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Inspection on 08/07/09 for Yew Tree Care Home

Also see our care home review for Yew Tree Care Home for more information

This is the latest available inspection report for this service, carried out on 8th July 2009.

CQC found this care home to be providing an Good service.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The people live in comfortable and homely accommodation. They are also offered choices about what they wish to do and to make decisions about how they spend their lives. Staff communicate well with them and respect their choices and decisions. They are cared for and supported by a caring, educated and committed team of staff who are aware of their needs and preferences. We saw throughout our inspection visit this taking place.Yew Tree Care HomeDS0000060593.V376412.R01.S.docVersion 5.2People who live in this home told us they were happy with the facilities provided and the way the staff care and support them. They told us, `I am very happy here` and `the staff are there to help me when I need them". People are offered a varied menu that takes into consideration their likes and dislikes. Comments in our recent surveys before the inspection to this service included, "I am always asked if there is anything special they can get for me as a treat for tea or any other meals. Nothing is too much trouble as I like special sauces". They are lead by an acting manager who is also the owner and has knowledge about management, the care and support for older people. There is a programme of education and training provided for staff, which ensures that staff know how to care and support the people who live at the home.

What has improved since the last inspection?

They have introduced new care records to make care more individual. They have increased the amount and variety of staff training to enable the staff to have the skills and understanding to care and support the people living in the home. They have appointed an activities co-ordinator. They have following discussions with the people reviewed the menu. They have redecorated 6 bedrooms, decorated the outside of the home, planted more plants in the garden with the involvement of the people and installed a new chair lift to the accommodation on the first floor.

What the care home could do better:

The three requirements from the last key inspection had been addressed. There were no requirements or recommendations as a result of this inspection. We asked the acting manager to ensure that all their information including the complaint`s procedure had our new National Contact Centre address and telephone number.

Key inspection report CARE HOMES FOR OLDER PEOPLE Yew Tree Care Home 60 Main Road Dowsby Bourne Lincs PE10 0TL Lead Inspector Tobias Payne Key Unannounced Inspection 8th July 2009 07:50 DS0000060593.V376412.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Yew Tree Care Home DS0000060593.V376412.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Yew Tree Care Home DS0000060593.V376412.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Yew Tree Care Home Address 60 Main Road Dowsby Bourne Lincs PE10 0TL 01778 440247 01778 440858 yewtree.gallac@btconnect.com 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) Yew Tree Residential Care Home Limited Vacant but an application for manager is in the process of being sent to CQC. Care Home 18 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (6) of places Yew Tree Care Home DS0000060593.V376412.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th August 2008 Brief Description of the Service: Yew Tree Care Home is a former rectory and is situated next to the church in the village of Dowsby. It is six miles from the town of Bourne, in Lincolnshire, which has shops, banks, post office, pubs and leisure facilities. The home is registered to provide personal care for eighteen people of both sexes over the age of 65 years, twelve of whom may have the diagnosis of dementia. There are 15 single bedrooms, two of which are en-suite and 3 double bedrooms, a dining room, a lounge and a conservatory which leads to the garden and patio. A stair lift serves the accommodation on the first floor. There is a single storey extension which provides accommodation for ten people. The home is set back from the road and has large enclosed gardens with spaces for car parking at the front of the home.. The philosophy of the home is to provide a home from home where our residents can feel at home in a friendly, secure and relaxed environment. We strive to preserve and maintain the dignity of our residents and remain sensitive to each persons ever changing needs. On the day of this inspection the weekly fees ranged from £360 - £520 depending on the persons assessed needs. Additional charges were for chiropody which was £11, hairdressing which ranged from £4.50 to £27 personal newspapers and personal toiletries. Information about the home including the statement of purpose, service users guide and a copy of the last inspection report are displayed in rack at the entrance to the home. Other information can be obtained from the acting manager of the home who is also the owner of the home. Yew Tree Care Home DS0000060593.V376412.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The inspection which was unannounced took place over 5 hours. The acting manager who is also the owner was present for part of the inspection but we were assisted throughout the inspection by the team leader who was given feedback at the end of the inspection. The main method of inspection used was called ‘case tracking’ which involved selecting 2 people and tracking the care they receive through the checking of their records, discussion with them and the staff, and where more appropriate observation of interaction between staff and the people living in the home and related care practices. We looked at a sample of care records and walked around the home to see the quality of accommodation and visited some of the bedrooms with the permission of the people living in the home. We spoke with 5 people living in the home, a visitor as well as 4 members of staff. An (AQAA) Annual quality assurance assessment was completed by the acting manager and sent to us prior to this report being completed. This is a self- assessment document completed by the manager of the care home. It sets out evidence from the provider to demonstrate that they are meeting the Care Home Regulations. We also sent out before this inspection 10 surveys to the people living in the home and 5 to staff. We received replies from 4 people and 3 from the staff. All were positive and their comments are reflected throughout this report. Where the use of we or us is used it refers to the Care Quality Commission. What the service does well: The people live in comfortable and homely accommodation. They are also offered choices about what they wish to do and to make decisions about how they spend their lives. Staff communicate well with them and respect their choices and decisions. They are cared for and supported by a caring, educated and committed team of staff who are aware of their needs and preferences. We saw throughout our inspection visit this taking place. Yew Tree Care Home DS0000060593.V376412.R01.S.doc Version 5.2 Page 6 People who live in this home told us they were happy with the facilities provided and the way the staff care and support them. They told us, ‘I am very happy here’ and ’the staff are there to help me when I need them. People are offered a varied menu that takes into consideration their likes and dislikes. Comments in our recent surveys before the inspection to this service included, I am always asked if there is anything special they can get for me as a treat for tea or any other meals. Nothing is too much trouble as I like special sauces. They are lead by an acting manager who is also the owner and has knowledge about management, the care and support for older people. There is a programme of education and training provided for staff, which ensures that staff know how to care and support the people who live at the home. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Yew Tree Care Home DS0000060593.V376412.R01.S.doc Version 5.2 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 Yew Tree Care Home DS0000060593.V376412.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3, 4, 5 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People coming in to the home receive information and support to help them make an informed choice of where to live. There are assessment processes in place, which ensure that individual needs can be met within the home. EVIDENCE: There was a detailed statement of purpose and service user’s guide together with a copy of our last inspection report at the entrance to the home. We noticed that the address and telephone number of our new National Contact Centre needed to be added to these documents. The acting manager agreed to act on this as soon as possible. The acting manager told us that since the last inspection no new person had been admitted to the home. However where a referral was made to stay in the home she would visit each person and make a thorough assessment of their needs involving the person and any other person involved in their care and support. As a result she would then send written confirmation to them that based on the assessment they could meet their Yew Tree Care Home DS0000060593.V376412.R01.S.doc Version 5.2 Page 9 needs. We saw in the records that assessments take place before admission to the home. The care home does not offer a dedicated intermediate care service. Yew Tree Care Home DS0000060593.V376412.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each person has a detailed care plan giving details about their care and support. We were told by the manager that this had been produced wherever possible with the involvement of the person, their family/advocate and other relevant people. Medication was given safely by staff who knew what they were doing. EVIDENCE: The acting manager told us that over the past year they had reviewed the way care was recorded and introduced a new system. We saw records for 2 people. Each person had a separate file with a photograph, admission information, consent to risk taking, medication, confirmation that the person had received information about the home, doctors notes, overall information covering their daily living activities and their background. From this a typed care plan for all aspects of care and support was produced. This contained what the problem was, what the caring instructions were, what the objective was and a monthly evaluation. Each person had a nutritional assessment using a nationally recognised tool, moving and handling assessment, risk assessment, weight Yew Tree Care Home DS0000060593.V376412.R01.S.doc Version 5.2 Page 11 and other assessments as required to meet the needs of the person. The care plans detailed their individual needs and how their care and support would be provided. Records were signed and dated. We could see that they also included a mental capacity assessment for each person. We saw instructions were personal and included choices and likes and dislikes. We saw an example in the case of a person who had a disturbed sleep pattern at night that staff should offer a drink when she wakes up during the night and check she is comfortable. We saw a person confined to bed who was comfortable, supported by pillows with bed protection rails and with a radio playing music she wanted to hear. There was also a chart showing the times her position was altered even though she was cared for on an alternating pressure mattress. There were also clear instructions about how staff should meet the particular needs of people who had a dementia. Throughout our visit we saw staff respecting the peoples wishes and choices in the way they made contact with the people living in the home and their response. We also saw staff showing good knowledge of the particular needs of the people living in the home. Comments we received included all the staff are very helpful and kind and have endless patience with us, They help me in every way. They care for us extremely well and are very kind to us all and the personal care for my mum provides all she needs. The staff care and love her, she feels at home. Where required, people living in the home were referred to their local doctor, community nurse, community psychiatric nurse, tissue viability nurse, continence nurse, physiotherapist, opticians, dentist and chiropodist. As part of their quality assurance measures the acting manager sent out questionnaires to the local doctors, community nurses, chiropodists and pharmacists during May and June 2009 to obtain their views about the home. Comments included, very caring, very good attitude, very good communication, well documented care and very helpful and friendly Care staff administered medication. There was a policy and procedure for this and the acting manager assessed each person before they were considered safe to administer medication. Records we saw were clear and well maintained with a good audit trail. The team leader in charge of the home on the day of our inspection told us that the people were encouraged by the staff team to self medicate but all the people needed a degree of assistance in order to ensure they took their medication safely. The service received a pharmacy inspection on the 23/6/2009. The report comments included no “problems and stock well controlled”. People we spoke with were satisfied with the way staff cared for them and had confidence in the staff. We saw throughout our inspection staff attended to the people in a warm, friendly and kind manner, knocking on doors before entering their bedrooms and asking whether they needed any help. We saw them laughing and spending time with them. One member of staff was walking with one of the people in the lawned garden talking to her and showing the garden. Yew Tree Care Home DS0000060593.V376412.R01.S.doc Version 5.2 Page 12 The people told us the staff are very kind, prompt and keen to help me and the staff are so friendly and kind. Yew Tree Care Home DS0000060593.V376412.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are encouraged to maintain and develop social interests and relationships of their choice. People receive a nutritious, varied diet, which meets their individual preferences and health requirements. Visitors are made to feel welcome and supported. EVIDENCE: When admitted to the home details were obtained of each persons interests. This was contained in their care records. Since the last inspection they have a pointed an activities co-ordinator. A formal programme of activities is not provided because most people who live at the home wished to have one to one interaction. We did see a notice about a Summer Fete due to take place on the 8/8/2009. Records and peoples comments showed us that the people had taken part in activities such as, singing and dancing, jigsaws, folding laundry, hand massages, walks in the grounds, ball games to aid coordination, movement to music and reminiscence therapy. A visitor to the home like all visitors was welcomed in a friendly manner and told us, I can visit whenever I wish and find the staff perfect and I am very satisfied with the way my mother is cared for”. Comment cards included, Yew Tree Care Home DS0000060593.V376412.R01.S.doc Version 5.2 Page 14 visitors always greeted and made welcome with tea, coffee/biscuits and cake provided on arrival free of charge. The people living in the home were offered 3 main meals a day plus snacks. The menu for the day was displayed at the entrance to the home outside the kitchen. There was a set menu but an alternative could be arranged to suit the needs of the person. South Kesteven District Council awarded the home 4 stars following an inspection, in recognition of the catering service provided. We examined the records for food temperatures, menus and cleaning rotas and found them well maintained and up to date. Meals were served in the dining room which was comfortable and spacious. Tables were set with clean tablecloths and flowers. Information provided in the AQAA and what people told us showed that the menus were varied and choice was offered. The cook told us about the menu options and specialist diets, which included pureed diets. People we spoke with told us they enjoyed the homemade buns and cakes. We saw breakfast and lunch being served and staff asking a person what they would like to eat. Comments we received included, food is always varied with good sized proportions, They help me in every way and great care is taken to feed her. Sometimes taking over ¾ of an hour. She has to be fed pureed food and this the staff do very well and carefully. We saw staff were assisting those people who needed assistance in a dignified and sensitive manner. All the people we spoke with were complimentary about the food. Yew Tree Care Home DS0000060593.V376412.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People know how to make a complaint and feel that staff will listen to their views. The care team know how to respond to a complaint and how to act in order to protect people from abuse. They are protected from abuse by correct and safe recruitment procedures. EVIDENCE: Each person received a copy of the complaints procedure in the service users guide. The information was also in the statement of purpose and displayed on the wall outside the kitchen at the entrance to the home. However it did not contain our new National Contact Centre telephone number and address. The acting manager agreed to address this. We and the home have received no complaints or safeguarding adult’s issues since the last inspection. The service had a copy of Lincolnshire County Councils adult protection procedures. All staff were correctly recruited including a check by the criminal records bureau (CRB). During their induction each member of staff received information about abuse. We asked 2 staff what abuse was and they knew their role and what to do if abuse was suspected. Staff also received regular refresher training to ensure their knowledge was up to date. None of the people living in the home, a visitor or the staff had any complaints about the home and felt they could discuss any concerns with staff or the Yew Tree Care Home DS0000060593.V376412.R01.S.doc Version 5.2 Page 16 acting manager. Staff also knew what to do if they received a complaint from a person living in the home. Yew Tree Care Home DS0000060593.V376412.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 23, 25 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in clean, comfortable, safe and well maintained accommodation. The infection control policy is followed and a safe environment is maintained. EVIDENCE: The home was well maintained and clean throughout. We were told that areas of the home had been redecorated with a number of bedrooms being painted. During our visit we walked around the home and found all areas of the home were clean, tidy and odour free. People we spoke with told us they were satisfied with the decoration and cleanliness of the home. They also spoke of how they liked their bedrooms. They were encouraged to bring into the home small items of furniture, television, pictures and personal items. People told us my room is very clean and comfortable and my washing is done as soon as I need it. Comments we received included, mum’s room is always clean and fresh, provides clean, spacious living accommodation and Rooms are lovely Yew Tree Care Home DS0000060593.V376412.R01.S.doc Version 5.2 Page 18 and clean and airy. There were signs showing people where their rooms, toilets and bathrooms were. There were grab rails and raised toilet seats. There were a variety of pressure relieving mattresses and a number of mobile hoists with a variety of slings and other moving and handling equipment. In shared rooms there were privacy screens. Gardens were well maintained. The lawns had been recently mown and there were hanging baskets and colourful plants on the patio at the rear of the home which overlooked the expansive lawned garden. There was which a large ramp leading to the front door and a ramp from the conservatory giving access the patio and garden area. A fence has been erected around the back and the side of the home to provide an enclosed area for the people to walk safely. Yew Tree Care Home DS0000060593.V376412.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are enough staff on duty to meet the needs of the people living at the home. Procedures for the recruitment of staff are robust and therefore offer protection for people living at the home. Staff have access to training to help them meet the needs of the people they care for. EVIDENCE: People we spoke with felt the home was adequately staffed with people who were experienced and competent to care for older people. People we spoke with did not express any worries about the level or availability of staff. During our inspection visit we saw staff attended to the needs of the people promptly and in a calm and friendly manner. Comments we received included, “They care for us extremely well and are very kind to us all” and “They look after our every need and wish. I have no worries here”. There were separate staff for care, cleaning, catering, activities and maintenance. We examined the files for 2 new members of staff. Records were clear, detailed and showed that staff were safely recruited in accordance with the regulations including receiving 2 references and a check by the Criminal Records Bureau (CRB). Each person received a supported induction programme and detailed staff handbook. After this induction they started a nationally recognised more comprehensive induction and thereafter staff were encouraged and supported to study for a National Vocational Qualification in Yew Tree Care Home DS0000060593.V376412.R01.S.doc Version 5.2 Page 20 care. We were told that 5 staff were studying for an NVQ level 2, 3 staff for NVQ level 3 and one had NVQ level 3. There was a years programme of training which showed training over the last year had included, moving and handling, infection control, safeguarding adults, dementia awareness, fire prevention, basic food hygiene, sensory deprivation awareness and nutrition. In addition the acting manager and team leader had attended training about the Mental Capacity Act 2005, Deprivation of Liberty Safeguards and putting people first which were all about ensuring that people’s rights were being promoted. Observation of care practices at the home showed us that staff were caring for people in an appropriate manner. They were visible in communal areas and responded well to peoples’ needs. The day seemed unrushed with staff having time to chat and spend time with the people. We spoke with one new member of staff who told us when I started here I had an interview, which was followed by an induction. I was supported and this prepared me for the work I was to do. I was also welcomed here when I started. Comments from staff we received included, the residents get a lot of love. The relatives are made very welcome and the relationship between the staff and clients and their relatives and the dignity is always maintained”. Yew Tree Care Home DS0000060593.V376412.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 33, 35, 36, 37 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People and staff benefit from the positive leadership of the acting manager. Management record systems show that their health, welfare, safety and choices are promoted. The management team ensures that the people living in the home have the opportunity to voice their views and opinions. They use feedback from questionnaires from people living in the home and other sources to make improvements. EVIDENCE: Since the last inspection we had been told that the previous manager had left and that the owner was in the process of applying to us to be registered as the manager of the home. She was assisted by a team leader who was very experienced and assisted us during our inspection visit. Yew Tree Care Home DS0000060593.V376412.R01.S.doc Version 5.2 Page 22 All the people we spoke with told us they were very satisfied with the management of the home. Comments we received included, The home is well run and friendly and caring and I know this home is the best possible place that my mother could be, with her extreme needs. She is looked after very well and I have peace of mind. Yew Tree is a place where staff have time to care for the residents properly”. Staff spoken with said they were happy working at the home and felt that it was well managed. They told us that they felt the home provided a safe, caring and homely environment for people to live in. Comments included, everyone works well together, it is a lovely environment, the care of the residents is brilliant. I enjoy being part of Yew Tree. The home has a quality assurance system so that it can gain the views of the people who use and are connected with the service. We looked at the results of their surveys returned in 2009, which showed that all the people thought the home was providing either a good or excellent service in all areas covered by the set questions. Comments included, very friendly, lovely pretty room, very comfortable, clean, tidy and fresh. Always treated with respect. Excellent, all staff allow the residents dignity and the staff always listen to us and resolve any issues. They also sought the views of people connected with the service including local doctors, community nurses, chiropodists and pharmacist. Comments were very positive. There was a system in place for peoples monies to be held in safe keeping by the home. This included keeping a running total of all transactions and obtaining receipts with two signatures. Records we saw showed that these were being maintained. There was a range of policies and procedures including equality and diversity, some of which had been reviewed and updated since the last inspection. There were also clinical procedures. Records and staff comments showed that staff were now receiving regular supervision. The home had comprehensive health and safety policies, which also included up to date risk assessments. There were regular tests of the fire system as well as regular fire drills. The last inspection by Lincolnshire County Councils fire and safety officer was on the 29/6/2009. There were no concerns and the fire risk assessment was in a folder at the entrance to the home. Records were available, up to date and well maintained. Information provided in the AQAA, showed us that regular checks on equipment such as hoists and fire fighting equipment had taken place. Records also showed that essential equipment was regularly serviced. Yew Tree Care Home DS0000060593.V376412.R01.S.doc Version 5.2 Page 23 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 3 X 3 3 X 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 3 3 3 3 X 3 3 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 3 3 3 X 3 3 3 3 Yew Tree Care Home DS0000060593.V376412.R01.S.doc Version 5.2 Page 24 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. 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 Yew Tree Care Home DS0000060593.V376412.R01.S.doc Version 5.2 Page 25 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastmidlands@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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