Inspection on 07/11/06 for York Lea

This inspection was carried out on 7th November 2006.

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 21/08/07

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 Geraldine Blow Key Unannounced Inspection 7th November 2006 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.V301392.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.V301392.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.V301392.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. 20th March 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. 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 now complete. The extension has provided a new conservatory style lounge, 4 single bedrooms with en-suite facilities, a new clinical room, a York Lea DS0000061291.V301392.R01.S.doc Version 5.2 Page 5 walk in shower room and 5 existing bedrooms have been refurbished which 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 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.V301392.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 20 March 2006 and some supporting information received in the pre-inspection questionnaire submitted by the home prior to this visit as well as 6 returned residents comment cards. This visit was an unannounced site visit, which forms part of the overall inspection process, and took place on Tuesday 7 November 2006. The opportunity was taken to look at all the key standards of the National Minimum Standards (NMS) and the requirements made at the inspection in March 2006. This visit was also used to decide how often the home is to be visited and to make sure that it meets the required standards. As part of the visit time was spent talking with the manager, the senior nurse, residents living at the home, the hairdresser, a relative and several members of staff. Also time was spent observing staff interaction with residents, assessing relevant documents and files and a tour of the premises was undertaken. What the service does well: The home offered a clean and pleasant environment for the residents who lived there. One comment received was that the “standard of cleanliness is nearly always excellent and the home does not have ‘the smell’.” The standard of décor and furnishings in the home was of a high standard. The new conservatory lounge was particularly nice and provided a pleasant environment for the residents. From observations made and from talking to staff, the hairdresser and a visitor to the home it appeared that the privacy and dignity of residents was protected and that residents were able to have choice with regard to their every day life. The hairdresser said that from what she has seen when she visits the home the staff always protect the privacy and dignity of residents and that the residents were always clean and appropriately dressed. The staff were seen to be kind and patient with residents and residents spoken to were positive with regard to the staff. One resident spoken to said, “The staff are very nice and kind and they have a laugh and joke with us”. The visitor spoken to said that he was very happy with the care his mother received at the home and that due to the care of the staff she very quickly settled into the home and was very happy. He said, “I can’t fault the place”. York Lea DS0000061291.V301392.R01.S.doc Version 5.2 Page 7 The returned comment cards had positive comments regarding the care received and one returned comment card from a relative stated, “I have been delighted with the care they have shown”. The home carried out a pre admission assessment before a resident was admitted to the home to make sure that the home can meet the person’s needs. Each resident has a detailed plan of care which set out in detail how that care was to be delivered and medication is given safely. The home had an open visiting policy and residents, a visitor and staff spoken to confirmed this. The visitor spoken to said that staff were very friendly and made him feel welcome when he visited. A choice of meals was available at each mealtime and the residents spoken to, and feedback from the returned comments cards indicated that people were happy with the quality and quantity of food. On the day of this visit it was the birthday of one of the residents and the chef was preparing an evening buffet and a birthday cake to celebrate. Staff and residents spoken to said that drinks and small snack’s were available on request. The home offered and encouraged training for staff to ensure that they had the necessary skills to meet the needs of the residents accommodated. Systems were in place to support residents or visitors to make a complaint. Residents and the visitor spoken to confirmed this and the returned comment cards also indicated that people knew how to make a complaint. The home looked after residents’ monies safely. The manager made herself available to both residents and staff and during the inspection visit she stopped and spoke with any resident that she passed. The residents and staff seemed to benefit from her strong leadership approach and her open door policy. One resident said that she is a “marvellous, wonderful person”. Staff spoken to said that the manager was very supportive and they could go to her with any problems. One member of staff said “the owner of the home and the manager really look after the staff and makes this a real home for the residents”. What has improved since the last inspection? Since the last inspection the home had employed a part time activity coordinator who appeared very keen and enthusiastic about her post. Evidence was seen of activities such as dominos, quizzes, cards and trips to the local shops taking place. York Lea DS0000061291.V301392.R01.S.doc Version 5.2 Page 8 Since the last inspection the home had continued to maintain its refurbishment and redecoration programme for the home. Several bedrooms and corridors had been re-decorated, a new ‘Parker’ bath and electrical hoist had been bought to support those residents who needed it and the shower room had been completed. The refurbishment and re-decoration of the home was still ongoing. It is commendable that the home had successfully completed The Investors in People Award, which is an award based around valuing staff and actively encouraging training and development. Since the last inspection the home had developed a ‘patient self assessment’ form. This form is used to obtain additional information about the resident on admission to the home. If the resident was not able to complete the form it was given to their relative or representative to fill in. This was seen as good practice. The requirements made in the last inspection report in relation to the unguarded radiators and the water temperature delivery had been met. What they could do better: 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.V301392.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.V301392.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home undertook an assessment of prospective residents’ care needs prior to their admission. EVIDENCE: The home has a documented pre admission assessment form that was used to ensure that prospective residents were only admitted on the basis of a full assessment of need being carried out. Evidence was seen that for those residents who were referred through Care Management arrangements the home obtained a summary of the Care Management Assessment. Following the pre-admission assessment the home confirmed in writing to the prospective resident that the home was able/not able to meet their assessed needs. Where possible, prospective residents and their family/representative were encouraged to view the home prior to making a decision about admission. York Lea DS0000061291.V301392.R01.S.doc Version 5.2 Page 11 Since the last inspection the home had developed a ‘patient self assessment’, which was used to obtain additional information about the resident. This was then used in conjunction with the care manager’s assessment and the homes pre-admission assessment. This was seen as good practice. The home did not provide an intermediate care service York Lea DS0000061291.V301392.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual plans of care were in place to ensure that residents’ health, personal and social care needs were fully met. The systems and procedures for dealing with medicines appeared to protect residents. EVIDENCE: A random sample of care plans was examined. The care plans examined had been generated from a needs assessment and the homes own care planning process. Each individual file was found to contain an assessment undertaken on admission and a care plan had been generated if appropriate. The plans of care were found to be detailed, informative and clearly set out the action that needed to be taken by staff to ensure that all aspects of health, personal and social care needs of the residents are met. Appropriate risk assessments had been included and the plans of care on the whole had been regularly reviewed to reflect changing needs and current objectives for health and personal care. York Lea DS0000061291.V301392.R01.S.doc Version 5.2 Page 13 Each resident were registered with a General Practitioner and evidence was seen of referral to other specialised services according to individual assessed needs. Evidence was seen that the Medication Administration Recording (MAR) sheets were recorded accurately and all deliveries and returns of prescribed medications had been recorded and accounted for providing a full audit trail. However, it was noted that a red tick system was in use on the MAR sheets to indicate that the medication had been received in the home and had been checked rather than a staff signature. It is recommended that a staff signature be used rather than a tick. If a drug was being used that staff may not be familiar with or have very specific side effects there was a care plan and an information leaflet in the MAR file for staff to easily and quickly access. The manager and senior nurse said that the home had a sample list of staff signatures for those staff who administer medication. However it could not be found on the day of the visit. The manager made assurances that a new list would be completed. A prescribed thickener, which was used to thicken drinks and soups for residents with swallowing impairment, had been signed for on the MAR sheet. However the senior nurse said the MAR sheet did not accurately reflect the correct number of thickened drinks that had been given. In order to ensure that residents care needs were being met appropriately an accurate record should be maintained of each drink / soup etc that had been thickened and any other liquid the residents may have had to drink. It is essential that the person making the drink signs a sheet, this does not have to be the nurse and it does not have to be signed on the MAR sheet, a separate drinks recording sheet may be constructed for each resident. In addition it is recommended that individual instructions for each resident is readily and easily accessible to staff involved in the preparation of drinks / food for a resident. This was discussed at length with the senior nurse. The senior nurse said that the prescriptions for medication came direct to the home for checking and are then sent to the dispensing pharmacy. In accordance with the Royal Pharmaceutical Guidelines and to maintian the safey of residents the home should have a copy of the original prescription to check against the MAR’s and items delivered by the pharmacy. From observations made during the inspection and discussions with residents, the hairdresser and members of staff it appeared that the nurses and care staff treated the residents with respect and dignity. York Lea DS0000061291.V301392.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities were provided and residents were able to maintain contact with family and friends. Meals served at the home were nutritious, well balanced and offered a healthy and varied diet for residents. EVIDENCE: Since the last inspection the home have employed a part time activity coordinator. She is a carer at the home and has been given protected designated hours to act as the activity co-ordinator. To ensure that her hours are protected and other staff are aware that she is working as the co-ordinator it is clearly marked on the rota and she wares a different top to the care staff. Evidence was seen that residents were consulted about their social interests and personal preferences and a record was kept of which residents attended activities. The staff, residents and a visitors to the home confirmed that visiting was facilitated and visitors could be received in the residents’ own room or any of the communal areas of the home. York Lea DS0000061291.V301392.R01.S.doc Version 5.2 Page 15 Details regarding Advocacy services were in the Service User Guide and the manager said that every resident had been given a copy. From speaking to staff it appeared that residents were able to exercise choice and control over their lives and that residents were encouraged to bring personal possessions into the home. The menu examined demonstrated that the home provided a varied diet, which was nutritionally balanced and included adequate supplies of fresh fruit and vegetables. There was a choice of food at each mealtime and any reasonable alternative to the menu was available on request. The residents were asked on a daily basis their choice of meals and there is a section on the sheet to write specific requests for the chef. Feedback from the residents and those included in the comment cards was positive. Comments included “the food is nice”, “the quality of food and the standard of cooking is very good. My birthday cake (with my name on) was an unexpected pleasure”, and one comment card filled in on behalf of a resident by his daughter stated “My father has a good appetite and even though his food has to be pureed he always enjoys his meals”. A tour of the kitchen was made. The kitchen was found to be clean and well organised. Adequate supplies of food were seen which included fresh fruit and vegetables. All food was seen to be stored appropriately. York Lea DS0000061291.V301392.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home encouraged and supported people to raise their concerns and complaints and had the policies, procedures and systems in place to protect residents from abuse. EVIDENCE: The home had a complaint procedure, which was included in the Service User Guide. A record was kept of all complaints made and included details of the investigation and any action taken. The manager said that she encouraged resident/relatives to bring any concerns to her so that they could be addressed as a priority. The visitor spoken to said that if he had any concerns he would go to the manager who always made time to talk to him and gave him good advise. Residents spoken to confirmed that they feel comfortable if they had to to make a complaint. One resident spoken to said that if she had a problem she would go to the manager who was a marvellous and wonderful person. At the time of this visit the home had received a concern from the social work department on behalf of a family. The concern was in the process of being investigated by the home and the Primary Care Trust (PCT). The home had detailed information and copies of correspondence regarding the concern. York Lea DS0000061291.V301392.R01.S.doc Version 5.2 Page 17 In addition the CSCI had recently received an anonymous concern, which was discussed with the manager during this visit. She said she would discuss it with the Responsible Individual (RI) and respond in writing to the CSCI. Evidence was seen that staff had received Protection of Vulnerable Adult (POVA) training and staff spoken to confirmed this. The home had policy’s relating to the Protection of Vulnerable Adults from Abuse and had a copy of the “No Secret’s Guidance”. However it is recommended that the policy be reviewed, as it did not accurately reflect the Adult Protection Procedures, ‘No Secret’s Guidance’ as it did not clearly identify that all allegations of abuse should be referred to Social Services under POVA for investigation. York Lea DS0000061291.V301392.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All areas of the home were clean, comfortable, well maintained and equipped to meet the needs of the residents. EVIDENCE: As already stated in this report the home had an ongoing programme for extensive re-decoration and refurbishment following the completion of the new extension. The home was well furnished to a high standard and was suitable for the residents living there. On the day of this visit the home was odour free and was found to be clean and tidy. Residents spoken to and information received from the comment cards indicated that the home was usually clean, tidy and odour free. Bedrooms were personalised with items brought in from resident’s own homes. In the last inspection report a requirement was made regarding unprotected radiators. Risk assessments had been completed and the manager said that York Lea DS0000061291.V301392.R01.S.doc Version 5.2 Page 19 the guards had been ordered and 17 were due to be fitted the week beginning 13 November 2006 and the remaining guards were due to be fitted the week beginning 20 November 2006. At the last inspection a problem maintaining appropriate water temperatures was identified and a requirement was made. A telephone conversation with the Responsible Individual during the visit confirmed that the home had contacted the boiler manufacturers and they had recommended to use the services of a boiler installation company. This company had been into the home and they need to reconfigure the pipe work and the boiler. A date of 20 November had been arranged for the work to be completed. York Lea DS0000061291.V301392.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The number and deployment of staff appeared sufficient to meet the residents’ assessed needs. Staff appear to be appropriately trained to meet the needs of the residents accommodated. EVIDENCE: At the time of this visit the home accommodated 29 residents. The numbers and skill mix of the staff appeared to be sufficient to meet the needs of the number of residents accommodated. One comment received on a comment card said “there are always plenty of staff on duty” however another comment received was “ we would like constant supervision in the lounge area”. The home employed 19 care staff, 9 of which had achieved NVQ Level 2 and a further 2 members of care staff had been registered to start the training. One member of care staff had achieved NVQ Level 3 and a further 2 members of care staff were registered to undertake the training. In addition the senior nurse was due to complete the Registered Managers Award, NVQ Level 4. Staff files were held at the business centre at the sister home in Clayton area of Manchester. Staff files were not examined during this visit as they were examined at the previous inspection and found to contain all the relevant information. The manager said that she received the application form and conducts the interview and notes are taken. She then phones for 2 verbal York Lea DS0000061291.V301392.R01.S.doc Version 5.2 Page 21 references, one being from the last employer. The business centre then applies for written references, a Criminal Records Bureau (CRB) and POVA check. On receipt of these the business centre contacts the home manager and confirms receipt and suitability of the information received. If appropriate employment is then offered and a contract and terms and conditions of employment are given. Evidence was seen of regular staff training. The homes manager had details of staff training and the business centre have a computerised matrix and systems in place to ensure that all staff have undertaken the necessary training. Staff had a detailed individual personal development plan which was incorporated in a ‘care worker’ or ‘nurse worker’ programme. Initially the member of staff completed a self-assessment, which included a scoring system. The manager then goes through the self-assessment with the member of staff offering feedback, support and discussing training needs. Following the self-assessment staff have “break point reviews” every 2 months to monitor and ascertain individual development/training needs and to ensure the personal goals of the staff are being met. An annual review was then undertaken. This process is commendable and seen as good practice. The home had a structured Induction Programme and the manager said all new members of staff must complete the induction process and then move onto the care or nurse worker programme, detailed above. York Lea DS0000061291.V301392.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home operates in the best interests of the residents. EVIDENCE: The home benefited from a committed, caring manager. She demonstrated a clear view of the need to continually develop the care service in the best interests of the residents and the necessity of continued staff support. The home had a quality audit system whereby the business centre send out questionnaires to residents, relatives and as recommended at the last inspection to visiting professionals to the home. The manager said that following a review of the completed responses a report is generated by the business centre and sent to her. At the moment the questionnaires are sent out on an annual basis, however the RI said that it was her intention to send York Lea DS0000061291.V301392.R01.S.doc Version 5.2 Page 23 this out perhaps quarterly. The manager said that in addition to the questionnaires sent out the home regularly held resident meetings in an attempt to gain their opinions and every quarter the business centre conduct an unannounced audit of the kitchen. Staff were regularly supervised via the ‘break point’ reviews conducted every 2 months and an annual review took place. Staff spoken to said that the manager and the owner of the home were very supportive of staff and “always listen to any concerns”. The business centre had the responsibility for maintaining the computerised records of resident’s personal allowance. Yorklea had ‘petty cash’ that is given to residents on request or when items were bought on behalf of a resident. If the resident was able they would sign for receipt of any money or 2 staff signatures would be obtained. A written record was kept of all transactions and receipts were kept. At the end of the month this information was sent to the business centre to be entered onto the computerised records. Evidence was provided that the home had appropriate service contracts in place for equipment and installations used in the home. Servicing was undertaken at the required intervals to ensure the safely of residents. Evidence was seen that appropriate fire safety checks were undertaken to ensure the safety of residents accommodated. York Lea DS0000061291.V301392.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 4 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 3 3 x 3 York Lea DS0000061291.V301392.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations 1. It is recommended that staff sign the MAR sheet on receipt of medication into the home. 2. It is recommended that staff sign for all thickened drinks/soups given to a resident. 3. It is recommended that individual instructions for each resident requiring thickened drinks/soups is readily and easily accessible to staff involved in the preparation of drinks / food for a resident. 4. It is recommended that the home keep a copy of the GP’s original prescription to check against the MAR’s and items received from the pharmacy. It is recommended that the registered provider review and amend the Protection of Vulnerable Adults policy to ensure that it accurately reflects the Adult Protection Procedures ‘No Secret’s Guidance’. DS0000061291.V301392.R01.S.doc Version 5.2 Page 26 2. OP18 York Lea 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.V301392.R01.S.doc Version 5.2 Page 27 - 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!