CARE HOMES FOR OLDER PEOPLE
York Lodge 54-56 Crofts Bank Road Urmston Manchester M41 0UH Lead Inspector
Val Bell Unannounced Inspection 6th January 2006 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 DS0000063237.V275092.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 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 DS0000063237.V275092.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service York Lodge Address 54-56 Crofts Bank Road Urmston Manchester M41 0UH Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0161 748 2315 0161 748 2315 alan.machen4@ntlworld.com Mr Alan M Machen Mrs Ann Elizabeth Crowe Mr Alan M Machen Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places York Lodge DS0000063237.V275092.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home accommodates a maximum of 22 service users requiring personal care only by reason of old age. 25th October 2005 Date of last inspection Brief Description of the Service: York Lodge is a private care home providing personal care and accommodation for up to twenty-two (22) older people. The communal facilities include three lounges, a dining room and a conservatory, which was being used as a smoking area. The furnishings and fittings were domestic in nature and of good quality. The conservatory was bright and airy with a small balcony seating area immediately off. The home was awaiting the installation of a hydraulic ramp to provide disabled access into the home at the conservatory entrance. The home is owned by Mr Alan Machen and Mrs Ann Crowe and managed by Alan Machen. The home is situated in a residential area of Urmston and is close to shops, pubs, the post office and local amenities. York Lodge DS0000063237.V275092.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out during daytime hours on 6th January 2006. Conversations were held with a number of residents, management and staff and various documents, including care plans, were examined. Two of the thirteen requirements made at the previous inspection had been met. What the service does well: What has improved since the last inspection? What they could do better:
The home does not provide disabled access and this is a cause for concern as this issue has been outstanding for some considerable time. The registered person must provide written confirmation to the Commission stating how disabled access will be provided and in what timescale. The registered manager was having difficulty in completing a course of study for NVQ level 4 in care and management due to a busy work schedule. The manager needs to offload some of his workload to the senior staff on his team. This should free up more time for him to devote to study.
York Lodge DS0000063237.V275092.R01.S.doc Version 5.1 Page 6 Two further requirements were made and these related to a recent fire safety inspection. The registered person is required to undertake improvements to fire resistance of the basement ceiling and to update the homes Service User Guide in line with the recommendations of the fire officer in relation to certain bedroom doors that must not be fitted with privacy locks. 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 DS0000063237.V275092.R01.S.doc Version 5.1 Page 7 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 DS0000063237.V275092.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the Standards in this section were assessed on this occasion. York Lodge DS0000063237.V275092.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Residents could be confident that their personal care and health needs would be met in a respectful manner and that residents right to privacy would be upheld. EVIDENCE: The requirement made at the last inspection for residents to be involved in their care planning had been addressed. Several care plans had been signed by residents indicating their agreement with the contents. A selection of care plans was examined. These had been subject to monthly review, or more regularly as individual’s needs had changed. The outcome of residents’ health appointments was being recorded in the medical intervention section of the care plans. The recording of medication administration had improved since the last inspection and individuals confirmed that staff treated them with respect and that their right to privacy was upheld. York Lodge DS0000063237.V275092.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 A range and variety of organised activities provided stimulation and interest for residents. EVIDENCE: Since the last inspection the home had employed an activities co-ordinator for fourteen hours per week. A visiting entertainer was providing a music session during the inspection. The inspector was told that three groups of residents were taken out of the home for their Christmas dinner and a Christmas party had been held in the home. York Lodge DS0000063237.V275092.R01.S.doc Version 5.1 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Implementation of robust procedures to protect residents from abuse safeguarded the welfare of people living in the home. EVIDENCE: Since the previous inspection a copy of Trafford Metropolitan Borough Council’s policy on the Protection of Vulnerable Adults from Abuse had been obtained. The home had subsequently adopted this policy and implemented the adult protection procedures. York Lodge DS0000063237.V275092.R01.S.doc Version 5.1 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 22 Improvements in safe working practices in the home protected resident’s health, safety and welfare. Failure to provide disabled access into the home deprives the right of people with disabilities access into and out of the home and their right to freedom of movement and independence. EVIDENCE: The registered person had consulted and taken advice from the fire officer about the use of door wedges in the home. It had been agreed that door wedges could only be used during daytime hours and strictly under the supervision of staff. Additionally, fire doors were being checked on a weekly basis to ensure that they were fully closing within their rebates. The home had not taken action to provide disabled access into the home. This requirement had been outstanding for some considerable time. Consequently, the registered person is required to submit an action plan to the Commission
York Lodge DS0000063237.V275092.R01.S.doc Version 5.1 Page 13 detailing how disabled access will be provided and the timescale in which the work will be carried out. York Lodge DS0000063237.V275092.R01.S.doc Version 5.1 Page 14 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Residents assessed needs were being met by a well-trained workforce. EVIDENCE: No staff recruitment had taken place since the previous inspection. It was confirmed that Criminal Record Bureau certificates had been obtained for all staff employed by the home. General Social Care Council Codes of Conduct had been issued to all staff, who had signed to confirm receipt. A training and development plan had been implemented and the manager was planning to undertake induction and foundation training with the staff team. Following this training programme staff were to receive performance appraisals and regular one-to-one supervision sessions. This was considered to be an area of good practice. The outcomes of the training programme, appraisals and supervision will be fully assessed at the next inspection. A variety of training courses had been provided, including food hygiene, fire safety and a moving and handling trainers course for a member of staff. Eight staff had also been booked on courses in dementia and infection control. Rota’s for week commencing 6th January 2006 confirmed that the home was being adequately staffed. The registered manager was planning to appoint a person-in-charge on each shift. The inspector was told that this would be
York Lodge DS0000063237.V275092.R01.S.doc Version 5.1 Page 15 detailed on the rota, which will also include the hours worked by the registered manager. York Lodge DS0000063237.V275092.R01.S.doc Version 5.1 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Inadequate fire resistance to the basement ceiling potentially places the safety of residents at risk of harm in the event of a fire. EVIDENCE: The manager stated that he was finding difficulty in making progress on achieving NVQ level 4 in care and management due to his heavy workload. During discussion it transpired that the manager was taking responsibility for undertaking all management tasks. It was agreed that the manager needed to delegate responsibility for some management tasks to his senior staff. Appointing a person-in-charge on each shift should alleviate this problem. The manager is required to submit an action plan to the Commission detailing how this will be achieved and the timescale involved. The inspector was told that the task of undertaking satisfaction surveys with residents would be delegated to the activities co-ordinator. A template was available for this exercise.
York Lodge DS0000063237.V275092.R01.S.doc Version 5.1 Page 17 The home managed the day-to-day finances for one of the residents. This had been agreed in consultation with the social worker. Detailed and accurate accounts were held and all withdrawals had been validated with receipts. The resident or two members of staff signed for withdrawals and the cash was held in a cash tin stored in a locked filing cabinet. The office in which this was located was kept locked overnight. The manager stated that he would be introducing weekly staff meetings on a shift basis and that minutes of the meetings would be recorded. This will be assessed at the next inspection. An accident book that complied with the Data Protection Act 1989 had been obtained. The home had been inspected by the fire service the week prior to this inspection and the inspector had received a copy of the report. The manager said that the fire officer had praised the quality of the homes fire risk assessment. The fire officer identified one area of non-compliance relating to fire resistance of the basement ceiling. Holes in the ceiling must be in-filled with fire resisting materials to afford at least the same degree of fire resistance as the existing basement ceiling. Additionally, the fire officer stated that all doors required for means of escape must be available at all times without the use of a key. This involves some residents’ bedroom doors. Consequently, the registered person must include this information in the Service User Guide and ensure that prospective residents are informed that some bedrooms may not be fitted with privacy locks. Residents admitted to these rooms must give their written consent prior to admission. York Lodge DS0000063237.V275092.R01.S.doc Version 5.1 Page 18 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X 1 X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 York Lodge DS0000063237.V275092.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 OP22 Regulation 23 (2) (n) Requirement The registered person must submit an action plan to the Commission detailing how disabled access will be provided to the home and the timescale in which the work will be carried out. The registered person must submit an action plan to the Commission detailing how he will achieve NVQ level 4 in care and management and the timescale involved. The registered person must take action to ensure that the requirements made by the fire officer in his inspection report dated 18/01/2006 are met. The homes Service User Guide must be reviewed and updated to inform prospective residents that some bedrooms are not fitted with privacy locks due to fire regulations. Timescale for action 31/03/06 2 OP31 9 06/02/06 3 OP38 13 (4) 06/03/06 4 OP38 5 06/02/06 York Lodge DS0000063237.V275092.R01.S.doc Version 5.1 Page 20 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 DS0000063237.V275092.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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