Inspection on 24/10/05 for York Lodge

This inspection was carried out on 24th October 2005.

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 31/07/06

York Lodge 09/06/05

York Lodge 30/09/04

York Lodge 22/04/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOME ADULTS 18-65 York Lodge 1-5 York Road Worthing West Sussex BN11 3EN Lead Inspector Mr E McLeod Unannounced Monday, 24 October 2005 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 H60-H11 S14865 York Lodge V248612 241005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service York Lodge Address 1-5 York Road, Worthing, West Sussex, BN11 3EN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01903 212187 Mrs Marie Anne Harrity Anthony McKernan Care Home 24 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (MD) - 24 Both, Mental Disorder, of places excluding learning disability or dementia - over 65 years of age (MD(E)) - 12 Both York Lodge H60-H11 S14865 York Lodge V248612 241005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1, The total number of persons accommodated should not exceed 24. 2, 12 Service Users will be over the age of 65 years. Date of last inspection 9.6.05 Brief Description of the Service: York Lodge is registered for the accomodation of up to 24 residents in the category of mental disorder, 12 of whom may be over the age of 65. The property is situated close to the seafront in central Worthing with access to local bus and train services. The registered provider is Mrs M. Harrity, and the registered manager is Mr Tony McKernan. York Lodge H60-H11 S14865 York Lodge V248612 241005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was arranged to update the assessments made at the previous inspection, and lasted 3.5 hours. The inspector interviewed five residents, attended a residents’ meeting, made a partial tour of the premises, and sampled three sets of care plans. Some policies and procedures including those for complaints and adult protection were sampled, and the inspector interviewed two members of staff and the registered manager. The inspector would like to thank everyone who contributed to the inspection. What the service does well: What has improved since the last inspection? The manager for the home has been registered with CSCI, and is undertaking the Registered Manager Award. A process for gathering views on the service provided has been commenced. More planned one to one staff time with residents is being provided. Residents are being supported to take up further education courses in the local area. York Lodge H60-H11 S14865 York Lodge V248612 241005 Stage 4.doc Version 1.40 Page 6 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 Lodge H60-H11 S14865 York Lodge V248612 241005 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection York Lodge H60-H11 S14865 York Lodge V248612 241005 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 5 Good information on the service is provided for residents and prospective residents, but some of this is in need of updating. The terms and conditions of residence should be expanded to include information specified under standards 5.2 – 5.5. EVIDENCE: The statement of purpose and service user’s plan which provide information to residents and prospective residents on what is offered by York Lodge, were read in part by the inspector. It was noted that some information such as the registered manager in the statement of purpose was not up to date. A copy of the terms and conditions of residence was read in part by the inspector, and was noted to not include some information specified under standard 5, such as rooms to be occupied (5.2(i)) and fees charged and who pays what part of the fee (5.2.(iv)). York Lodge H60-H11 S14865 York Lodge V248612 241005 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9 Residents are being consulted on aspects of life in the home, and are being assisted to develop skills and independence. EVIDENCE: Three sets of individual care plans were part read by the inspector, each plan including risk assessments and aims and objectives. Care plans seen were being regularly reviewed. Records indicated that there is good liaison with local mental health services, with a community psychiatric nurse visiting regularly. Mr McKernan said that plans were in place for regular Care Programme Approach (CPA) reviews to take place including the responsible consultant psychiatrist. The inspector attended a residents’ meeting, where residents decided on a time and content for their Christmas party and discussed the menu for Christmas dinner. Residents participated fully in the meeting. Discussion with residents and staff indicated that staff are assisting residents to access peer support. York Lodge H60-H11 S14865 York Lodge V248612 241005 Stage 4.doc Version 1.40 Page 10 Risk assessments are in place for each resident. Staff interviewed provided good examples of responsible approaches that are being taken to assist residents to develop skills and independence. York Lodge H60-H11 S14865 York Lodge V248612 241005 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 16 Residents are being supported to make use of the local community, and have their rights and responsibilities recognised in their daily lives. EVIDENCE: Residents interviewed said they were accessing local facilities such as shops, library, cinema, swimming, and advocacy and support sessions. Staff and residents interviewed gave examples of one to one support time with residents being provided outside of the home – assisting with college attendance or visits to cafes and pubs, for example. Interaction between staff and residents observed indicated that residents are being treated with respect, and that personal care is being provided the way the resident would wish it to be provided. Activities and events provided, such as the residents’ meeting on the day of the inspection, are a matter of personal choice for residents. Residents can choose to be part of a cleaning rota which residents help run, and the rewards system which is part of this includes meals out. York Lodge H60-H11 S14865 York Lodge V248612 241005 Stage 4.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Residents receive support in the way they prefer and require. EVIDENCE: On the day of the inspection, the inspector was aware of personal support such as bathing being provided which was at the time and in the manner preferred by the resident. Residents were being assisted with their finances in private. York Lodge H60-H11 S14865 York Lodge V248612 241005 Stage 4.doc Version 1.40 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 The protection of residents should be further ensured by the adult protection procedures being updated to include the key role of the adult and caring services department and to the protection of vulnerable adults register. EVIDENCE: The complaints policy and the record of complaints was seen. Registered Manager Mr McKernan said that no complaints have been received since the previous inspection. Staff training records seen indicated that staff have been receiving training in adult protection issues. The procedures for the investigation of adult protection incidents were seen, and the inspector suggested that section 25.3 refer to the need to contact the social and caring services department (adult duty team) when abuse has been suspected or reported. The inspector also suggested that section 25.5 should refer to the provider’s responsibility to refer staff who have been seen to be unsuitable to work with vulnerable adults to the Protection of Children and Vulnerable Adults registers. York Lodge H60-H11 S14865 York Lodge V248612 241005 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 27 Residents will benefit from planned refurbishment in the home. EVIDENCE: The premises are being reasonably well maintained, and benefit from a handyman being employed. Mr McKernan said he recognised the need for some redecoration in the home and new carpeting in the dining room, and they were the priorities for refurbishment at present. The refurbishment of the main bathroom is also planned. York Lodge H60-H11 S14865 York Lodge V248612 241005 Stage 4.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 Residents are benefiting from a well supported and supervised staff team. EVIDENCE: Staff interviewed said that regular one to one supervision which was being recorded was being received. Staff said that supervision was covering training and development needs, and supported the work being carried out with residents, and that staff meetings were useful for talking through dealing with situations and sharing knowledge and skills. Staff interviewed said they found the home relaxed and friendly, and that the training, experience and stability of the staff team was contributing to the quality of the care being provided. York Lodge H60-H11 S14865 York Lodge V248612 241005 Stage 4.doc Version 1.40 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 42 The home is being well managed, and improvements which benefit the residents are being introduced. A workable system for seeking the views on the service provided has been introduced. The registered manager should ensure risk assessments are carried out for all safe working practice topics covered in standards 42.2 and 42.3, and that significant findings of the risk assessments are recorded. EVIDENCE: Since the previous inspection, Mr McKernan has been registered as manager of the home, and has been undertaking the registered manager award. It was noted that Mr McKernan has developed the service towards staff providing more individual time with residents, and residents being encouraged to take up opportunities for further education. A system for seeking views on the performance of the service and measuring how well the aims and objectives of the home are being achieved has been put York Lodge H60-H11 S14865 York Lodge V248612 241005 Stage 4.doc Version 1.40 Page 17 in place. On the day of the inspection, residents were independently answering questionnaires on this, and examples of responses received from their family, visitors, and involved professionals were advised to the inspector. Mr McKernan said that once the responses received had been collated and summarised, they would be published and made available. Records relating to fire drills and testing of equipment were seen. Mr McKernan advised that all water outlets now had valves to control the risk from hot water, but that no records of hot water temperatures were kept. Mr McKernan carried out a risk assessment of the premises on 13.5.05, and advised that action needed had been carried out. The inspector noted that the risk assessment record did not show that risk assessments had been carried out for all safe working practice topics covered in standards 42.2 and 42.3. York Lodge H60-H11 S14865 York Lodge V248612 241005 Stage 4.doc Version 1.40 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x 2 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 3 x x x Standard No 11 12 13 14 15 16 17 x x 3 x x 3 x Standard No 31 32 33 34 35 36 Score x x x x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 York Lodge Score 3 x x x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 2 x H60-H11 S14865 York Lodge V248612 241005 Stage 4.doc Version 1.40 Page 19 no Are there any outstanding requirements from the last inspection? 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 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 23 Good Practice Recommendations The adult protection procedures should be updated to include reference to the key role of the adult and caring services department and to the protection of vulnerable adults register. The adult protection procedures should be updated to include reference to the key role of the adult and caring services department and to the protection of vulnerable adults register. The statement of purpose should be updated. The contract/terms and conditions of residence should include all information specified under standard 5.2. 2. 42 3. 4. 1 5 York Lodge H60-H11 S14865 York Lodge V248612 241005 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection 2nd Floor, Ridgeworth House Liverpool Gardens Worthing, West Sussex BN11 1RY 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 Lodge H60-H11 S14865 York Lodge V248612 241005 Stage 4.doc Version 1.40 Page 21 - 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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