt the home was well managed and all said their views were listened to. The home has a written Quality Assurance policy and returned questionnaires from staff and service users were seen in the Quality file. The Manager is aware that Quality systems may need to be expanded in the future. Fire equipment had been recently serviced and residents confirmed that regular fire drills and tests took place in the home. The fire alarm had also been checked by the fire service and was deemed to be working well. Accident and incident recording was being properly documented and any resulting York House (York Way) DS0000019632.V326797.R01.S.doc Version 5.2 Page 19 issues were followed up and details were recorded. Some fire doors in the home had magnetic closure devices fitted and staff were reminded that no fire doors should be wedged open to ensure safety in the home. York House (York Way) DS0000019632.V326797.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 x 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 1 35 3 36 2 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.V326797.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. 1. Standard YA34 Regulation 19 & Schedule 2 Requirement The Registered Provider must ensure that thorough staff recruitment procedures are followed in the home and must obtain evidence of all the checks listed in Regulation 19 and Schedule 2 for all staff, including full employment histories; two appropriate written references; a health declaration and CRB clearance. The Registered Provider must ensure that all staff at the home receive formal, recorded supervision at least six times each year. (The time scale here is for this procedure to be planned and started.) Timescale for action 01/04/07 2. YA36 18(2) 01/04/07 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.V326797.R01.S.doc Version 5.2 Page 22 York House (York Way) DS0000019632.V326797.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hertfordshire Area Office 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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