CARE HOMES FOR OLDER PEOPLE
York Lea 15/17 York Road Chorlton Manchester M21 9HP Lead Inspector
Geraldine Blow Unannounced Inspection 09.30 20 March 2006
th 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.V278980.R01.S.doc Version 5.1 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.V278980.R01.S.doc Version 5.1 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 (34), Physical disability (3) of places York Lea DS0000061291.V278980.R01.S.doc Version 5.1 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. Three 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. Staffing for service users assessed as requiring personal care only must comply at all times with the minimum levels set out in the Residential Forum Guidelines for Staffing in Care Homes for Older People. 11th October 2005 3. 4. 5. 6. 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. 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 residents who use a wheelchair. The home has had planning permission granted for an extension. The plans have been submitted to the Commission for Social Care Inspection (CSCI) and building work is nearing completion and many of the rooms are in use. The extension will provide a new conservatory style lounge, 4 single bedrooms with
York Lea DS0000061291.V278980.R01.S.doc Version 5.1 Page 5 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.V278980.R01.S.doc Version 5.1 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on the 20th March 2006. During the inspection time was spent talking to the responsible individual, the registered manager, the senior nurse and several of the residents to find out their views of the home. In addition residents files, records and other relevant documentation were examined. A tour of the premises was also made. At the time of this inspection the majority of building work was completed and the rooms were in use. Once it is fully completed it is proposed that the internal decoration will commence. Since the last inspection the CSCI has not received any complaints about the service. As this was the second unannounced inspection within the last 12 months only the core standards not covered and the requirements made from the first inspection were assessed. Therefore, this report must be read in conjunction with any previous reports to gain a full picture of home What the service does well:
Of the core standards assessed during this inspection the home does well in the following: The home had a warm friendly atmosphere and staff were observed to be pleasant and courteous with residents. Staff were seen to have good interactions with residents and were observed dealing with residents individual needs. The residents appeared well dressed, happy and settled. The manager and the senior nurse were continuing to work hard to improve the service delivered to residents and demonstrated a commitment to meeting the National Minimum Standards. During discussions they were able to identify the individual needs of the residents. The home carries out assessments of each perspective resident before admission to the home to ensure that the home can meet all the needs of the resident. The resident and/or their representative are encouraged to view the home before making a decision about admission. After the pre-assessment the home writes to the resident or their relative informing them of the outcome. The home encourages and support staff to undertake the necessary training and learning they require to support the residents accommodated at the home. York Lea DS0000061291.V278980.R01.S.doc Version 5.1 Page 7 The home has a quality auditing system in place, which is based on seeking the views of the people living at the home and their representatives. Following a review of all completed questionnaires a report and action plan is produced. The manager said that the last action plan was produced in November 2005. It has been recommended that the questionnaire also be sent to visiting professionals in order to gain their view of the service provided. From the systems in place it appeared that the financial interests of residents are safeguarded. What has improved since the last inspection? What they could do better:
Improvements, as already mentioned in this report, have been made in the care planning process, however the recording in the daily journal was variable. The daily journal must contain an accurate record of the nursing care provided. York Lea DS0000061291.V278980.R01.S.doc Version 5.1 Page 8 Activities were being provided for the residents and since the last inspection each resident had an activity recording sheet. The manager said that residents are consulted on an individual basis with regard to their hobbies and interests. However, this had not been documented, as required at the last inspection. The manager said that she holds regular resident/relative meetings and activities are discussed as part of this. The home was in the process of organising a celebration for the Queens birthday. It is recommended that the home employ the services of an activity organiser. At the last inspection, on a random test of water temperature delivery,it was found to be to hot. The responsible individual had addressed the issue immediately following the inspection. However, on a randon water temperature test, duirng this inspection, it was found to be too cold. The responsible individual told the insepctor they were aware of the problem, she said that the home had a new water system that had been commissioned but since then the home has had new boilers installed and now the whole system requires commissioning. This issue must be addressed as a matter of some urgency. At the previous 2 inspections a requirement was made that all unguarded radiators must be fitted with appropriate safety covers to avoid potential risk to residents. This requirement had not been met and has been reiterated in this report. As identified at the last inspection the inspector was told that new slim line, decorative covers were waiting to be cut and delivered as part of the refurbishment of the home. Some risk assessments had been completed to help reduce the risk of accidents. All unguarded radiators must be risk assessed until the guards have been fitted. 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.V278980.R01.S.doc Version 5.1 Page 9 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.V278980.R01.S.doc Version 5.1 Page 10 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): 3 The home undertakes an assessment of prospective residents care needs prior to their admission. EVIDENCE: The home conducts a pre-admission assessment of prospective residents to ensure that the home can meet all assessed needs. The assessment included the involvement of the prospective resident, his/her representatives and any relevant professionals. The manager said that following the pre-admission assessment the home confirms in writing to the prospective resident that the home is able/not able to meet their assessed needs. Where possible, prospective residents and their family/representatives are encouraged to view the home prior to making a decision about admission. For residents who are referred through Care Management arrangements the home obtains a summary of the Care Management Assessment prior to admission. The home does not provide an intermediate care service.
York Lea DS0000061291.V278980.R01.S.doc Version 5.1 Page 11 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): No judgements were made at this inspection EVIDENCE: As already stated in this report the home had continued to improve the standard of the individual plan of care and all the requirements made at the last inspection in relation to care planning had been met. However, it was noted that the standard of recording in the daily journal was variable and did not always refer to the residents’ assessed needs or evidence of the actual care delivered. It is commendable that the home has employed the services of an independent clinical audit consultant who will be auditing the medication procedures and the care planning process on an ongoing basis. The first clinical audit of medication had taken place on the 10th February 2006 and was available for inspection. The core standards were assessed at the previous inspection. York Lea DS0000061291.V278980.R01.S.doc Version 5.1 Page 12 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): No judgements were made at this inspection EVIDENCE: The previous inspection report required that the home must keep an accurate record of all activities undertaken by individual residents. The manager said that each resident now has an activity sheet that is completed after each activity undertaken. As identified at the last inspection activities were available to residents and regular resident/relative meetings were held and activities were discussed at these meetings. The inspector was informed that in addition to the meetings residents are regularly consulted on an individual basis regarding activities. However, no evidence could be found to support this. The requirement that evidence must be provided that residents are consulted regarding the planning of activities, outings and entertainment has been reiterated in this report and it has been recommended that the home employ the services of an activity organiser. The core standards were assessed at the previous inspection. York Lea DS0000061291.V278980.R01.S.doc Version 5.1 Page 13 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): No judgements were made at this inspection EVIDENCE: The core standards were assessed at the previous inspection. York Lea DS0000061291.V278980.R01.S.doc Version 5.1 Page 14 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): No judgements were made at this inspection EVIDENCE: As already referenced in this report the requirement made, at the last 2 inspections, that all unguarded radiators must be fitted with safety covers had not been met. The requirement has been reiterated in this report. Some risk assessments had been completed on the unguarded radiators. It is required that all unguarded radiators have a risk assessment in place to avoid the risk of unnecessary injury to residents and the guards must be fitted as a matter of some urgency. A discussion took place with the responsible individual regarding the water temperature delivery. At the last inspection the temperatures ranged from 50.2°c to 51.7°C in residents bedrooms and some bathrooms. On a random test during this inspection they ranged from 35.9°C to 36.2°C. Water must be delivered at about 43°C. As already stated in this report the responsible individual told the insepctor they were aware of the problem, she said that the home had a new water system that had been commissioned but since then the
York Lea DS0000061291.V278980.R01.S.doc Version 5.1 Page 15 home has had new boilers installed and now the whole system requires commissioning. This must be actioned as a matter of some urgency. Evidence was seen that the home conducts water temperature testing. It was noted on a tour of the premisie that the free standing wardrobes in residents’ private accommodation had not been secured to the walls or risk assessments had not been completed. This must be actioned in an effort to reduce the possibility of avoidable accidents. The inspector was informed that communal toiletries are no longer used in the home. The requirement that the 2 hoists must be cleaned had been met. The core standards were assessed at the previous inspection. York Lea DS0000061291.V278980.R01.S.doc Version 5.1 Page 16 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): 30 Staff have access to the training and learning they require to support the residents accommodated at the home. EVIDENCE: The homes manager keeps a list of all staff training that has been undertaken. This information is then given to the staff at Windsor House, the sister home, Dove’s Nest. The information is then stored on a computerised training matrix which demonstrates what training has been undertaken. There are systems in place to ensure that all staff have undertaken the necessary mandatory training. This matrix was viewed during the unannounced inspection of Dove’s Nest Nursing home on the 6th March 2006. The manager can request this information at any time. However, it is recommended that this information be given to the home manager so that the matrix can be used to develop an individual training and development plan for each member of staff and then be discussed and updated during supervision. The home has a structured Induction process. The Induction is currently based on the TOPPS guidance. However, the organisation that set the standards of training for all social care services and workers recently introduced new guidance on what an induction programme for new staff should include. These new standards will be compulsory in September 2006. The responsible individual is aware of this new development and is currently reviewing the Induction programme to make sure that it meets the new standards. The remaining core standards were assessed at the previous inspection.
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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): 31, 33, 35 & 38 The manager has the experience to manage the home. A quality assurance system has been developed to seek residents’ views and the systems for managing residents’ money appeared to protect their interests. EVIDENCE: The residents in the home benefit from a committed, caring manager who is registered with CSCI and has the continued clinical support from an experienced senior nurse. As already stated in this report the home has a quality audit system whereby Windsor House sends out questionnaires to residents and relatives in order to obtain feedback on the service provided. Following a review of all completed responses an action plan is produced and that information is then disseminated to all staff working in the home. The manager said that the last report produced was in November 2005. It has been recommended that the
York Lea DS0000061291.V278980.R01.S.doc Version 5.1 Page 18 questionnaire be sent to visiting professionals in order to gain that opinion of the service being delivered. It is commendable that the home has recently purchased the services of a Business Process Engineer who is to review all the homes documentation including the policies and procedures. He is to work closely with the responsible individual and the homes manager. These will be assessed at the next inspection. Windsor House has the responsibility and the computerised records of resident’s personal allowances. Yorklea has ‘petty cash’ that is given to residents on request or when items are bought on behalf of a resident. If the resident is able they will sign for receipt of any money or 2 staff signatures will be obtained. A written record is kept of all transactions and receipts are kept. At the end of the month this information is sent to Windsor House to go on the computerised system. Evidence was seen that the home ensures the health, safety and welfare of the residents and staff are protected at all times. York Lea DS0000061291.V278980.R01.S.doc Version 5.1 Page 19 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 X 9 X 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 x COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x X X X X X X x X STAFFING Standard No Score 27 X 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 York Lea DS0000061291.V278980.R01.S.doc Version 5.1 Page 20 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. 2. Standard OP7 OP12 Regulation 17 Schedule 3 16 Timescale for action The daily journal must include an 31/03/06 accurate record of all nursing care provided. Evidence must be provided that 30/04/06 residents are consulted regarding the planning of activities, outings and entertainment. (Previous timescale of 30/11/05 had not been met) The responsible individual must ensure that the freestanding wardrobes present within the service user’s private accommodation are secured to the walls in an effort to reduce the possibility of avoidable accidents. 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 and 01/12/05 had not been met) Requirement 3. OP24 13 30/04/06 4. OP25 13 01/05/06 York Lea DS0000061291.V278980.R01.S.doc Version 5.1 Page 21 2. The responsible individual must ensure that measures are taken to ensure that hot water is delivered at about 430c. (Previous timescale of 01/12/05 had not been met) 3. All unguarded radiators must be risk assessed until the guards have been fitted. The home must develop an induction programme based on the Skills for Care Common Induction Standards. 5. OP30 18 01/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP12 OP30 Good Practice Recommendations It is recommended that the home employ the services of an activity organiser. It is recommended that the computorised record of staff training be given to the manager in order for her to develop an individual training and develoment plan for each member of staff and to facilitate supervison. It is recommended that the qulaity audit questionnaire also be sent to visitng professionals in order to gain their view of the service being delivered. 3. OP33 York Lea DS0000061291.V278980.R01.S.doc Version 5.1 Page 22 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
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