Inspection on 01/11/05 for Yeldall Manor

This inspection was carried out on 1st November 2005.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Yeldall Manor 27/08/08

Yeldall Manor 31/08/06

Yeldall Manor 31/05/05

Yeldall Manor 29/11/04

Yeldall Manor 17/06/04

Yeldall Manor 09/03/04

Similar services:

Flint House

The Ley Community

Cherwood House Care Centre

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

CARE HOME ADULTS 18-65 Yeldall Manor Blakes Lane Hare Hatch Reading Berkshire RG10 9XR Lead Inspector Stephen Webb Unannounced Inspection 1st November 2005 10:15 DS0000011361.V263477.R01.S.doc Version 5.0 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 DS0000011361.V263477.R01.S.doc Version 5.0 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. DS0000011361.V263477.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Yeldall Manor Address Blakes Lane Hare Hatch Reading Berkshire RG10 9XR 0118 940 4411 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) Yeldall Manor Christian Centres Mr Noel Alexander Fawcett Care Home 27 Category(ies) of Past or present alcohol dependence (27), Past or registration, with number present drug dependence (27) of places DS0000011361.V263477.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st May 2005 Brief Description of the Service: Yeldall Manor is a drug/alcohol residential rehabilitation centre for up to 27 men between the ages of 20 and 40 years, which operates within a Christianbased treatment ethos. Each resident signs a personal contract which binds him to the conditions of residence and to complete the rehabilitation programme at Yeldall Manor. The contract acknowledges that Yeldall Manor operates certain practices and policies which would normally fall outside of mainstream care practice in residential care homes. Yeldall Manor is located in a large period house set in a thirty-eight acre rural estate between Reading and Maidenhead. The estate includes fields, workshops, vegetable garden, picnic area, football and volleyball pitches, a swimming pool and areas of woodland and lakes. Up to twenty-seven male residents are accommodated in the main house and its annexe which together have 8 double rooms and 11 single rooms. DS0000011361.V263477.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out between 10.15am and 3.45pm on 1/11/05. The inspection included discussion with the manager, examination of records and procedures, discussion with a number of residents and a chance to see many of the communal areas of the unit. The inspector also had lunch with residents. This was a positive inspection, with all of the previous requirements either having been addressed, or in progress. The fire officer has granted an extension to the completion date, for the remaining fire safety works. The feedback from residents was very positive, with some showing good insights into their needs and the rationale of the treatment programme. What the service does well: What has improved since the last inspection? The monitoring and analysis of accident records has been improved, and these are now monitored on a monthly basis. Complaints records are also now monitored monthly as part of Regulation 26 monitoring visits by the Director. DS0000011361.V263477.R01.S.doc Version 5.0 Page 6 Medication recording has been improved by the inclusion of records of the quantities of medication coming into the unit, which now provides for a proper audit trail of medication. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000011361.V263477.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000011361.V263477.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the standards in this section were examined on this occasion. EVIDENCE: Standards 2 and 4 were examined at the last inspection and found to be met. DS0000011361.V263477.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8, 9 Residents are appropriately consulted on the service received, in the context of their presence on a time-limited therapeutic programme. Residents are initially assessed and appropriately supported within a risk assessment system. EVIDENCE: Residents join the time-limited programme at Yeldall Manor with the specific aim of learning how to remain drug or alcohol free and re-integrate into society without resuming previous destructive behaviours. On admission a resident is given a resident’s handbook, contract, details about the programme rules, complaints procedure and other information. Feedback from quality assurance questionnaires to residents indicated that some felt they had not been given sufficiently clear information so the need to ensure this information is provided has been reiterated to staff. All residents also go through the relevant information in detail, during the four-week initial assessment period, by which time they have some experience of the programme with which to relate the information given. DS0000011361.V263477.R01.S.doc Version 5.0 Page 10 Residents are asked to complete quality assurance questionnaires at different stages of the programme and their feedback is discussed by the staff team. There is also a resident’s board, with six residents elected by the current resident group. The members are re-elected every two months, and the group meets weekly, usually without staff attendance, though the manager reserves the right to attend if he feels it is necessary. Residents can raise issues for consideration by the board anonymously if they wish to, via a suggestions box. The chair reports back to the manager on the issues and ideas raised and these are then discussed within a part of the staff meeting, with the chair of the resident’s board present. The unit has certain specific criteria for admission, based on a risk assessment approach, including prospective residents having no history of serious violence, or recent self-harm. Individual risk assessments are also compiled at the referral stage as required, and where applicable, may come with a new resident from their previous placement. The unit also has risk assessments in place relating to the health and safety issues such as operating various machinery, as part of the work programme. Training is also provided to residents before they can operate any of the machinery. DS0000011361.V263477.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 Resident’s rights are respected appropriately in the context of the treatment programme in which they are engaged. Residents are provided with sufficient and healthy food, and are generally satisfied with the meals provided. EVIDENCE: As noted above the programme provides a structured daily routine with which all residents all residents are expected to conform. This includes regular mealtimes, work programme, individual and group therapy sessions, and free time for leisure. The details of the programme are provided to residents on admission, and the programme is explained in detail to residents during the four-week assessment phase. The quality assurance feedback indicated that some residents wanted a clearer explanation of the “chit” system, by which the staff indicate to individuals that they are not conforming appropriately to the programme. The manager will ensure that a clear explanation is provided. DS0000011361.V263477.R01.S.doc Version 5.0 Page 12 By the nature of their needs, residents are appropriately expected to conform to the set structure and their individual plan agreed with their counsellor. Certain exceptions to the provision normally expected within residential homes are also acceptable within the treatment context of the programme, such as a proportion of bedrooms being shared, bedrooms not being lockable and no individual lockable spaces being provided to residents. The unit does have a safe where residents can secure personal belongings if necessary. Once a resident enters the resettlement phase, which is not part of the inspected service, they have single bedrooms in a shared lodge house, which are lockable, and other additional provisions and freedoms in recognition of their transition to life out in the community. Residents within the main programme can be away from direct staff supervision for up to an hour at a time, before having to ‘check-in’ with a staff member, during leisure time. A good range of leisure pursuits are made available on and off-site, where appropriate. Residents can be breathalysed or asked to provide a urine sample by staff at any time, to try to reduce the risk of resident’s engaging in substance misuse. Meals are provided by employed kitchen staff, though there is currently one vacancy for an assistant cook. The menu is planned by the cook one week at a time, taking into account specified likes and dislikes, and providing alternatives where necessary. The inspector ate lunch with residents, who were complimentary about the meals, in terms of both quality and quantity. Residents are expected to take meals together in the attractive wood-panelled dining room. The meals are at set times within the daily routine. Once residents move out to the lodge house, in the resettlement phase, they receive a weekly allowance with which to buy their food and other items, as part of learning to manage on a budget. They are also offered support on planning the repayment of existing debts, if this is an issue, and advice on nutrition. DS0000011361.V263477.R01.S.doc Version 5.0 Page 13 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 Accidents to residents are now regularly monitored to ensure that their safety is maximised and any issues which emerge, are reported upon. The welfare of residents is now more effectively protected by the provision of an audit trail for medication. EVIDENCE: These standards were only examined on this occasion in relation to specific requirements made at the last inspection. Accident records indicated that a system of regular monitoring and countersigning of the records had been instigated. A monthly audit of all recorded accidents is now in place. Examination of resident’s medication records indicated that the quantities of medication coming into the unit are now checked and recorded to provide the start of a medication audit trail in accordance with Royal Pharmaceutical Society guidelines. The remaining areas of these standards were not examined on this occasion, having been found to be satisfactory at the previous inspection. DS0000011361.V263477.R01.S.doc Version 5.0 Page 14 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): 22, 23 Residents feel that their views are listened to and complaints are resolved appropriately. The unit provides appropriate protection from abuse to residents and addresses the issue of self-harm where applicable. EVIDENCE: Since the last inspection, a system of monthly countersignature of the complaints log has been instigated to indicate that the record is monitored. The complaints log indicated two recent recorded complaints, one of which had been withdrawn by the complainant, in favour of resolution through discussion with their counsellor. The remaining complaint had been appropriately resolved to the satisfaction of the complainant. The residents spoken to indicated that they felt their views and opinions were listened to, and the resident’s board was also cited as another forum where they could express their views. Although residents are reportedly given details of the complaint procedure on admission, the staff have been reminded of this procedure, following feedback from the quality assurance survey, indicating that not all residents felt they had received this information. The unit has an appropriate vulnerable adults protection procedure and a copy of the local multi-agency procedure is also available. The staff are all being sent on POVA training. DS0000011361.V263477.R01.S.doc Version 5.0 Page 15 There are clear rules on the use of physical aggression and threats, and serious instances would lead to expulsion from the programme. Serious consideration is give to the appropriateness of referrals with a history of self-harm, and this is discussed explicitly with them and an undertaking included within their contract. DS0000011361.V263477.R01.S.doc Version 5.0 Page 16 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): 24, 25, 27 For the most part the residents live in a homely, comfortable and safe environment, consistent with the short-term treatment ethos of the unit, though remaining fire safety works will need to be completed within the recently extended deadline. The bedrooms suit the needs of residents, and the presence of a proportion of shared bedrooms, and lack of door-locks is consistent with the unit’s treatment ethos. The toilet and bathroom provision meets the basic needs of residents, within the context of a short-term therapeutic unit, but the planned and current improvements will provide for greater comfort, privacy and homeliness. EVIDENCE: Fire safety remedial works were in process in response to a deficiency notice from the fire officer. The deadline for completion of these works had reportedly been extended until the 15th of November 2005, but confirmation of this was not available in writing and should be obtained by the home and copied to the inspector. DS0000011361.V263477.R01.S.doc Version 5.0 Page 17 The majority of the environment seen was satisfactory although some areas were in need of redecoration. Some refurbishment was in progress and a team of church-based volunteers was due to come in soon to carry out further work. Given the treatment ethos and time-limited nature of placements in the unit, the provision of some shared bedrooms is deemed appropriate. Residents tend to move to single bedrooms as they progress through the programme to the regeneration phase, as they become available; though in individual cases, single bedrooms are considered at other times, on their merits. It is appropriate that bedrooms are not lockable in this unit. There are plans to improve the bathing and toilet facilities in the unit. The toilets have already been replaced and the feasibility and costs of various options for improvements to bathrooms and showers are being explored. This work is in the initial planning stages but would be an improvement to the physical environment to provide more homely facilities. DS0000011361.V263477.R01.S.doc Version 5.0 Page 18 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): 34, 36 Residents are appropriately protected by the unit’s recruitment systems, and benefit from a well-supported, regularly supervised, staff team. EVIDENCE: The unit had no care staff vacancies at the time of inspection, and had only an assistant cook post to fill. Since the last inspection a new counsellor and a trainee counsellor had been appointed. Appropriate recruitment checks had been carried out, though copies of the application forms were not on file. It is recommended these be filed with the other recruitment information. All staff receive monthly one-to-one supervision within the management hierarchy. There are weekly staff meetings, and daily meetings to address dayto-day issues. DS0000011361.V263477.R01.S.doc Version 5.0 Page 19 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): 39 Residents felt that their views are taken into account in the operation of the unit, within the context of the overall treatment focus of the programme. Some further development of the quality assurance system was needed. EVIDENCE: A round of quality assurance questionnaires was completed in October 2005, by residents who were one week into the programme, and a further group completed a more detailed questionnaire after twelve weeks on the programme. This is now an established system. The issues raised have been collated though as yet, have not been fed back to residents in a brief summary report. The areas raised have been considered by the management team, and either addressed, or referred for discussion by the staff team. A summary report should be produced to report the findings back to residents, together with details of any action taken in response. DS0000011361.V263477.R01.S.doc Version 5.0 Page 20 The quality assurance cycle should be broadened out to include questionnaires to staff, funding authorities, and other appropriate parties, in order to obtain a broad range of feedback on perceptions of the service. The views of residents can also be voiced via the elected resident’s board which meets weekly. This has been established with a clear remit and guidelines and provides a voice to all residents. At present the quality of the minutes of this forum is variable, and perhaps could be improved by offering a standardised format for their recording. Feedback from residents indicated that they felt they had a voice, and that their views were listened to. DS0000011361.V263477.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 X 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score X X 2 X X X X DS0000011361.V263477.R01.S.doc Version 5.0 Page 22 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 YA24 Regulation 23 Requirement The remaining fire safety works must be scheduled in accordance with the priorities agreed with the fire officer, and details of this schedule must be provided to the inspector. Please obtain written confirmation of the extension of the previous deadline for these works and copy to inspector. Please confirm to the inspector in writing when the fire safety works are completed. Quality assurance feedback should be sought from appropriate additional parties on the effectiveness of the unit. A summary report of the results of the quality assurance survey should be made available to residents and the inspector. Timescale for action 01/12/05 2. 3. YA24 YA39 23 24 01/12/05 01/03/06 4. YA39 24 01/04/06 DS0000011361.V263477.R01.S.doc Version 5.0 Page 23 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 YA24 Good Practice Recommendations Consider establishing a written rolling programme for the redecoration of the building. DS0000011361.V263477.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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. 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