Inspection on 31/05/05 for Yeldall Manor

This inspection was carried out on 31st May 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 but made no statutory requirements on the home.

Other inspections for this house

Yeldall Manor 27/08/08

Yeldall Manor 31/08/06

Yeldall Manor 01/11/05

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 Steve Webb Unannounced 31 May 2005 @ 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. YELDALL MANOR H52-H01 11361 Yeldall Manor V217234 310505 Stage 4.doc Version 1.30 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 Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Yeldhall Manor Christian Centres Mr Noel Alexander Fawcett Care Home 27 Category(ies) of Alcohol dependenet past/present (A) registration, with number Drug dependence past/present (D) of places YELDALL MANOR H52-H01 11361 Yeldall Manor V217234 310505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Total number of service users in both categories combined must not exceed 27. Date of last inspection 29/11/04 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. YELDALL MANOR H52-H01 11361 Yeldall Manor V217234 310505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, carried out between 10.00am and 5.00pm on Tuesday the 31st of May, 2005. The inspection included a review of previous requirements, the examination of files and records, discussion with the manager and some staff and discussion with a number of residents. The inspector also had lunch with residents. This was a positive inspection, with the majority of feedback from residents reflecting a sense of commitment to the programme and ethos of Yeldall Manor. Some residents felt that they owed their lives to the unit. Some did feel that they would like more opportunities for one-to-one counselling, and whilst this can be provided if requested, it was noted that residents sometimes did not make the most effective use of that which is offered. Although there were some critical comments about the food, most acknowledged that it was good, and both the meal sampled and the tea observed in preparation were of a good standard. The current resident group was felt to be rather volatile, and this reflected the relatively high proportion of residents who were still at an early stage in the treatment programme. What the service does well: The service provides an opportunity for those who have misused alcohol or drugs, to experience an alternative lifestyle without these elements. This is provided through a Christian-based programme of individual and group therapy and peer support, together with planned work and leisure time. Whilst the programme does not suit everyone, firm efforts are made to assess individual suitability and motivation at the assessment stage. Those who leave the programme prematurely, may be offered the option to re-start the programme where appropriate, as long as funding can be agreed. The programme has clear boundaries and structures in place to provide a safe environment to help residents develop their own skills, understanding and coping strategies as they progress through its various stages. The inclusion of some staff within the team, who have themselves abused alcohol or drugs in the past, enables them to bring their own experiences and insights into the therapeutic environment for the benefit of residents. YELDALL MANOR H52-H01 11361 Yeldall Manor V217234 310505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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. YELDALL MANOR H52-H01 11361 Yeldall Manor V217234 310505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection YELDALL MANOR H52-H01 11361 Yeldall Manor V217234 310505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 4 The suitability, needs, motivation and aspirations of prospective service users are fully assessed prior to admission and prospective service users are able to visit the unit before becoming resident unless they are coming from prison, when this may not be possible. EVIDENCE: The unit initially receives a completed referral application form together with copies of any relevant third-party reports, such as those on psychiatric or medical issues, which go to the referrals co-ordinator. A risk assessment is completed on such aspects as self-harm, suicide and risk or harm to others. A resident has to have not self-harmed within the previous three months, and be considered a low risk in terms of harming others to be considered, and has to demonstrate their commitment to the Christian-based ethos of the unit. If they meet the criteria, a prospective resident is invited to visit for interview, or may be visited, if in prison. If they visit the unit they are shown around and have lunch and time to chat with residents during their visit. They are then interviewed and an assessment form is completed. The papers then go to the manager together with a recommendation, for the final decision. If a place is offered, this is for an initial four-week assessment period in the unit, during which certain objectives have to be met by the prospective YELDALL MANOR H52-H01 11361 Yeldall Manor V217234 310505 Stage 4.doc Version 1.30 Page 9 resident to demonstrate their commitment to treatment. This includes writing an autobiography and completing a test on the unit rules, as well as demonstrating a positive attitude to the programme. At this stage, residents also complete the first of two quality assurance questionnaires as part of the unit’s quality assurance system. The second one is done after three months on the treatment programme. YELDALL MANOR H52-H01 11361 Yeldall Manor V217234 310505 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 The needs and goals of residents are addressed within the standard and individualised elements of their “contract”, on which residents have appropriate and increasing input as they progress through the programme. EVIDENCE: All residents take part in a set treatment programme with defined stages, within which an individual contract is devised during the six-month “Regeneration Phase”. This contract is effectively their care plan, outlining targets for the individual to achieve, which are agreed with the individual’s allocated counsellor. The resident works on their goals with support from their individual counsellor and a trainee counsellor. The “contract” contains a mix of standard goals and individualised elements, and is reviewed after three months, and any issues identified. On moving to the “Re-Entry” phase of the programme, a separate contract is again agreed with the individual’s counsellor, with a focus on goals towards re-integration with the community, obtaining housing and employment. Residents have an input into setting their individual goals, and their level of decision-making and independence increases as they progress successfully through the programme. YELDALL MANOR H52-H01 11361 Yeldall Manor V217234 310505 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15 Residents can take part in a wide range of appropriate activities, and can do so within the community, increasingly as they progress through the programme. They are enabled to attend external places of worship within appropriate constraints, depending on their position in the programme. Residents are encouraged to work to maintain and rebuild appropriate relationships such as those with family. EVIDENCE: A wide range of activities is available to residents on-site, including a gym, football and volleyball pitches, woodworking shop, music room, walks, fishing, cycling, swimming, pool, golf and table tennis. Some activities are less supervised and access would depend on their counsellor’s agreement. As residents progress through the programme they have increasing opportunities to access off-site activities within the community, in negotiation with their allocated counsellor. YELDALL MANOR H52-H01 11361 Yeldall Manor V217234 310505 Stage 4.doc Version 1.30 Page 12 As residents near the end of the “regeneration” phase of the programme, and within the “re-entry” phase, residents also go off-site to do voluntary work and later seek employed positions. Residents can go to off-site places of worship, initially with counsellor support during the “regeneration” phase, and later may go alone. They may also attend external Alcoholics Anonymous or Narcotics Anonymous meetings. Residents are encouraged to maintain and rebuild their often-damaged relationships with family outside the unit, and some of the individual goals set within their contracts will relate to this area. Family are encouraged to visit the unit and residents can go to visit their family as part of their increased time off-site as they progress through the programme. New residents are not allowed to go off-site, unsupervised, for the first 4 weeks. YELDALL MANOR H52-H01 11361 Yeldall Manor V217234 310505 Stage 4.doc Version 1.30 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 standard(s) 18, 19, 20 Residents receive support both individually and within groups, from staff and their peers. The programme addresses their physical, emotional and spiritual needs effectively. However, the person carrying out the monitoring visits under Regulation 26, should countersign the accident records as evidence of their monitoring of these records. The system for the management of resident’s medication is appropriate apart from lacking the initial stage of the medication audit trail. The quantities of medication received by the unit need to be recorded to provide this. EVIDENCE: Each resident is supported through the programme by an allocated counsellor a trainee counsellor, and a pastoral leader, as well as receiving support from other care staff and fellow residents within the culture of the unit. Support is available through regular planned individual counselling and group sessions as well as informally throughout the day. The structured programme itself provides a physically, emotionally and spiritually supportive framework, within which residents learn to address their addiction and develop skill to enable them to move towards a life without alcohol or drugs. YELDALL MANOR H52-H01 11361 Yeldall Manor V217234 310505 Stage 4.doc Version 1.30 Page 14 Residents earn increasing freedom and spend more time off-site as they make progress within the programme, and are supported to obtain voluntary work, then paid work and accommodation towards the end of their stay. The residents spoken to, indicated that the programme was appropriate and supportive, although some felt, at times that it was very restrictive. Overall, resident’s feedback was very positive, and more than one said that Yeldall Manor had saved their life. Some residents felt that they would benefit from additional individual counselling, but it was noted that some may not make effective use of the time already available. The manager indicated that additional counselling time would be made available if considered appropriate. The previous requirement that the Person carrying out monthly Regulation 26 monitoring visits needs to countersign the accident records to confirm their monitoring of these, had not been met and should be actioned. Residents retain inhalers and prescribed creams, but other medication is held by the home and administered by appropriately trained staff, who receive pharmacist training. All medication is collected from the pharmacist by unit staff and ‘checked in’ by the manager or deputy, although currently the quantities coming in are not checked, as the start of the medication audit trail. Administration is recorded on individual MAR (medication administration record) sheets and there is a returns log for any unused medication. In order to complete the audit trail the quantities of medication coming into the unit must be recorded, this would normally be done on the MAR sheets. As part of accepting appropriate responsibility, residents are expected to report at the necessary times to be given their medication, and failure to do so, would be discussed in counselling. If a particular medication were to be critical to an individual’s well-being, the administration record would be checked daily to ensure the medication was given. YELDALL MANOR H52-H01 11361 Yeldall Manor V217234 310505 Stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 The unit has an appropriate complaints procedure and record in place, although some residents do not always feel they are listened to. The complaints log must be countersigned to confirm its monitoring by the person carrying out monthly Regulation 26 visits. EVIDENCE: The unit has an appropriate complaints procedure in place, which residents were aware of, although some felt they would not be listened to. Residents newer to the programme seemed to be the most negative about this aspect. There were three recorded complaints since the previous inspection, all of which appeared to have been addressed appropriately. One complaint had been withdrawn, once the complainant had been referred to the unit director. Some issues and frustrations were reported to arise from residents objections to receiving “chits” for bad behaviour, which if accumulated, lead to loss of privileges. Residents can however, appeal against these disciplinary measures, but have to do so within 24 hours, to avoid misuse of the appeals procedure to avoid sanctions. Complaint records were still not being countersigned by the person carrying out monitoring visits under Regulation 26. This was the subject of a requirement from the last inspection. These records must be countersigned to evidence their monitoring. YELDALL MANOR H52-H01 11361 Yeldall Manor V217234 310505 Stage 4.doc Version 1.30 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 standard(s) 24, 30 The accommodation was satisfactorily maintained and comfortably furnished overall, and was clean and hygienic. Some areas will need decorative attention as a priority, once the remaining fire safety works have been addressed. EVIDENCE: The unit is based in a mock-Tudor period building, which is, for the most part, in reasonable decorative order. Some areas are beginning to deteriorate and will need redecoration soon as part of the ongoing cycle of works. The main communal rooms are attractive and present a selection of spaces which residents can use freely. The premises were clean and free of unpleasant odours. There was a detailed schedule of planned maintenance in place but no similar document relating to cyclical redecoration, which would be beneficial in such a large and ageing property. Furnishings are comfortable and appropriately homely. Bedrooms were satisfactorily decorated. There remain some outstanding remedial fire safety works, but the previous requirement to produce a proposed schedule for these works has now been complied with. The fire officer is due to visit the unit to assess the appropriate prioritisation of the works, and these must then be actioned accordingly. YELDALL MANOR H52-H01 11361 Yeldall Manor V217234 310505 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35 Resident’s needs are met by an appropriately recruited, experienced and trained staff team, which is also diverse in terms of ethnic origin and gender. EVIDENCE: The unit has an appropriate hierarchy within the staff team and clearly defined job roles. With the recent promotion of one trainee counsellor, to counsellor, this leaves a trainee counsellor post as the only current vacancy. Counsellors are trained via the Institute of Christian Counselling. Two staff are currently undertaking a course leading to a “Certificate in Addictive Behaviour”. A core-training programme is given to all care staff, which includes fire safety, first aid, health and safety, protection of vulnerable adults and medication training. NVQ courses are not considered to offer relevant input. The recruitment records for the latest recruit were checked and confirmed that an appropriately rigorous vetting process is in place. The staff team is appropriately diverse in terms of ethnic origin and gender. Some members of the team are recovered alcoholics or drug abusers, and are able to bring this special insight into their work with residents. YELDALL MANOR H52-H01 11361 Yeldall Manor V217234 310505 Stage 4.doc Version 1.30 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 The health, safety and welfare of residents is promoted and protected by the systems and staff training in place. EVIDENCE: The certification for all cyclical servicing and maintenance checks was examined and found to be up to date. Routine servicing, etc. is planned within a maintenance schedule. Planned fire drills are not carried out as there are regular un-planned ones owing to false alarms and residents tampering. Detailed drill records are maintained. Some of the ongoing maintenance is carried out by the maintenance supervisor and other staff, and some by residents, as part of the work programme. Specialist needs are contracted in. Staff receive appropriate training in health and safety, first aid, medication administration etc. to enable them to manage health and safety risks. YELDALL MANOR H52-H01 11361 Yeldall Manor V217234 310505 Stage 4.doc Version 1.30 Page 19 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 3 x 3 x Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x x Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 YELDALL MANOR Score 3 2 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x H52-H01 11361 Yeldall Manor V217234 310505 Stage 4.doc Version 1.30 Page 20 YES 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 19 Regulation 26 Requirement The accident records must be countersigned by the person carrying out Regulation 26 visits. This requirement remains outstanding from the previous inspection. The quantities of medication coming into the home must be checked and recorded as part of the medication audit trail. The complaints records must be countersigned by the person carrying out Regulation 26 visits. Timescale for action 1/7/05 2. 20 17 1/7/05 3. 22 26 1/7/05 4. 24 23 This requirement remains outstanding from the previous inspection. The remaining fire safety works 1/7/05 must be scheduled in accordance with the priorities agreed with the fire officer, and details of this schedule must be provided to the inspector. YELDALL MANOR H52-H01 11361 Yeldall Manor V217234 310505 Stage 4.doc Version 1.30 Page 21 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 24 Good Practice Recommendations Consider establishing a written rolling programme for the redecoration of the building. YELDALL MANOR H52-H01 11361 Yeldall Manor V217234 310505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Park Theale Reading 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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