CARE HOMES FOR OLDER PEOPLE
York Lea 15/17 York Road Chorlton Manchester M21 9HP Lead Inspector
Geraldine Blow Unannounced Inspection 11th October 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service York Lea Address 15/17 York Road Chorlton Manchester M21 9HP 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) 0161 862 9338 0161 860 5815 Yorklea Limited Jaqueline Harper Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (35), Physical disability (2) of places York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Nursing or personal care may be provided for a maximum of 37 service users of either sex. Two named service users require nursing care by reason of physical disability. If these service users no longer reside at the home or their primary reason for requiring care changes, these places will revert to the OP category. Registration is subject to compliance with the minimum staffing levels indicated in the Notice previously served in accordance with Section 25(3) of the Registered Homes Act 1984 and dated July 2001. The manager must be supported at all times by an experienced RGN trained nurse . An experienced RGN trained nurse must undertake all recruitment of qualified nurses. 8th March 2005 3. 4. 5. Date of last inspection Brief Description of the Service: Yorklea Nursing Home is registered to provide accommodation for up to 37 older people assessed as requiring nursing or personal care. At the time of inspection the home was providing accommodation for 30 residents. There are two named residents accommodated out of category by reason of physical disability and the home was in the process of applying to vary their conditions of registration to accommodate a further resident requiring nursing care by reason of physical disability. The home is owned by Yorklea Limited. The Responsible Individual; is Ms Helen Claffey. The home is located in the Chorlton area of Manchester. It is close to local facilities, bus routes and the City Centre. There is parking to the rear of the building. The home is a large detached house that has been converted and refurbished from 2 original Victorian dwellings. Accommodation for the residents is provided on four floors, served by a passenger lift and the home is accessible to service users who use a wheelchair. The home has had planning permission granted for an extension. The plans
York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 5 have been submitted to the Commission for Social Care Inspection (CSCI) and building work has commenced. The extension on completion will provide a new conservatory style lounge, 4 single bedrooms with en-suite facilities, a new clinical room, a walk in shower room and 5 existing bedrooms will be refurbished which will include en-suite facilities. In addition the home is in the process of extensive re-decoration and refurbishment. The number of registered places and conditions of registration will remain unchanged as some existing double rooms will be used as single rooms on completion of the building York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over the course of 7 hours on Tuesday 11th October 2005. During the course of the inspection, time was spent talking to the responsible individual, the registered manager, the senior nurse, residents, a visitor and staff to find out their views of the home. Time was spent examining records, documents and residents files. A tour of the building was also conducted. Since the last inspection, in February 2005, the Commission for Social Care Inspection (CSCI) has not received any complaints. The home kept a record of any complaints made directly to them, which included details of the investigation and any action taken. The CSCI has received one anonymous concern regarding the décor and furnishings to one of the bedrooms. The home has an extensive programme of re-decoration and furniture replacement in place. During this inspection only a selection of the key National Minimum Standards were assessed. Therefore in order to gain a full picture of how the home meets the needs of residents, this report should be read with the previous and any future reports. What the service does well:
The staff have a clear commitment to improving the service delivered to the residents. All of the residents spoken to described positive experiences of the way staff treated them. One resident said, “the girls are great, nothing is too much trouble for them”. Further comments received by residents included “ I am happy with everything, I can’t fault anything” and “the staff are very kind”. One relative spoken to said, “the staff are excellent, very professional, nice and considerate”. One resident said “the staff here are great, when I came here I couldn’t do anything for myself and with the encouragement of the staff and seeing the physio every week I can now get in and out of bed on my own and walk with a frame. I have lost 6 stone in weight and now feel great, all with the help of the staff”. The staff spoken to said that residents do get choice and some control over their daily lives, unless it is detrimental to their care, and residents spoken to confirmed this. All the residents spoken to said that they were given choices in
York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 7 relation to what time they go to bed, get up in a morning and one resident said “ I have complete choice to what I do in my bedroom”. Some of the residents had their own phone in their room and one resident has a laptop and Internet connection. Staff were seen sat chatting with residents in the lounge and were observed to treat residents with respect and dignity. The responsible individual (the joint owner of the home) and the manager were known to the residents and relatives spoken to by their first names. All the people spoken to said that if they had any concerns or problems they would go to Jacqui, the manager, or Helen, the owner and they would sort it out for them. One resident said that when she first moved into the home she had a few “blips to start with” but she said “I was listened to by staff when I was less than happy and changes have been made”. The manager said that the home had an open visiting policy. One relative spoken to confirmed this. He said “I call in to see my wife every day, 2 or 3 times a day sometimes”. The home appears to provide adequate pressure relieving equipment for the prevention and treatment of pressure sores. Meals times appeared to be relaxing and feedback regarding the quality and quantity of food was positive. The menus examined seemed to provide a nutritious balanced diet and alternative meals were available at all meal times. A large supply of fresh fruit and vegetable was seen during the inspection. One resident said, “when I moved into the home I said I liked fresh fruit and I was given a bowl of fruit to keep by my bed”. The manager and senior nurse said that drinks and snacks could be requested at any time of the day and night. The residents spoken to confirmed this. A physiotherapist attends the home on a twice-weekly basis to do group and individual sessions with residents. A beautician also attends the home who does facials, manicures, foot massage, head massage etc. What has improved since the last inspection?
Since the last inspection a lot of building work has been competed. The new conservatory style lounge has been finished and is being used by the residents. It is a lovely, large, airy room to the rear of the building with patio doors that will lead out onto an enclosed patio area. It is hoped that the patio will be completed around Christmas time. The residents spoken to all really liked the new lounge. Two of the new bedrooms with en-suites had been finished and 3 refurbished rooms with en-suites were being used by residents. Two further
York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 8 new bedrooms with en-suites and the walk in shower room were not yet completed. A new clinic room was in use, which overlooked the lounge area. The home was in the process of extensive re-decoration and refurbishment. The home had worked hard and had improved the standard of the residents’ plans of care since the last inspection. The Service User’s Guide and the Statement of Purpose had been updated and combined into one document. All new residents were given a copy on admission to the home. The general recording of the medication had improved since the last inspection in order to protect the residents. Also to protect the residents the senior nurse had written care plans to clearly show the signs and symptoms of some of the more uncommon drugs used by residents. The complaints procedure has been amended to include the name and address of CSCI. The updated policy is on display within the home and in the Service User’s Guide. What they could do better:
Any residents who are taking any of their own medication must have a risk assessment to make sure they are safe to give themselves the medication. It was noted at the last inspection that not all of the radiators had protective covers in place to avoid any possible risk to residents. The inspector was told that slim line, decorative covers were just waiting got be cut and delivered to the home. Risk assessments had been completed to help reduce the risk of accidents. Since the last inspection the home has had 2 new boilers and a complete new system. However on testing the water from taps in some of the bedroom and bathroom sinks it was too hot. The plumbers must be contacted immediately. Although staff said that they asked residents what activities they would like to do this had not always been recorded. The home did not always record when residents had been involved in activities especially if the activity was an individual activity. The home must not have communal toiletries in the bathrooms. All residents must have their own personal toiletries. To help prevent the risk of cross infection the 2 hoists that are used to transfer residents who are unable to transfer on their own must be cleaned as they looked ‘grubby’. York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 9 Although the relative spoken to said that the staff kept him informed of any changes to his wife there was no written evidence in the residents files inspected that the resident or their relatives had been involved in drawing up of the care plan. The home obtains verbal references as well as applying for a written reference. However, new staff must not be allowed to start work at the home until the 2 written references have been received. 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 Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 11 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Information was available for prospective residents to make a choice about where to live. EVIDENCE: At the last inspection the Service User’s Guide and the Statement of Purpose was under review and a requirement was made that on completion a copy must be supplied to CSCI, which had been met. The documents had been reviewed and combined into one booklet. The inspector was told that the booklet was available on request and all new residents were given a copy on admission to the home. York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9, & 10 Each resident had an individual plan of care and overall the health and personal care needs of the residents were being met at the home. Residents who are self-medicating must have a risk assessment to assess their capabilities. EVIDENCE: A random sample of care plans were examined. Evidence was seen of ongoing work to improve the documentation of the care planning system. However, there was some contradictory information identified. For example, one file examined stated on 2 occasions that the resident was at low risk of falls then further into the file it stated that the resident was high risk of falls. In the main the plans of care set out the action to be taken by care staff to ensure the needs of the residents were met, however some parts were found to be rather vague e.g. ‘follow correct moving and handling techniques’ and ‘position correctly for meals’. York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 13 Most of the plans had been reviewed on a monthly basis, however one bed safety rail assessment had documented a monthly review. No evidence was seen that a review had taken place. The requirement from the last inspection that all entries within the individual plan of care must be dated and signed by the person completing them had been met with the exception of one wound care plan that had been signed but not dated. There was a daily journal completed for each resident. Of the files inspected here was no evidence that the plans of care had been drawn up with the involvement of the resident and/or their representative. The senior nurse told the inspector that he was in the process of addressing this. All residents were registered with local General Practitioners and had access to visiting healthcare professionals e.g., Dietician, Chiropody, Dentistry and Ophthalmology. As part of the building work the home has a new spacious clinic room where all medication was found to be securely stored. The home used the Venalink system and each tablet/capsule was sealed into a separate compartment for easy identification. On examination the MAR sheets they were found to be clear and contain accurate recordings. The file contained a list of all staff signatures and a photograph of the residents, which acted as an aid to identification at the time of medication administration. It was noted that one resident was self-medicating her own saliva spray and hypermellose eye drops. Evidence must be provided that all residents who self-medicate have had a risk assessment to ascertain their capabilities and appropriateness to self-administer their own medicines. The recommendation from the last inspection that the home implement a policy relating to the verbal orders of medication had been implemented. The senior nurse stated that verbal orders were only accepted if supported by a fax. The original GP prescriptions come to the home to be checked before they are collected by the pharmacy to be dispensed. Medication had been signed into the home and inline with new legislation, from the 1st Aril 2005, the home had recently employed the services of an independent company to dispose of pharmaceutical waste. The senior nurse said that unused medication to be disposed of would be recorded and witnessed by 2 people 1 of who must be a registered nurse. York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 14 From observations made during the inspection and discussions with members of staff and residents it appeared that the nurses and care staff treated the residents with respect and dignity. Privacy screens were available in the double rooms. York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 It appeared that residents were able to maintain contact with family/friends and were able exercise choice and control over their daily lives. Meals appeared to be nutritious and well balanced. However, limited activities were available to residents. EVIDENCE: From observations and speaking to staff and residents it was clear that some activities were available to residents. This, on the whole, tended to be individual activities. The manager held monthly residents meetings, which included discussing activities. Hand written minutes were available for inspection. The manager and the senior nurse both told the inspector that residents are regularly consulted on an individual basis regarding activities. There was no documented evidence to support this and the written evidence did not accurately reflect all the activities undertaken by residents. The home operated an open visiting policy and visitors could be received in private or in any of the communal areas. The residents and relative spoken to confirmed this. Visiting was only restricted if requested by a resident or their
York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 16 advocate. Any restriction was formally recorded and communicated to all persons concerned. It appeared that residents were able to exercise choice and control with regard to their day-to-day lives. Several of the bedrooms had been personalised with residents belongings brought in from home. Personal belongings were recorded on admission to the home. The menu inspected had been developed on a 3-week rota system. The main meal of the day was provided at lunchtime although this could be changed to evening on request. The home provided one dining room and meals were served over 2 sitting. The first sitting was for the residents who could eat their meal independently and the 2nd sitting was for residents who required assistance with feeding. Residents were encouraged to use the dining room but could take their meals in other areas of the home if they preferred. York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The complaints procedure was on display and residents appeared to know how to make a complaint. The home’s policies and procedures served to protect the residents from abuse. EVIDENCE: The home had the complaint procedure on display in the main reception area, which was seen to include all the relevant information. The home maintained a complaint file, which contained details of the complaint, staff statements, the actions taken and the outcomes. All residents spoken to said they would complain to the manager or Helen the owner if they had any concerns. The home had a copy of the Manchester Multi-Agency Policy for the Protection of Vulnerable Adults from Abuse, which would be followed if an allegation of abuse were made. Staff spoken with were able to describe the appropriate actions to be taken in the event of an allegation of abuse. The responsible individual told the inspector that the home was in the process of implementing review sessions with staff. York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 & 26 The homes environment was generally clean, comfortable and equipped to meet the needs of the residents. However, some areas of concern were identified which posed a risk to residents and staff. EVIDENCE: As already stated the home was in the process of undergoing building work. Some areas of the home were identified as showing signs of ‘general wear and tear’ i.e. some of the bedroom furniture was in need of repair and some bedrooms and corridors were in need of re-decorating. However a programme of re-decoration and refurbishment was in place to address these issues. The requirement from the last inspection that the remaining unguarded radiators must be fitted with appropriate covers had not been met. Risk assessments were in place but some of the unguarded radiators did feel very hot to the touch. The guards must be fitted as soon as possible.
York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 19 The home has previously had problems with water temperature delivery exceeding 43 °C. Advice had been sought from the Environmental Health who advised that warning signs were placed at every sink. Evidence was seen that this had been implemented and risk assessments were completed. Since the last inspection a new system had been installed and the home was just waiting for it to be commissioned. However on a random test of the water temperatures it was found to excessively hot, it ranged from 50.2°c to 51.7°C in residents bedrooms and some bathrooms. This places vulnerable people and staff at risk. It was noted in some of the bathrooms communal toiletries were being used. This is an unacceptable practice and residents must have their own personal toiletries. The responsible individual said that the home had received the new Infection Control Guidelines and the home was working towards them. Personal Protective Equipment (PPE), which includes gloves, aprons and wipes were available in residents’ bedrooms to facilitate the management of personal care. The inspector was told that residents who required the use of the hoist had their own slings to help reduce the risk of cross infection. The manager told the inspector the hoists were cleaned on a weekly basis. The Infection Control Guidelines recommended that equipment is cleaned in between resident use and the home should make equipment wipes available in the nurses’ office, sluices and next to hoists to facilitate cleaning. It was noted that the hoist were generally ‘grubby’ and required cleaning. York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 29 The numbers and skill mix of staff appeared to be sufficient to meet the needs of the residents. The homes recruitment policies and procedures appeared to promote the safety and wellbeing of the residents. However, one shortfall in relation to written references was identified. EVIDENCE: At the time of the inspection the home accommodated 30 residents i.e. 29 residents assessed as requiring nursing care and 1 resident assessed as requiring personal care only. The numbers and skill mix of the staff, at the time of inspection, appeared to be sufficient to meet the needs of the number of residents accommodated. The home employed 14 care staff, of those 1 carer had achieved NVQ level 3 and 4 care staff had achieved NVQ level 2. A further 5 care staff were currently undertaking NVQ level 2 and there were plans for 1 carer to undertake NVQ level 3 and for the senior nurse to enrol on NVQ level 4 in Management. All staff files are stored at the administration and training centre at the sister home in the Newton Heath area of Manchester. During the recent inspection at the sister home a random sample of staff files were inspected. York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 21 A random sample of staff files were inspected. Two of the files did not contain a written reference. Both files contained 2 verbal references and one written reference. Evidence was seen that the responsible individual had made every effort to obtain the 2nd written reference without success. The responsible individual was reminded that staff must not take up post until 2 satisfactory written references have been obtained. There was a computerised system in place to check expiry dates of PIN numbers and work permits. Evidenced was seen that CRB and POVA checks had been undertaken on all newly appointed members of staff. York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the Standards in this section were assessed on this occasion. York Lea DS0000061291.V255681.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 Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x 2 2 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x x x x York Lea DS0000061291.V255681.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 OP7 Regulation 15 & 13 Requirement 1. The residents’ plan of care must set out in detail the action to be taken to ensure all aspects of care are met. 2. The plans of care must be clear and not contain contradictory information. 3. Reviews must take place at the identified and documented time. 4. Evidence must be provided that the plan of care, where possible, is drawn up with the involvement of the resident and once agreed it must be signed for by the resident whenever possible and/or their representative. 5. The implementation date of all care plans must be recorded. Timescale for action 30/11/05 York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 25 2 OP9 13 3 OP12 16 Evidence must be provided that all residents who are currently self-medicating have had a risk assessment to ascertain their capabilities and appropriateness to self-administer their own medicines. 1. Evidence must be provided that residents are consulted regarding the planning of activities, outings and entertainment. 2. The home must keep an accurate record of all activities undertaken by individual residents. 1. The remaining unguarded radiators must be fitted with appropriate safety covers so as to avoid potential risk to residents. (Previous timescale of 31/5/05 had not been met) 2. The responsible individual must ensure that measures are taken to ensure that hot water is delivered at about 430c. 30/11/05 30/11/05 4 OP25 13 01/12/05 5 OP26 13 1. Communal toileteies must not used in the home. 2. The 2 hoists must be cleaned to help prevent the risk of cross infection. Two written references must be obtained before appointing a member of staff. 30/11/05 6 OP29 19 Schedule 2 30/11/05 York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 26 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 Refer to Standard OP26 Good Practice Recommendations It is recommended that: 1. The home should ensure hoist equipment is cleaned in between each use. 2. The home should make equipment wipes available in sluices and next to hoists. York Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Lea DS0000061291.V255681.R01.S.doc Version 5.0 Page 28 - 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!
