Inspection on 24/05/07 for York Lodge

This inspection was carried out on 24th May 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 Lodge 24/05/06

York Lodge 25/10/05

York Lodge 26/04/05

York Lodge 05/12/04

York Lodge 20/07/04

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

CARE HOMES FOR OLDER PEOPLE York Lodge Myrtle Road Crowborough East Sussex TN6 1EY Lead Inspector Jennie Williams Key Unannounced Inspection 24th May 2007 10:00 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 Lodge DS0000021294.V337771.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 Lodge DS0000021294.V337771.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service York Lodge Address Myrtle Road Crowborough East Sussex TN6 1EY 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) 01892 661457 01892 661457 fred@millcroft.plus.com Millcroft and York Lodge Care Homes Ltd Mr Fred Bramble Dr Bozena Bramble Care Home 22 Category(ies) of Dementia - over 65 years of age (22) registration, with number of places York Lodge DS0000021294.V337771.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is twenty-two (22). Service users must be aged sixty-five (65) years or over on admission. Only adults with a dementia type illness are to be accommodated. Date of last inspection 17th October 2006 Brief Description of the Service: York Lodge is a care home providing care for up to twenty-two (22) residents over the age of sixty-five (65) with a dementia type illness. Nursing care is not provided at this establishment. The home is located in a quiet residential area of Crowborough. The town centre is located within walking distance of the home. There is nearby access to public bus routes. There are car-parking facilities at the home for approximately seven cars. York Lodge is a large detached three-storey building. Rooms are located over three floors, all of which are served by a passenger shaft lift. Twenty rooms are for single occupancy of which 18 have en suite facilities. There is one double room that is provided with an en suite. There are two communal toilets located near communal areas and a bathroom located on each floor, two of these being assisted facilities. There are grab rails placed throughout the home in areas where residents may require some assistance with mobilisation. Weekly fees range between £400 and £575. There are additional fees; hairdressing (£10 to £22), Chiropody (£15), newspapers and personal toiletries(at cost). The cost of having some entertainment brought into the home is shared amongst the residents who attend the session. Residents are invoiced for food when they are taken out of the home for outings. This information was provided to the CSCI on the 24th May 2007. Prospective residents/representatives are provided with a Statement of Purpose and Service User Guide that offer information on the services and facilities provided at the home. These documents provide information that CSCI inspection reports are available to read upon request at the home. Residents/relatives know about the service through social service referrals, word of mouth and from living in the area. York Lodge DS0000021294.V337771.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. It should be noted that following recent CSCI consultation, it was identified that service users prefer to be called people who use services. It was confirmed to the Inspector that people who use this service are called residents. For the purpose of this report, people who use the service will be referred to as residents. This unannounced key site visit took place over seven hours on the 24th May 2007. Five residents were spoken with individually throughout the inspection process. Two care plans were viewed and specific areas of care were looked at in a further four care plans. Both Registered Managers and seven other staff members were spoken with including; the Head of Care, three care staff, a cleaner, a cook and a person undertaking work experience at the home. Staff files were unable to be inspected, as this information was not available at the home. A tour of the environment was undertaken and some individual rooms were viewed. Medication procedures were inspected. The quality assurance system was discussed and recent results viewed, complaint and Safeguarding Adult procedures and records were viewed. Copies of the staff rota were provided and menus were viewed. An Annual Quality Assurance Assessment (AQAA) was sent to the home prior to the site visit. This was to obtain information about the establishment to assist CSCI in the inspection process. There were twenty-one residents residing at the home on the day of the inspection. What the service does well: The home has information available for prospective residents/representatives on the facilities and services provided to make an informed decision if their needs can be met at the home. Prospective residents are provided with opportunities to visit the home prior to moving in to ensure the home will meet their needs. Residents were complimentary about the staff working at the home and felt that their personal care needs were being met. Residents felt that their privacy and dignity are respected. Routines of daily living are generally to the individual’s choice and preference. Activities are provided at the home that is within an individual’s choice, interest and ability. York Lodge DS0000021294.V337771.R01.S.doc Version 5.2 Page 6 Visitors are welcomed at the home and residents may receive visitors in private. Residents were complimentary about the provision of food at the home and confirmed that choice is provided. Complaints are dealt with appropriately and action is taken wherever necessary. Residents found their rooms to be comfortable and the home was clean and communal areas free from offensive odours. Staff receive training appropriate to their roles to ensure their safety and that residents needs continue to be met. Staff were observed to have a good professional rapport with residents and were heard to be calling them by the preferred term. Residents and staff benefit from supportive and approachable management within the home. The quality assurance and quality monitoring system implemented ensures that the home is run in the best interest of service users. What has improved since the last inspection? A random unannounced inspection has been undertaken between the last key inspection and this key inspection. This was to ensure compliance had been made with the requirements made at the last key inspection. Improvements made have been judged from requirements made at the random unannounced inspection. All five of the outstanding requirements have been met. These included ensuring that all prospective residents are assessed prior to admission to ensure that all the needs can be met with the skill mix of staff and facilities provided at the home. All residents have care plans in place that cover all aspects of health, personal and social care needs. The reviewing process in place ensures staff are provided with up to date information on the current needs of residents and the involvement of residents/representatives in the reviewing process ensures individual choice and preference is taken into account. Staff confirmed that the care plans in place are more user friendly. Training has been provided to some staff on undertaking risk assessments. Work has been done and is continuing to be undertaken to ensure all residents have appropriate risk assessments in place and identifies action to take to reduce any identified risks. All new staff undertake induction and foundation training that complies with the Common Induction Standards set by the Skills for Care. This will enable staff to provide an improved quality of care and meet residents’ needs more effectively. Recommendations that the home has addressed to improve practices within the home include: ensuring at least 50 of care staff have completed or are currently undertaking National Vocation Qualification level 2 and the Registered York Lodge DS0000021294.V337771.R01.S.doc Version 5.2 Page 7 Manager confirmed that the health survey that all prospective staff must complete has been expanded to include past and current health illnesses. 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. The summary of this inspection report can be made available in other formats on request. York Lodge DS0000021294.V337771.R01.S.doc Version 5.2 Page 8 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 Lodge DS0000021294.V337771.R01.S.doc Version 5.2 Page 9 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, 5 & 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has information available for prospective residents/representatives on the facilities and services provided to make an informed decision if their needs can be met at the home. The pre admission process ensures that only residents whose needs can be met at the home are admitted. EVIDENCE: Prospective service users/representatives are provided with a Statement of Purpose and Service Users Guide that provides them with information on the services and facilities provided at the home. The full content of these documents were not read. All prospective residents are assessed prior to admission. The Head of Care undertakes the assessments of prospective residents, who confirmed that the form had been amended to ensure clear information is obtained on the needs York Lodge DS0000021294.V337771.R01.S.doc Version 5.2 Page 10 of all prospective residents. Other health professional assessments/information is obtained wherever possible. Pre admission assessments viewed demonstrated that the needs of the individual can be met. All prospective residents/representative are encouraged to visit the home prior to moving in. The Head of Care confirmed that they encourage prospective residents to visit for a morning and participate in activities. Overnight trial visits can be accommodated with prior arrangements with the home. Care staff spoken with confirmed that all residents currently residing at the home are suitably placed and all needs are being met. It was confirmed that there was no one residing at the home from any minor ethnic community, social/cultural or religious groups with any specific needs or preferences. The AQAA identifies that the home is aware of equality and diversity issues and have appropriate policies in place. Equality and diversity issues are discussed with all staff and reviewed at care meetings. It was confirmed that the first four weeks are considered as a trial period and this is confirmed in the contract. The home does not take emergency admissions and there is no dedicated accommodation to provide intermediate care. Respite is available if there is a spare place. York Lodge DS0000021294.V337771.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being met with the information provided in the care plans on the assessed needs of residents. Residents are safeguarded by the medication procedures in place. EVIDENCE: All residents have a care plan developed and implemented at admission. Care plans viewed provided information to staff on the assessed needs of the individual. There is a key worker system in place who are responsible for undertaking the monthly reviews of care plans. Every three months the residents/representatives are invited and encouraged to be involved in the reviewing process to ensure that individual choices and preferences are catered for. A designated person monitors care plans to ensure that they are being regularly reviewed. York Lodge DS0000021294.V337771.R01.S.doc Version 5.2 Page 12 Residents receiving respite care have care plans implemented and specific areas of care noted throughout the inspection were reflected in care plans. There is a nutritional screening tool being used, however this was not completed for one resident. The Head of Care will ensure this is addressed. Residents are weighed on a monthly basis and specialist advice is sought regarding nutrition whenever the need arises. There was evidence that an audiologist appointment was being arranged for a time that is suitable for the individual and not for the convenience of the audiologist. It was confirmed that residents have annual eye checks. The AQAA identified and it was observed in care plans that a new recording sheet had been implemeneted to record personal care provided on a daily basis. On veiwing an individuals record, it appeared that a resident had not had a wash for a period of time. It was confirmed by staff that this individual refused assistance to wash. It was recommended to the staff that they record when the individual refuses assistance to evidence that an opportunity has been offered, but not accedpted. Residents spoken to confirmed that they were happy residing at the home. Of those asked, all confirmed that staff encourage their independence, wherever possible. A senior member of staff has undertaken a health and safety course, which included information regarding risk assessments. Risk assessments were viewed to be in place for individual residents and provide guidance for staff on how to reduce the risk. There were some risk assessments that had not been implemented for some individuals. This was discussed on the day and it was confirmed that action will be taken to address this. No requirement/recommendation has been made in relation to this as the home confirmed action will be taken to address this. It was confirmed that there are policies and procedures in place for all aspects of dealing with medications. The content of these were not viewed. Medication Administration Records (MAR) charts inspected demonstrated that medication is being signed for at the time of administration. Staff administering medication have received suitable training. There is no one selfmedicating at the home. There are suitable records being maintained of controlled drugs. Of the residents that were asked, all felt that their privacy and dignity are respected. Staff were observed to have a good professional rapport with residents and were heard calling residents by their preferred term of address. Staff were observed to knock on resident bedroom doors prior to entering. Quality assurance results recently obtained by the home from visiting health professionals evidenced that all seven felt the staff treat their resident/client with the dignity and respect that they would expect. York Lodge DS0000021294.V337771.R01.S.doc Version 5.2 Page 13 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 & 15. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ lifestyle within the home is their own choice and residents are provided with sufficient stimulation to fulfil their interests and needs. EVIDENCE: There is no activities person employed at the home. Staff on duty provide activities for residents. The activities programme is developed on a weekly basis. Activities are provided every morning and afternoon during the week and once a day on the weekend. There is an activities notice board in the dining room, displaying what activities are on for the week. Some of the activities being provided for the week were: quizzes, outings, reminiscence, dancing, flower arranging and dominos. The AQAA demonstrates that activities and outings for residents are areas that they have improved in the last 12 months. Ten residents were observed to be participating in an activity on the day of the inspection. It was noted in an individual’s assessment that they used to attend a ‘day centre’ twice a week, however no longer attending this service. The Head of York Lodge DS0000021294.V337771.R01.S.doc Version 5.2 Page 14 Care confirmed that they were willing to assist this individual to continue with these visits. It was decided by health professionals that it would be more disruptive for the individual to continue visiting this service and would benefit more from being involved in the activities programme at the home. There is a mini bus van available at the home and outings are arranged twice a week for residents. Due to the limited number of seats in the mini bus van, staff ensure that all residents are provided with an opportunity for an outing on a regular basis. The Head of Care confirmed that relatives would often meet up with the residents if they are going out for a pub lunch. There is a small shop trolley used once a week at the home for residents to purchase confectionary and toiletries etc, if they need. Residents’ routines of daily life are flexible and residents were observed to move freely around the home. Some residents spoken to confirmed that their lifestyle is their own choice and are able to choose their own routines; such as when to get up and go to bed, whether they wish to participate in activities etc. It was noted that watches owned by residents were on the wrong time and date or not working at all. The Inspector was pleased to be informed by a Registered Manager that the staff had identified this and action is taken whenever it is noted. Visitors are welcomed at the home and there is a visitors book kept by the entrance for all people to sign when entering and leaving the building. Visitors are encouraged to visit between 10.00am and 10.00pm. These restrictions are imposed for the benefit of the residents well being. Visits are able to be made outside of these times on arrangement with the home. Monthly communion is held at the home for those residents wishing to attend this service. Residents spoken with were complimentary about the food provided at the home and confirmed there is a choice available. The menu demonstrates that there is a variety of food offered. Eighteen residents were observed to be enjoying the lunchtime meal in the dining room. The mealtime was observed to be relaxing and unhurried. Staff have lunch at the same time as the residents. Residents were observed to be provided with drinks through out the day whenever they asked. The Head of Care confirmed that there was no resident requiring a specialist diet. The cook confirmed that she has a list of residents likes and dislikes. It was confirmed that Environmental Health visited the home in December 2006 and no shortfalls were identified. It was confirmed that all staff dealing with food are up to date with food and hygiene training. York Lodge DS0000021294.V337771.R01.S.doc Version 5.2 Page 15 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 & 18. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Complaints are dealt with appropriately, reassuring those involved that they are being listened to and that action will be taken, if necessary. Safeguarding Adult procedures and the training of staff ensure residents are safeguarded. EVIDENCE: There is a complaints procedure in place that everyone has access to. There have been three complaints dealt with by the home since the last inspection. These complaints were around clothing being worn or lost for an individual, and two relating to personality conflicts between residents. All complaints were substantiated and resolved quickly. Records viewed demonstrated that suitable records are maintained of complaints and any necessary action required is taken and recorded. One resident spoken to confirmed that they would know who to speak to if they were unhappy about anything and feels that action would be taken. There are guidelines in place for the Safeguarding of Adults. One of the Registered Manager’s and the Head of Care have undertaken the ‘train the trainer’ course in January 2007 and ensure staff receive suitable training. Staff spoken with confirmed that they are familiar with the procedures to follow in York Lodge DS0000021294.V337771.R01.S.doc Version 5.2 Page 16 the event of an allegation of abuse being made. There have been no Safeguarding Adult alerts made since the last inspection. The Registered Manager, Mrs Bramble, has been proactive and is currently in the process of obtaining information on the changes in the Mental Capacity Act and is trying to access courses in the area for staff to undertake. York Lodge DS0000021294.V337771.R01.S.doc Version 5.2 Page 17 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 & 26. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and homely environment and are provided with comfortable indoor and outdoor communal facilities. EVIDENCE: Residents spoken with are happy with the environment and with their individual rooms. Rooms randomly viewed were seen to be personalised to reflect the individuals’ choice and personality. Rooms are located over three floors. There is a passenger shaft lift that accesses all floors, ensuring all residents can access all areas of the home. There are alarmed gates at the top of every stairway to alert staff if someone is accessing the stairway, ensuring the safety of residents. There is a call bell system in all rooms at the home. York Lodge DS0000021294.V337771.R01.S.doc Version 5.2 Page 18 On walking through the home, the Inspector noted that some of the carpets throughout the home had ‘busy’ patterns on them and there was limited signage noted throughout the home to assist residents on their orientation. On the day of the inspection, orientation did not appear to be an issue with the residents observed. No requirement or recommendation has been made in respect of this, however the Registered Managers should take this into account when any refurbishment work is undertaken. The AQAA received demonstrates that there is a refurbishment programme in place. It should be noted that due to the type of door locks provided on individual bedrooms, some of the doors lock when they are closed. This restricts individuals being able to freely access their rooms. Residents will ask staff to unlock their rooms when needed. The Registered Managers confirmed that this has been discussed with residents/relatives. This will be addressed when all doors are provided with dorguards. Dialogue has been held between the home and CSCI on previous occasions regarding this practice. It is recommended that the home provide written evidence that this practice is in agreement with current residents or their relatives. Some flooring in individual bedrooms and en suite were noticed to have been replaced and were being kept free from offensive odours. This had been noted as an area of concern at previous inspections. It had previously been recommended that shared hand towels be replaced in communal areas, as this does not promote good infection control practices. Hand towels continue to be used in communal bathrooms. It was confirmed that these are changed at least daily. There are grab rails placed throughout the home in areas where residents may require some assistance with mobilisation. Two of the three baths are assisted. There are some bathing/showering facilities in approximately four of the en suites. These are not assisted facilities and residents must be able to mobilise safely to use these. There were thermostatic controls noted to be installed on hot water outlets that residents have access to. Radiators were observed to have been guarded or confirmed they were of guaranteed low surface temperature. Alarms are placed on stair gates to alert staff when individuals are accessing stairways. There is a garden at the rear of the home that residents have access to. A Registered Manager confirmed that quotes are currently being obtained for installation of tiles in the patio area. It is proposed that this area will be levelled to assist in reducing the risk of falls. There is a maintenance person who works four days a week and is on call whenever the need arises. Any minor shortfalls noted in the environment were discussed with the home on the day of the inspection. York Lodge DS0000021294.V337771.R01.S.doc Version 5.2 Page 19 The home was clean and free from offensive odours on the day of the inspection. A cleaner spoken with confirmed that hey are provided with enough equipment and working hours to undertake their duties effectively. The cleaner confirmed that they had undertaken infection control training at a previous place of employment. The AQAA demonstrates that there are policies and procedures in place for communicable diseases and infection control. The content of these policies were not read. There are suitable washing machine facilities in place that has a sluice cycle to ensure dirty linen is suitably washed. York Lodge DS0000021294.V337771.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 & 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being met with the number and skill mix of staff on duty. EVIDENCE: Staff and residents spoken with confirmed that there were sufficient numbers of staff on duty at all times. There are generally four staff working in the mornings, three in the afternoon and two staff that work a waking night duty. Staff were observed to have a good professional rapport with residents. Staff files were unable to viewed on this occasion, as these were not kept on site at the home. It was discussed with the Registered Manager that these should be available for inspection at all times at the home, however due to the manager not being present at all times, staff have requested that files are not kept at the home. The AQAA received demonstrates that all staff have all relevant recruitment checks undertaken prior to commencing employment. A foreign staff member spoken with confirmed that they felt their recruitment was done fairly. The AQAA identifies that the Registered Managers have had to recruit staff for whom English is not their first language. The home overcomes this barrier by York Lodge DS0000021294.V337771.R01.S.doc Version 5.2 Page 21 ensuring these staff have ample opportunity to attend English classes and to improve their communication skills. The AQAA identifies and it was confirmed on inspection, that eight care staff have obtained National Vocation Qualification (NVQ) level two and an additional five care staff are currently undertaking these studies. The Head of Care has undertaken the Registered Manager Award course and is NVQ level 4. She is also a NVQ level 3 Assessor. Staff spoken with confirmed that they are kept up to date with mandatory training and are provided with opportunities to undertake additional training relevant to their roles. Recent training provided to staff include: Protection of Vulnerable Adults (POVA), fire, dementia awareness and medication. Staff confirmed that they are provided with regular supervision. There is a plan in place to ensure that all staff receive supervision. It was noted that some staff had not been receiving regular supervision, however this shortfall had already been noted by the home and action was being taken to address this. No requirement or recommendation has been made in respect of this. The AQAA identifies and it was confirmed on inspection that all staff undertake an induction programme. It was confirmed that this complies with the Common Induction Standards as devised by the Skills for Care sector. Two senior staff attended a workshop on the new Common Induction Standards. York Lodge DS0000021294.V337771.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, 36 & 38. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is suitably managed and the quality assurance system in place ensures the home is run in the best interest of residents. The health, safety and welfare of residents and staff are promoted and protected so far as is reasonably practicable. EVIDENCE: There are two designated Registered Managers at the home, Mr and Mrs Bramble, each with specific areas of responsibilities. Other responsibilities have also been delegated to senior staff. Staff spoken with confirmed that there are clear roles and responsibilities within the home and with the senior management in the home. York Lodge DS0000021294.V337771.R01.S.doc Version 5.2 Page 23 The home has done work to improve their quality assurance and qualitymonitoring systems to ensure that the home is ran in the best interest for the residents. The home is currently negotiating with an external company to undertake annual questionnaires. Feedback is sought from residents, relatives/visitors, staff and health professionals. A quality assurance report undertaken in May 2007 was viewed and it was confirmed that action is taken wherever necessary. It was discussed on the day of the inspection that management think about ways to make the results of the quality assurance system available to any stakeholders involved with the home. Staff meetings are held every six weeks and residents meetings are held every six weeks, where relatives are invited to attend. The AQAA received from the home identifies areas that have improved in the last twelve months, what they could do better and plans for the next twelve months on how they propose to improve specific areas. The home does not hold any personal allowance for residents. The Registered Manager confirmed that relatives manage the finances for individuals. It was confirmed that all relevant health and safety checks are undertaken on a regular basis and designated staff are responsible to ensure these are completed. The home maintains an analysis of all accidents within the home and records are kept. The home reports all relevant accidents to the CSCI as required by regulation. One of the Registered Managers undertakes the fire training of staff and an external company provides training once a year. Mrs Bramble has obtained a Level 3 Certificate in Occupational Health and Safety. It was confirmed that fire drills are undertaken on regular basis. The home has obtained information regarding the new smoking laws that are coming into force in July 2007. No health and safety records were viewed as it was confirmed at inspection and evidenced in the AQAA that the home ensures maintenance of all equipment is undertaken. Dorguards are in place for those residents wishing to remain in their rooms. The Registered Manager, Mr Bramble, confirmed that there is a rolling program in place to have all doors provided with dorguards. York Lodge DS0000021294.V337771.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 3 3 N/A 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 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 York Lodge DS0000021294.V337771.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. Refer to Standard Good Practice Recommendations York Lodge DS0000021294.V337771.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Lodge DS0000021294.V337771.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. 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