Inspection on 11/01/07 for Yew Bank

This inspection was carried out on 11th January 2007.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Yew Bank 07/12/09

Yew Bank 08/08/07

Yew Bank 08/02/06

Yew Bank 02/08/05

Yew Bank 31/01/05

Yew Bank 15/06/04

Yew Bank 01/03/04

Yew Bank 05/11/03

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Yew Bank 19 Huckleberry Close Purley on Thames Reading Berkshire RG8 8EH Lead Inspector Robert Dawes Unannounced Inspection 11th January 2007 10:30 DS0000011170.V325358.R01.S.doc Version 5.2 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 DS0000011170.V325358.R01.S.doc Version 5.2 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. DS0000011170.V325358.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Yew Bank Address 19 Huckleberry Close Purley on Thames Reading Berkshire RG8 8EH 0118 9427608 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) Purley Park Trust Limited Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (5) of places DS0000011170.V325358.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th February 2006 Brief Description of the Service: Yew Bank is one of eight separate units within the Purley Park Trust estate. The unit accommodates five male adults with a learning disability, in a pleasant unit providing each service user with their own individualised bedroom. Communal accommodation consists of a shared lounge/kitchen/dining area, with comfortable furnishings, bathroom and toilets. The staff work together with service users on various aspects of the day-to-day running of the unit. Service users are currently charged between £605 and £633 per week. DS0000011170.V325358.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced site visit which took place during the day on the 11th January 2007. The pre-inspection questionnaire was returned and all five service users’ questionnaires. The pre-inspection questionnaire, the service users’ questionnaires and the site visit were the main sources of information for the key inspection. During the site visit the inspector spoke with all the service users; interviewed the team leader and a support worker; toured the premises; looked at records; case tracked; and observed the interaction between service users and staff. Twenty-three standards were assessed during the site visit of which three were exceeded, eighteen were met and two were almost met. Three requirements, of which two were carried over from the previous inspection, and one recommendation were made. What the service does well: What has improved since the last inspection? What they could do better: Undertake monthly regulation 26 visits; develop an effective quality assurance and quality monitoring system; undertake an up to date risk assessment on the service user who suffers from epileptic seizures; and arrange for someone outside of the home to audit the accounts of the service users’ personal money held by the home. DS0000011170.V325358.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. DS0000011170.V325358.R01.S.doc Version 5.2 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 DS0000011170.V325358.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Number 2. Quality in this outcome area is good. The home has an appropriate admission procedure in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no admissions to the home since 2004. There is an admissions policy and procedure in place. DS0000011170.V325358.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 6, 7 and 9. Quality in this outcome area is good. All service users have individual plans that are reviewed at least every six months. Service users make decisions about their lives with assistance as needed. Service users are supported to take risks as part of an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All the service users’ files looked at had detailed individual care plans that had been reviewed in the last six months. The files also contained daily notes and a photograph of the service user. Staff said service users are encouraged to make choices and decisions about their daily lives. In response to the questions in the service users’ questionnaire, ‘do you make decisions about what to do each day?’ and ‘can you do what you want during the day, in the evenings and at week ends?’ All the service users said ‘always’. A service user said he can choose what to do during the day. The Inspector observed a very relaxed atmosphere with service users making decisions about what to do. DS0000011170.V325358.R01.S.doc Version 5.2 Page 10 The home looks after small amounts of personal money for all the service users. Receipts and records are kept. The accounts are checked by the team leader once a week but not by someone from outside of the home. Service users are encouraged to be as independent as possible. Service users were observed to make snacks and hot drinks with assistance from staff when required; to answer the phone and front door bell; and undertake as much of their own personal care as possible, i.e. bathing alone. One service user goes by bus on his own to work. Appropriate risk assessments were seen on service users’ files. DS0000011170.V325358.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 12, 13, 15, 16 and 17. Quality in this outcome area is good. Service users are able to take part in appropriate activities; they participate in the local community; and are enabled to keep in touch with their families and friends. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service users are offered a wide range of fulfilling activities by the Trust’s day centre or organised by the home’s staff. These include the ‘Monday club’ where different social events take place and people from outside the trust attend; communication and numeracy skills sessions provided by Reading College; gardening sessions; music sessions; and craft sessions. One service user works one morning a week at a local supermarket for which he receives a weekly wage. Service users go on annual holidays. Service users’ individual needs are catered for. Service users said ‘there is plenty to do’. Personal interests are encouraged, i.e. one service user has a drum kit in his room. DS0000011170.V325358.R01.S.doc Version 5.2 Page 12 Service users are enabled to take full advantage of the community by attending church services and bible classes for adults suffering from a learning disability, going into town to shop, visiting the local working men’s club, and going to restaurants and the cinema. At weekends, day trips and excursions are arranged. All the service users maintain some degree of contact with members of their family through visits, the phone and the internet. Some go home on a regular basis. Staff will transport service users to their relatives if it enables contact to be maintained. Staff were observed to treat service users in a respectful, supportive and considerate manner. Service users are offered a key to their own rooms; can choose when to be alone and when to join in an activity; and assist with household tasks. The relationship between staff and service users was relaxed and positive. Service users can move about the campus freely and often visit friends in the other units. Service users said they enjoy the meals. Every Sunday the service users discuss the next week’s menu with staff. A menu is produced which balances the service users’ choice with the need to have a healthy diet. Service users participate in the shopping and help prepare the meals. Mealtimes were observed to be relaxed and flexible to suit the needs of the service users. Individual preferences are catered for. DS0000011170.V325358.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 18, 19 and 20. Quality in this outcome area is good. Service users receive personal support in the way they prefer and require and their physical and emotional health needs are met. Staff adhere to the medication policy and procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users said staff are nice and they like living in the home and they can lie in bed if they want to. In response to the service user survey all the service users said staff treat them well and listen and act on what they say. Staff were observed to respond to service users kindly and patiently. Service users are supported to undertake personal care tasks only when required. Service users choose what they wear. Detailed medical records were seen on the files and showed medical professionals are contacted when required. Service users health is monitored through regular dental and eye checks and their weight is regularly monitored. A seizure chart is maintained for one service user who suffers from epileptic seizures. Service users are encouraged to go for walks at the weekends DS0000011170.V325358.R01.S.doc Version 5.2 Page 14 Four service users take prescribed medication. None self medicate. Only trained staff administer the medication. The storage of the medication and the medication administration records were in order. DS0000011170.V325358.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 22 and 23. Quality in this outcome area is good. Service users feel their views are listened to and acted on. Service users are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No complaints to the home or the Commission have been made since the last inspection. The home has clear complaints procedures in place. Service users are provided with complaint procedures in an easy to read format. In response to the questions in the service users’ questionnaire, ‘do you know who to speak to if you are not happy?’ and ‘do you know how to make a complaint?’ all the service users replied ‘yes’. No allegations of abuse have been made to the Commission since the last inspection. A vulnerable adults procedure is in place. The home does not need to employ physical restraint in the home. Staff attend ‘non violent crisis intervention’ and ‘vulnerable adult’ training courses. DS0000011170.V325358.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 24 and 30. Quality in this outcome area is good. Service users live in a homely, comfortable and safe environment. The home is kept clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is suitable for it’s purpose and is generally well decorated and maintained. The home has recently had a new lounge carpet fitted. The team leader has requested the home has new carpets in the hall and downstairs bedroom. On the day of the site visit the home was clean and hygienic. In response to the question in the service users’ questionnaire, ‘is the home fresh and clean?’ all the service users replied ‘always’. DS0000011170.V325358.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 32, 34, 35 and 36. Quality in this outcome area is good. An effective, competent and qualified staff team who are appropriately trained supports service users. The home operates a thorough recruitment procedure. Regular supervision needs to be maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two of the four permanent staff have achieved a NVQ 2 or above in care. One member is currently studying for a NVQ in care. Staff interviewed demonstrated a good understanding of the service users’ needs and the skills necessary for the tasks they are expected undertake. Staff recruitment files seen showed the organisation complies with the recruitment procedures. The organisation provides an induction and foundation training programme, which incorporates LDAF, for all new staff. The organisation provides a very comprehensive training programme which includes the necessary basic training and courses on topics such as, POVA, first aid, key worker responsibilities, equal opportunities, medication, non-violent crisis intervention, DS0000011170.V325358.R01.S.doc Version 5.2 Page 18 and supervision skills. A member of staff said she had received a good induction and training when she started in the home. Supervision of staff has started on a more regular basis which now needs to be maintained. New staff appraisal formats have been produced by the Trust and will be used to regularly appraise staff. Regular staff meetings take place in the home and monthly meetings for all the Trusts’ staff. DS0000011170.V325358.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 37, 39 and 42. Quality in this outcome area is adequate. The manager’s position is vacant but the team leader is running the home well. The organisation needs to introduce an effective quality assurance and quality monitoring system and ensure the Regulation 26 visits take place as required. The health, safety and welfare of service users are promoted and protected except for the risk assessment that needs to be carried out on the service user who suffers from epileptic seizures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager’s position is vacant. The team leader is taking responsibility for the day to day running of the home. A member of the management team is responsible for the broader management responsibilities. The staff member interviewed considered the team leader was very supportive and clear about how he wants the home to operate. The team leader has enrolled on the NVQ4 and Registered Manager’s course DS0000011170.V325358.R01.S.doc Version 5.2 Page 20 Satisfaction questionnaires were sent to service users, relatives and key professionals in November 2006 but a summary of the responses and an annual development plan have not been produced. Regulation 26 visits and reports are not taking place as required. The management team acknowledged that an effective quality assurance and quality monitoring system needs to be put in place and are currently addressing it. Monthly service user meetings take place. All health and safety checks and inspections are up to date and completed as required. All necessary health and safety policies and procedures are in place. Service users had risk assessments on their files. One service user who suffers from epileptic seizures requires an up to date risk assessment, involving key professionals, because there is no member of staff on duty in the home at night. This could pose a risk to the service user. In addition, no record can be made of seizures that he suffers at night to inform the medical profession. DS0000011170.V325358.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X DS0000011170.V325358.R01.S.doc Version 5.2 Page 22 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 YA39 Regulation 24 Requirement The registered provider must establish an annual quality assurance and review system in accordance with Standard 39, and make the resulting reports available to interested parties. (This requirement was made at the previous inspection) The registered provider must ensure that the unit is visited in accordance with Regulation 26 and reports are produced. (This requirement was made at the previous inspection) To undertake an up to date risk assessment on the service user who suffers from epileptic seizures. Timescale for action 31/03/07 2. YA39 26 28/02/07 3 YA42 13 28/02/07 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 YA7 Good Practice Recommendations Someone from outside of the home regularly checks the DS0000011170.V325358.R01.S.doc Version 5.2 Page 23 accounts of the service users’ personal money held by the home. DS0000011170.V325358.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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