Inspection on 21/08/07 for York Lea

This inspection was carried out on 21st August 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 Lea 07/11/06

York Lea 20/03/06

York Lea 11/10/05

York Lea 08/03/05

York Lea 19/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE York Lea 15/17 York Road Chorlton Manchester M21 9HP Lead Inspector Val Bell Unannounced Inspection 12:00 21st August and 11 September 2007 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.V346097.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 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.V346097.R01.S.doc Version 5.2 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.V346097.R01.S.doc Version 5.2 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. 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. 7th November 2006 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. A recently completed extension has provided a conservatory style lounge, four single bedrooms with en-suite facilities, a clinical room, walk in shower room and five existing bedrooms that were refurbished now include en-suite facilities. The home’s redecoration and renewal programme is ongoing. York Lea DS0000061291.V346097.R01.S.doc Version 5.2 Page 5 The number of registered places and conditions of registration has remained unchanged as some existing double rooms are being used as single rooms. The charges for fees range from £395.00 per week. There are additional charges for chiropody, newspapers, hairdressing toiletries and outings. York Lea DS0000061291.V346097.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) since the last inspection on 7th November 2006. Site visits to the home form part of the overall inspection process and the lead inspector conducted two visits during daytime hours on Tuesday 21st August and Tuesday 11th September 2007. The opportunity was taken to look at the core standards of the National Minimum Standards (NMS) This inspection will also be used to decide how often the home needs to be visited to make sure that the required standards are being met. During the visit time was spent talking to five people living in the home and discussions were held with the provider, the registered home manager, a nurse and three care assistants. Conversations were also held with two relatives of a resident that were visiting during the second days visit. Telephone conversations were held with the relative and a friend of two residents and four satisfaction surveys were completed and returned to the Commission on behalf of five residents. Relevant documents, systems and procedures were assessed, a tour of the home was undertaken and the manager provided written information prior to the inspection in the form of a self-assessment. What the service does well: Staff and residents had formed good relationships that were based on mutual respect and trust. Six residents spoken to praised the way staff were meeting their personal and healthcare needs and confirmed that the home was managed well. Systems were in place to ensure that residents were afforded protection from harm and residents were confident that their concerns were being listened to and addressed in a timely manner. One resident said, “The resulting action is always clearly explained to me.” Staff had access to training to ensure that they had the knowledge and skills to meet residents’ needs and care was taken to recruit the right staff to work with older people. The atmosphere in the home was relaxed and a homely and a safe living environment had been provided for residents. The provider took care to ensure that the décor was kept in good condition and that furniture and fittings were replaced as necessary. The home was found to be clean and hygienic and no unpleasant odours were present. Priority was given to listening to residents and their relatives and suggestions for improvements had been taken on board. York Lea DS0000061291.V346097.R01.S.doc Version 5.2 Page 7 Residents spoken to praised the quality of catering provided and one person said, “Excellent catering.” Residents were afforded choice in their diet and the chef took care to present meals in an attractive way. What has improved since the last inspection? What they could do better: Four requirements and seven good practice recommendations were made during this inspection. Six care plans were chosen and assessed for evidence that residents’ needs were being met. One of the residents had been admitted to the home six days prior to the first inspection visit, although no care plan had been written. Additionally, there were no risk assessments in place for this person. There was no evidence to suggest that the resident’s welfare had been compromised due to these shortfalls. However, staff must have written guidance on how to meet residents’ needs safely from the moment they are admitted to the home. During discussion with the manager it transpired that a clinical procedure had been undertaken with a person who had been assessed by the manager as needing personal care only. It was accepted that the action had been taken in the person’s best interests in response to an emergency situation and there was no evidence to suggest that this person’s health and welfare had been compromised. However, undertaking clinical procedures with people admitted for personal care only could potentially place the welfare of individual at risk. One recommendation was made to ensure that people should be advised to request care manager assessments of need prior to admission. Care records were generally up to date although several minor shortfalls were found, in relation to staff omitting to sign and date documents. Furthermore, there was a lack of written evidence that residents’ social, cultural and religious preferences were being met. Conversations with residents and their relatives confirmed that these needs were being met, but staff were not writing this down. In discussion with the inspector the manager stated that she was keen to develop this in a person-centred way. The inspector joined residents in the dining area for the midday meal. It was noted that the main entrance to the home opened into the dining area and several visitors entered and left by this entrance during the meal. The registered person should consider alternative arrangements during mealtimes York Lea DS0000061291.V346097.R01.S.doc Version 5.2 Page 8 to ensure that the residents’ rights to privacy and dignity are not compromised. Recommendations were made to review verbal communication between residents and staff and the staff response times for residents using the nursecall system. This was based on comments made by a resident that completed a satisfaction survey. Finally, the fire risk assessment was almost two years old and should be reviewed to ensure that it complies with fire safety legislation recently introduced. 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 Lea DS0000061291.V346097.R01.S.doc Version 5.2 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.V346097.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessment process in place ensures that people referred to the home are consulted about their needs and this enables them to take a decision on whether the home will be the right place for them to live. EVIDENCE: The files for six people living in the home contained care manager assessments of need and in-house pre-admission assessments of need. Two residents and four relatives confirmed that they had been consulted throughout the assessment process. Discussion with the manager revealed that a clinical procedure had been undertaken with a person previously admitted to the home for a weeks respite care. This person had been self-funding and had not received a care manager York Lea DS0000061291.V346097.R01.S.doc Version 5.2 Page 11 or nursing assessment of need, but had been assessed by the home manager for personal care only. The provider stated that the policy was to refer people receiving personal care only to the district nursing service or the accident and emergency department if they developed healthcare needs. However, the provider said an emergency situation had developed and the district nursing service could not be contacted. The provider explained that, “the senior nurse carried out the procedure after lengthy discussion with and under the instruction of the service user’s general practitioner. Our senior nurse is competent and skilled in the clinical procedure performed and having used his professional knowledge, judgement and skill relieved the service user of pain and discomfort and avoided the indignity of a long wait in the accident and emergency department.” It is accepted that this action was taken in the best interests of the person concerned. This situation could not have been foreseen and there was no evidence that this person’s health had been compromised by the action taken. However carrying out clinical procedures with people that have not received nursing assessments of need could potentially place their health and welfare at risk. A recommendation was made to ensure that people have an appropriate needs assessment prior to admission. The home did not offer an intermediate care service. York Lea DS0000061291.V346097.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People admitted to the home can be confident that their personal and healthcare needs will be met according to their individual preferences. EVIDENCE: The care records belonging to six people living in the home were examined. Five care plans had been developed from information supplied by the local authority and in-house assessments of need. The sixth person had been admitted six days before the inspection visit although there was no evidence of a care plan. The manager said that staff followed the pre-admission assessment until a care plan was in place. This leaves the interpretation of how a person’s needs are to be met up to individual staff. Specific instructions must be in place at the point of admission to ensure that people receive a consistent personal and healthcare service according to their individual preferences. Furthermore, the resident’s assessment of need identified risks York Lea DS0000061291.V346097.R01.S.doc Version 5.2 Page 13 associated with moving and handling, diabetes and nutrition. These risks had not been assessed nor were there any instructions informing staff how to keep the person safe. However, there was no evidence to suggest that the shortfalls in care planning and risk assessment had compromised the resident’s safety or welfare. A telephone call was made to a niece of the resident who confirmed that the family were very satisfied with the care provision. She said, “The staff are very kind and are marvellous with my uncle. The home is absolutely the right place for my uncle to live.” A friend of one of the other residents was also contacted by telephone and asked if she was satisfied with the care her friend was receiving. She said, “My friend’s behaviour can be very difficult at times as she suffers from dementia. The staff are so patient with her and do a wonderful job.” One of the residents made the following comments in their satisfaction survey, “General practitioner visits are arranged speedily by the nursing staff and medication is properly monitored.” During the second visit the daughter of a resident came to thank the provider for ensuring that her mother received a daily bath according to her preferences. Minor shortfalls were found in care plan paperwork. Staff must ensure that documents such as care plans and risk assessments are signed and dated and that weight recordings are kept up to date. Additionally, moving and handling risk assessments must specify the type of equipment to be used when transferring people. Medication was securely stored and records appeared to be accurate and up to date. Throughout the two inspection visits staff were observed to interact well with residents and to provide support in a dignified and private way. Six residents spoken to confirmed that they were satisfied with the care they received and that staff always treated them with respect. York Lea DS0000061291.V346097.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from being afforded choice, healthy diets and the provision of a range of interesting activities. EVIDENCE: The six care plans examined contained little evidence of social care assessments. The manager explained that this had previously been included but the paperwork had been changed to comply with the requirements of a previous inspection. This had resulted in important information relating to social, cultural, spiritual and relationship needs being omitted from the care plans. Consequently, daily journals focussed on how residents’ personal and healthcare needs were being met but excluded the outcomes of the activities people engaged in on a daily basis. The manager was keen to reinstate the social care plans by developing life histories for individual residents. This will provide evidence of an emerging person-centred service and its development will be monitored at future inspections. It was evident that daily activities were provided such as manicures, music, films, armchair exercises and visiting York Lea DS0000061291.V346097.R01.S.doc Version 5.2 Page 15 ministers, although the residents’ experiences were not being written down. One of the residents commented in their satisfaction survey, “I am not always aware of what is on offer. Encouragement to take part (in activities) is given but there is no regimentation or being forced into any kind of routine that does not suit the individual.” During the two inspection visits residents were observed to receive visitors at different times of the day. The inspector spoke to two visitors on the second days visit. They said they were always made welcome in the home and that staff always contacted them if there were any concerns with their relatives care. These two people were taking an active interest in how residents living in the home spent their days and had contributed soft toys to facilitate fundraising and stimulating activities. Staff working in the home were in support of this. Involving relatives in the day-to-day lives of people living in the home is an example of good practice. The inspector joined two residents for their midday meal in the dining room. One of the residents said that the food was good and that she was afforded choice at mealtimes. The five people that returned satisfaction surveys to the Commission said that they always enjoyed the meals and one comment said, “Excellent catering.” During the meal it was noted that the main entrance door opened into the dining area and several people entered and left the home during the meal. The proprietor should consider alternative arrangements to this to ensure that residents’ right to privacy and dignity is maintained. The chef took care with the presentation of meals and support was available during the meal for people who needed assistance to eat. The kitchen and food stores were clean and food was stored appropriately. Cleaning schedules and fridge and freezer temperatures were accurate and up to date. York Lea DS0000061291.V346097.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to deal with complaints and to keep residents safe from harm. EVIDENCE: People living in the home had been provided with information at the point of admission on how to make a complaint. Two relatives of a resident confirmed this. Suitable policies and procedures for dealing with complaints were in place and this included a recording system for the complaints received. One complaint had been made since the last inspection. Examination of the records revealed that this had been resolved satisfactorily within the prescribed time limit. Residents spoken to during the inspection visits confirmed that they knew who to speak to if they had a complaint and this was also confirmed by the four people that completed satisfaction surveys. One resident commented, “The resulting action is always clearly explained to me.” Suitable policies and procedures were in place to ensure that people living in the home were safe from abuse. Staff had received training in how to recognise abuse and the procedure to follow if abuse was alleged or suspected. The relative of a person recently admitted to the home for respite care (personal care only) had expressed concerns about his physical health York Lea DS0000061291.V346097.R01.S.doc Version 5.2 Page 17 condition on discharge from the home. These concerns had been referred to the Local Authority for investigation under their Safeguarding Adults procedures. The outcome of the investigation was not known at the time of writing this report. York Lea DS0000061291.V346097.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A rolling programme of redecoration and maintenance ensures that residents are provided with a safe, pleasant and comfortable living environment. EVIDENCE: A tour of the home’s communal and private space was undertaken. The home was found to be clean and hygienic and no unpleasant odours were present. The building had been suitably adapted to provide access and support to people with disabilities, including specialised bathing and showering facilities. A redecoration and maintenance programme was in place to ensure that a safe, comfortable and pleasant environment was provided for people living in the home. York Lea DS0000061291.V346097.R01.S.doc Version 5.2 Page 19 Work was in progress to provide a patio off the main lounge area for the benefit of residents. During the inspection visit one of the residents was observed to utilise the outdoor seating arrangements with her two visitors. This resident told the inspector that the home’s environment suited her needs and that she had been able to bring some of her personal possessions in with her on admission. Her visitors added that this had meant a lot to her and had made the transition from her own home less traumatic. Suitable laundry facilities had been provided. A care assistant explained that residents’ clothing was marked with the individual’s name and named boxes in the laundry room ensured that clothes were returned to the correct person. One of the satisfaction surveys contained the following comment, “Very high standard of cleanliness. Cleaning and laundry staff are to be highly commended.” Policies and procedures were in place for the control of infection in the home. York Lea DS0000061291.V346097.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust recruitment and training procedures safeguard the residents’ welfare by selecting staff that have the right level of qualifications, experience, skills and personal qualities. EVIDENCE: On the two inspection visits it was noted that sufficient staff had been deployed to meet the assessed needs of people living in the home. The following comment was taken from a satisfaction survey completed by a resident, “The nurse-call answer service is not always satisfactory. When you are not the patient you do not always realise how long a five minute wait can be.” A maintenance technician had been delegated responsibility for providing training to staff in health and safety. Other training undertaken by staff included a management training programme, infection control and training in the conditions associated with old age. Care assistants had access to National Vocational Qualifications (NVQ) levels 2 and 3 and a senior nurse had achieved NVQ level 4 in management. One of the residents made the following comment in a satisfaction survey, “Sometimes the standard of English York Lea DS0000061291.V346097.R01.S.doc Version 5.2 Page 21 communication is inadequate. On the job ‘English as a Foreign Language’ classes would be good and training in using the telephone is needed by some staff.” A recommendation was made accordingly. Two personnel files were examined for evidence that care had been taken to make sure the staff recruited were suitable to work with older people. Both files contained copies of the required pre-employment checks such as Criminal Record Bureau disclosures and two written references, one of which was from their most recent employer. York Lea DS0000061291.V346097.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed in the best interests of residents’ welfare. EVIDENCE: The registered manager was experienced in the care of older people and had achieved NVQ level 4 in management and care. Clinical management had been delegated to a senior nurse who had achieved NVQ level 4 in management. The manager said that all staff working in the home had been supervised every two months and their performance was appraised every year. Residents and relatives spoken to praised the efficient management of the home. York Lea DS0000061291.V346097.R01.S.doc Version 5.2 Page 23 The home had achieved the Investors in People Award at the end of 2006 and quality-monitoring surveys were issued to residents and their representatives on a regular basis. Relatives or the local authority’s client affairs department managed the personal finances of people living in the home. A sample of health and safety records was examined for evidence that the homes equipment was being checked regularly. Records were accurate and up to date. A recommendation was made to review the home’s fire risk assessment to ensure that it complied with current fire safety regulation introduced since it was written on 28th November 2005. York Lea DS0000061291.V346097.R01.S.doc Version 5.2 Page 24 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 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 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.V346097.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP4 Regulation 14 Requirement Timescale for action 30/09/07 2. OP7 15 3. OP8 13 (4) 4. OP12 16 (2) (m) and (n) The registered person must ensure that clinical interventions are not undertaken with people living in the home that have not been assessed as needing nursing care. Care plans must be in place at 30/09/07 the point of admission to ensure that people receive a consistent personal and healthcare service according to their individual preferences. Risk assessments and risk 30/09/07 management plans must be in place for all people at the point of admission to the home. These must specify the action that staff are to take to meet residents needs safely. People admitted to the home, or 30/09/07 their representatives, must be consulted about their social, cultural and religious needs and their preferences in these areas must be documented in their care plans. York Lea DS0000061291.V346097.R01.S.doc Version 5.2 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. 2. 3. 4. 5. 6. Refer to Standard OP3 OP7 OP12 OP15 OP27 OP30 Good Practice Recommendations People should be advised to request care manager assessments of need prior to admission to the home. Care documents should be kept up to date and be signed and dated by the member of staff concerned. Daily journals should detail how residents’ cultural, religious and social needs have been met in a personcentred way. The registered person should consider alternative means of entrance to the home during mealtimes to ensure that residents’ rights to privacy and dignity are maintained. A review should be undertaken to assess the time staff take to respond to calls from residents using the nurse-call system. Residents and their representatives should be consulted on how they view the verbal communication between staff and residents. Action should be taken according to the outcome of the consultation as necessary. The home’s fire risk assessment should be reviewed and updated as necessary to comply with fire safety legislation introduced since it was written on 28/11/05. 7. OP38 York Lea DS0000061291.V346097.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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. Extracts may not be used or reproduced without the express permission of CSCI York Lea DS0000061291.V346097.R01.S.doc Version 5.2 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!