Inspection on 26/01/06 for York Lodge

This inspection was carried out on 26th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found no outstanding requirements from the previous inspection report, but made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

York Lodge 01/06/07

York Lodge 21/06/05

York Lodge 04/10/04

York Lodge 16/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 York Lodge York Lodge 129 Balcombe Road Horley Surrey RH6 9BG Lead Inspector Pat Collins Unannounced Inspection 26 January 2006 11:20 th York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 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 DS0000013847.V273469.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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 DS0000013847.V273469.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service York Lodge Address York Lodge 129 Balcombe Road Horley Surrey RH6 9BG 01293 785235 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) Welmede Housing Association Ltd To Be Confirmed Care Home 8 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (1) of places York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 21 65 YEARS, TO INCLUDE TWO (2) PERSONS OVER 65 YEARS 21st June 2005 Date of last inspection Brief Description of the Service: York Lodge is a care home registered for provision of personal care and support for up to eight adults whose primary support need is a learning disability. Service users may have a secondary mental health disorder or sensory impairment. Registration conditions provide for either male or female service users, referred to as ‘tenants’ in the report At the time of this inspection the user group was all male. The service aim is to enable ‘tenants’ to lead as independent and fulfilled life as possible, providing support that maximises skills to the fullest potential. The property is a large, detached two storey building situated in a residential area. Horley town centre is within walking distance and community facilities and services are accessible. At the front of the building is a large garden and car parking facilities and an enclosed garden is available at the rear. Communal accommodation is arranged on the ground floor, comprising of a spacious lounge and smaller, second lounge, the latter designated as a smoking area. There is a large dining room, a well equipped kitchen, separate utility room and combined staff office/ sleeping – in facility also on this floor. Bedroom accommodation is arranged on the first and second floors, accessible by stairs only. All bedrooms are single occupancy and are situated near to toilet and bathing facilities. The Registered Provider, Welmede Housing Association specialises in care and support of adults with learning disabilities. York Lodge is part of a group of care homes operated in Surrey by this organisation. Hyde Housing Association owns this property and is responsible for its maintenance. York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the home’s second inspection for the year 2005/2006. It was unannounced therefore staff and service users were not informed in advance of the inspection being carried out. The inspection commenced at 11.20 hrs and concluded at 16.30 hrs. The manager and deputy manager were each present for part of the inspection and a ‘floating’ support worker was present throughout. Four of the six service users currently accommodated, referred to as ‘tenants’ throughout the report on the basis of their stated preference, were at home for part of the inspection. One was home for the full duration. The inspection process included review of progress for compliance with statutory requirements made at the time of the last inspection. A partial tour of the home was undertaken and records were sampled. Standards reviewed included catering and food hygiene, medication practices, staff recruitment procedures, management, health care and elements of health and safety including infection control and risk management. The inspector consulted all staff and ‘tenants’ present as part of the inspection process. Information contained in six comment cards completed by ‘tenants’, some with the assistance of staff’, received after the inspection also formed part of the inspection process. The inspector would like to thank the ‘tenants’ and staff for their courtesy and cooperation throughout the inspection. What the service does well: In their interaction with ‘tenants’ staff were respectful and helpful in their approach. They demonstrated effective communication skills, the manner of address being age-appropriate and enabling. Discussions with ‘tenants’ confirmed most were satisfied with their lives at York Lodge. They were supported and enabled to lead fulfilling, interesting lives and individuals went out in the community unaccompanied by staff. A ‘tenant’ was observed to independently use the telephone to clarify arrangements for his support for a round of golf played on the day of the inspection and arranged his own transport. Three ‘tenants’ attended an advocacy group meeting in the community in the afternoon. Discussions with ‘tenants’ confirmed pursuit of a wide range of interests, leisure and educational activities. One ‘tenant’ had recently commenced paid employment and another engaged in regular voluntary work. ‘Tenants’ were encouraged to maintain as much independence as possible and risk management was seen as vital to enabling individuals to maximise their full potential. Staff described arrangements for ensuring levels of support required for enabling ‘tenants’ to acquire and practice independent living skills commensurate with individual capabilities. York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 6 At the start of the inspection the ‘tenants’ were busily involved in cleaning communal areas for which they shared responsibility. They assumed individual responsibility for cleaning their own bedrooms, for personal laundry and for budgeting, purchasing and preparing their own meals. Management and administration systems were organised and effective. Observations indicated satisfactory teamwork within the small staff group. It was evident that the ‘floating’ support workers were integral members of the team vital to continuity of care and routines. Staff on duty demonstrated knowledge of ‘tenants’ individual needs. Systems were in place for consultation with ‘tenants’ on relevant operational and management decisions. The management of medication was determined satisfactory. Decisions for individual ‘tenants’ to self – medicate were underpinned by risk assessments. An enhanced risk management strategy specific to self-medication had been recently implemented aimed to minimise risks for a named person whilst endeavouring to promote continued, individual independence. What has improved since the last inspection? What they could do better: The need to ensure adequate risk assessments carried out for a ‘tenant’ with a recent history of a seizure was discussed with management. Related risk management strategies must be documented in the person centred plan for this individual. York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 7 The manager was advised to review infection control risks specific to the decision not to provide paper hand towels in dispensers fitted in communal bathrooms and toilets. Record keeping systems for meals were not in sufficient detail to determine whether dietary needs were adequately met and meals sufficiently varied and nutritious. The record viewed was incomplete. The available information at the time of this inspection indicated that service users did not routinely have a balanced, health diet however. This conclusion was discussed with the manager and staff who asserted that ‘tenants’ were encouraged to plan healthy, varied meals however often rejected advice. The service aims promoted ‘tenants’ rights to live like others in the community and to make choices relating to their lifestyle which including choice in what they eat. Staff confirmed that they were monitoring the weights of individual ‘tenants’ and if concerned would ensure referral to a dietician. The damaged bath panel in the first floor smaller bathroom required replacement. Condensation problems in the larger bathroom required attention. It was reported this problem had recently been assessed and it had been concluded that nothing could be done. Staff stated the advice had been for the window to be left open when ‘tenants’ were taking a bath. It was evident that this solution was not practical in the winter months however. Noting condensation was stated not to pose a problem in the smaller bathroom it was suggested that the adequacy of the extractor system in the larger bathroom be investigated. The extractor in the large bathroom was significantly smaller than the one fitted in the small bathroom and unlike that one, was not automatically activated by the light switch. Attention was required to staff recruitment and vetting procedures, specifically relating to CRB Disclosures. As a minimum, POVA/First checks must be in place for any new staff taking up post prior to obtaining a CRB Disclosure. Evidence of these must be held on personnel files in the home. Attention was drawn to the matter that CRB Disclosures were no longer portable for care homes. Attention is also required to the storage, recording, retention and disposal of CRB Disclosures at this home. The Licence Agreement sampled required updating. Consideration could be given to developing this document in a ‘user friendly’ format. 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 DS0000013847.V273469.R01.S.doc Version 5.1 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 1,5. The statement of purpose accurately depicted service provision. This document required minor amendment. ‘Tenants’ were issued with a statement of the terms and conditions of their contract of residency (License Agreement). The relevant parties signed these. The License Agreement sampled required updating. EVIDENCE: The Statement of Purpose required updating to reflect recent changes in personnel and to change reference to the regulator from NCSC to CSCI. On the file sampled the ‘tenant’ had an old License Agreement document issued by Hyde Housing Association. Welmede Housing Association had written to this individual in recent years, specifying the room number of the accommodation occupied as part of this Agreement. The inspector noted that the Agreement referred to the ‘tenant’ being responsible for part payment of Council Tax and Water rates. The manager advised that this information was out of date and ‘tenants’ were not responsible for these charges. The License Agreement also referred to ‘tenants’ property being covered by the organisations insurance. The manager was not aware if there was a maximum amount of insurance cover. On noting an inventory record of personal possessions belonging to a ‘tenant’ worth a substantial amount of money it was suggested that the manager clarifies the level of existing insurance cover to establish if additional cover was needed. The License Agreement ideally should include this information. York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 10 Relevant parties had signed the License Agreement. The format of this document was not considered ‘user friendly’. York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 6, 7, 8, 9. Whilst overall these standards were effectively met review was required of risk assessment and risk management strategies relating to a health condition for a named ‘tenant’. The information must be reflected in this individual’s person centred plan documentation. EVIDENCE: Each ‘tenant’ had an Essential Lifestyle Plan (ELP) in place based on a person centred planning approach. These had been formulated through discussions with ‘tenants’ who had each lead this process and plans based on what ‘tenants’ perceived to be important in their lives. On the ELP examined, which the manager stated the title needed to be amended to PCP (Person Centred Plan), there was a range of information recorded. This pertained to the needs, goals, aspirations and risk management strategies for this individual. Observations identified the need to review the risk assessment and management of risk for this individual specific to seizures. This was discussed with the manager and deputy manager who both initially maintained this individual’s seizures were well controlled. A review of recent incident reports however identified a recent seizure reported. The risk assessment must consider whether any further measures might be appropriate to minimise risks for this individual. Example of this might be to connect a lead York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 12 to the emergency call system in the bathroom and/or review the appropriateness of this individual locking the bathroom door when taking a bath unsupervised. Discussed with the manager was the importance of demonstrating through this individual’s care documentation that these factors have been subject to recent medical assessment and review. Other care records and risk assessments were recorded and had been regularly reviewed. The need to maintain adequate records to demonstrate sufficient support in planning a balanced diet was also discussed with the manager. Care Management reviews were clearly documented on the file sampled. Internal review meetings took place at least every six months. Each ‘tenant’ had a record kept of their development and of communication with them, associated professionals, relatives and others. ‘Tenants’ were very active and were encouraged to maintain as much independence as possible. Risk assessments were in place to support individuals in leading fulfilling lives and to be included in and participate in community based activities. Risk assessments sampled included use of public and other transport, management of personal finances, crossing roads, absconding, cooking, falls and other activities of daily living. ‘Tenants’ were encouraged and supported in making decisions and choices in their daily lives. Any limitation of choice or rights was evidently made in the best interest of individuals and discussed and agreed with them. Opportunity was available for ‘tenants’ to influence decisions in the home and its operation of the home through day-to-day contact with staff, ‘tenants’ meetings and user satisfaction questionnaires, which were a recent development. The deputy manager was observed facilitating a discussion between two ‘tenants’ regarding a change proposed by one individual to the household-cleaning rota. This was managed with diplomacy and skill whilst maximising choice, control and autonomy for both individuals involved. York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 11, 12, 13, 14, 15, 16, 17. ‘Tenants’ were enabled to lead independent and fulfilling lives and received support that maximised individual potential. ‘Tenants’ choose how they spend their time and their presence and participation in the community was promoted and facilitated. ‘Tenants’ planned their own menus and were responsible for budgeting for their own meals and for shopping for food and preparing their own meals. Staff stated that they offered advice and support on these activities and encouraged to ‘tenants’ to eat healthily. They acknowledged however that their advice was often rejected. EVIDENCE: The ‘tenants’ were observed to lead interesting and fulfilling lives. Individuals were able to go out independent of staff, engaging in various communitybased activities. On the day of the inspection one ‘tenant’ was at work in paid employment. Another individual stated he undertook regular voluntary work in a charity shop several days a week, which he enjoyed and found satisfying. Three ‘tenants’ attended a self-advocacy group on the afternoon of the inspection attended by taxi and another individual went to play a round of golf. Comment cards received after this inspection confirmed overall satisfaction with life at the home. One individual who expressed appreciation at the home’s York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 14 location, which is convenient for the town and transport, described a happy and friendly atmosphere. Photographs were displayed in the home of past holidays and excursions enjoyed by ‘tenants’. One of the ‘tenants’ spent time discussing the photographs and his recollections of each holiday/excursion with the inspector. Holidays and trips in recent years had been spent in Blackpool, New York, Eastbourne and London. Individual ‘tenants’ enjoyed attending premier football matches and one had subscribed to a premier sports television channel. The manager confirmed efforts by staff to accompany these individuals’ to football matches once a month though sometimes this was not possible owing to pressure on ticket availability. A ‘tenant’ informed the inspector that they had not yet decided on where they would go on holiday this year, confirming they were always consulted. ‘Tenants’ were encouraged to pursue educational and training opportunities and to develop new skills. Individuals’ attended college courses in pottery, art, cookery and computer skills. Evidence was viewed indicating that ‘tenants’ encouragement to retain family links and friendships. received support and All ‘tenants’ were encouraged to actively participate in the running of their home, including assuming responsibility for cooking, cleaning and laundry. The inspector observed three bedrooms with the agreement of occupants and these were clean and mostly tidy. One bedroom was very congested with personal possessions and clothing. Clean laundry was overflowing from linen bins in this bedroom and the impression given by this individual was that wardrobe and cupboard storage space was at a premium, exacerbating the untidy appearance of his room. In separate discussions with this individual and the manager it was evident that staff support was given to ensure standards of cleanliness and tidiness was maintained in this room to an acceptable level. ‘Tenants’ planned their own menus. Staff stated they encouraged selection of foods necessary to provide a varied, balanced and nutritional diet. The basic record of food consumed by ‘tenant’ was incomplete and it was difficult to establish how staff were able to supervise and monitor the adequacy and nutritional content of diets. Staff stated that ‘tenants’ who disliked and refused to eat vegetables, salads and fruits often rejected healthy eating options that they promoted. The record of meals for the week displayed in the kitchen was noted to comprise of mainly frozen fast food, such as pizza and pies and ready meals. On the day of the inspection, though individual ‘tenants’ were observed in the kitchen making hot drinks, they were not observed to prepare food. The manager informed the inspector that they had each eaten a substantial breakfast including cooked breakfasts prior to the inspector’s arrival. This was not evident from the record of food examined. York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 15 ‘Tenants’ confirmed that they withdrew money for their food from their bank accounts to which direct payment of benefits was made. This was understood to include money intended for purchasing food. Each had a set day for doing so. The night before they would prepare a shopping list and staff would offer suggestions and advice on the content if necessary. Staff confirmed six monthly medical reviews and could request referral to a dietician if necessary. The weights of individual ‘tenants’ were stated to be monitored by staff. Food storage was satisfactory and temperature records for fridges, freezers and meat probing were maintained. The deputy manager confirmed that all staff had received basic food hygiene training and updated training. The kitchen was clean and hygienic and had benefited from a relatively recent refurbishment. York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 16 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 the following standard(s): 19, 20. Healthcare arrangements ensured access to primary and specialist health care services. The need to review the risk management strategy for a named service user specific to a recent history of a seizure was discussed. Medication practices were satisfactory and included additional monitoring arrangements as necessary to manage risks associated with self-medication practices. EVIDENCE: The care records sampled demonstrated needs were assessed and support provided to ensure that the health care needs of ‘tenants’ were appropriately met. They received support to access a wide range of primary and specialist healthcare services and facilities. Observations identified the need to review risk assessments for a ‘tenant’ with a recent history of a seizure reported and for this condition and risks to be addressed in his PCP. The medication policy was viewed and the signatures of all staff held on record. All staff working at the home were responsible for administration of medication and had received training, which included assessment of their practice. A monitored dosage medication system was operational and medication was stored securely in a metal medication cupboard. Medication administration records were signed and records included receipt and disposal of medication. Risk assessments had been carried out for service users who York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 17 were self-medicating. Risk monitoring relating to self-medication was evident and had increased for one individual in response to a recent incident. Individuals who were self-medicating had lockable facilities in bedrooms for the storage of their medication. No controlled drugs were prescribed at the time of the inspection. One ‘tenant’ informed the inspector of his wish to move out to live in a flat shared with fewer people. It was confirmed that Care Management was actively pursuing his request. He emphasised that his wish to do so was based on a desire for a change, having lived at the home for many years. He had no adverse criticism of the conduct of the home or of the care and support received. York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 18 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 the following standard(s): These standards were not assessed. At the time of the last inspection they were fully met. EVIDENCE: York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 19 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 the following standard(s): 25, 26, 27, 28, 29, 30. The home mostly met each of these assessed standards providing a reasonable level of accommodation appropriate to the needs of the current service users. The risk of cross-infection in the communal use of towels in toilets should be reviewed. EVIDENCE: The home offered a reasonable standard of accommodation. There were eight bedrooms, six on the first floor and two on the second floor. Bedrooms sizes varied and all were compliant with the national minimum spatial standards. ’Tenants’ mostly had keys to their bedroom doors. The three occupied bedrooms inspected were suitably decorated and furnished. All were personalised, reflecting ‘tenants’ individual tastes, interests and lifestyles. There was evidence of regular cleaning schedules for bedrooms with staff support. Comment has been made in another section of the report on the overcrowded environment in one bedroom. Communal areas were comfortable and clean and provision included television and audio equipment for communal use. ‘Tenants’ also had televisions, videos/DVD’s and audio equipment in their bedrooms, which they had purchased. York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 20 Bathing facilities included a ground floor shower and toilet and two bathrooms with showers and toilets and a separate toilet on the first floor. Observations identified a cracked bath panel requiring replacement in the smaller first floor bathroom. Condensation problems were reported in the larger bathroom on this floor, which required further investigation, and a suitable resolution found. ‘Tenants’ did not have physical disabilities and did not require specialist equipment or aids for mobility or communication. An emergency call system was installed throughout the premises. It was suggested that risk management strategies for individuals’ with a history of seizures could include provision of call bell leads accessible when taking a bath. Discussed with the manager was the need to review of infection control risks in communal toilets and bathrooms. Specifically hand towels shared by ‘tenants’ for drying hands after hand washing following use of the toilet. Though paper towel holders were fitted in these areas provision was not made of paper towels. York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 21 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 32, 34 and 35 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, 34 Staff on duty were aware of the individual needs of ‘tenants’ and relationships between staff and ‘tenants’ appeared positive. Recruitment procedures were not sufficiently robust and additional attention was required to recruitment record keeping practices. EVIDENCE: A ‘tenants’ stated, “staff are very nice”. The relationship between staff and ‘tenants’ was perceived to be supportive. Staff confirmed they had received job descriptions and were evidently clear of their roles and responsibilities and job purpose. They knew and supported the aims and the values of the service. There was a systematic approach to the delegation of responsibilities on a daily basis to meet the needs and lifestyles of ‘tenants’. The small staff team of five had experienced significant turnover and change since the last inspection. The ‘acting’ manager had been appointed to the vacant manager’s position and a new deputy manager and support worker had taken up vacant posts created through retirements. Good continuity of care was demonstrated and ‘floating’ support workers were integral to minimum staffing levels. Staffing levels were routinely one on a shift increasing to two between the hours of 09.00hrs and 18.00hrs. One member of staff was on duty at night, on sleeping/on call at the home. There was an on call, out of hours duty system operational for support, advice and assistance if necessary. York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 22 The staff file examined for a new employee identified that recruitment and vetting procedures were not sufficiently robust. This employee had taken up post on the basis of a CRB Disclosure carried out 10 months prior to taking up post by a previous employer. This practice is unacceptable owing to CRB Disclosures no longer being portable. There was no evidence of a POVA/First on the personnel file of this staff member. A new CRB Disclosure had been applied for but not yet received. Other vetting practices were in accordance with statutory requirements for this employee. Observations confirmed failure to adhere to CRB policy for a record to be maintained of CRB Disclosures for staff, and for appropriate storage and disposal of CRB Disclosures. York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 23 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Observations concluded that the management of the home was underpinned by the aims and values and stated purpose of the home. Whilst generally the health and safety and welfare of ‘tenants’ was promoted and protected by the policies and procedures of the organisation, attention was required to deficiencies identified in the management of risk specific to a ‘tenant’ with a medical condition and in relation to recruitment procedures. EVIDENCE: An application for registration of the manager was being processed at the time of the inspection. The manager stated he had attained a certificate in care at NVQ Level 3 and described relevant background experience in the care and support of adults with learning disabilities. He stated his intention to apply to study for the Registered Managers Award qualification NVQ Level 4 later this year. He stated that he currently did not meet the eligibility criteria set by his employer to make application at this time. Welmede Housing Association had employed both the manager and deputy manager for a number of years. They were familiar with the organisation’s policies and procedures. The deputy manager was noted to also have attained York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 24 an NVQ Level 3 in Care qualification. Observations indicated that the home was being effectively managed. Positive relationships were perceived to exist within the staff team and between staff and ‘tenants’. Processes were in place for eliciting feedback from ‘tenants’ on a regular basis through day-to-day discussions, reviews, ‘tenants’ meetings and a recently implemented survey. Systems for continuous self-monitoring were operational, and monthly statutory visits carried out by a senior manager on behalf of the Responsible Individual. Copies of these reports were available in the home and forwarded to the Commission for Social Care Inspection. The records sampled were well organised, held confidentially and were regularly updated. Attention was required to the storage, recording and disposal of CRB Disclosures. Records sampled specific to the safety of the environment included recent documentation and correspondence relating to a fire safety audit. There were no fire safety signs displayed in the home other than the procedures and a notice displayed by the front door and in the office. The organisation’s health and safety manager had advised the area manager that within the Fire Precautions (Workplace) Regulations 1997 as amended there was scope for a flexible approach to the display of fire evacuation and other signs in small, domestic style care establishments, subject to a number of control measures. These were specified in the record viewed and compliance with these noted. The inspector also examined risk assessments implemented for smoking since the last inspection. Health and safety records and report of the last full audit in May 2004 were also examined. Risk assessments were in place for the unrestricted widows. Observation made of a gas fire in the dining room highlighted the need to ensure adequate risk assessment in place for this appliance, both generally as a potential fire hazard and individually for each ‘tenant’. Other records sampled were the gas and electrical maintenance records, portable electrical appliance records, hot water temperature monitoring, fridge, freezer and food temperature records York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 25 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 Standard No Score 1 3 2 x 3 x 4 x 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 x 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 x 33 3 34 2 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 2 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 x x x x x 2 x x York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 26 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 YA5 Regulation 5 (1)(b) Requirement For License Agreements to be updated to reflect the agreement is between ‘tenants’ and Welmede and reflect accurately any additional charges. For review of risks and risk management strategy for seizures for a named ‘tenant’. For review of arrangements for supporting and educating ‘tenants’ to make healthy choices to meet dietary needs. Record keeping practices must demonstrate how this is achieved and monitoring systems. For the broken bath panel in the first floor bathroom to be replaced. For further review of condensation in the large first floor bathroom. For POVA/First checks to be carried out on staff taking up post prior to receipt of CRB Disclosures and for evidence of these checks to be held on personnel files in the home. Staff in post on the basis of DS0000013847.V273469.R01.S.doc Timescale for action 26/04/06 2 3 YA42YA41YA19 YA18YA9YA6 YA41YA17YA7 12(1)a 14(2)b 13(4)b)c 16(2)(i) 17(1)(a) 29/01/06 26/02/06 4 5 6 YA27YA24 YA27YA24 YA41YA34 23(2)(b) 23(2)(b) 19(1)(a) Sch2.2 26/04/06 26/04/06 29/01/06 York Lodge Version 5.1 Page 27 7 YA41 19 Sch 2.2 POVA/First checks must work under direct supervision when involved in the delivery of personal care. For compliance with CRB policy regarding recording, storage and disposal of CRB Disclosures. 26/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA 5 Good Practice Recommendations For License Agreements to clarify maximum amount of insurance cover provided for personal possessions. York Lodge DS0000013847.V273469.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 DS0000013847.V273469.R01.S.doc Version 5.1 Page 29 - 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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