Inspection on 02/08/05 for Yew Bank

This inspection was carried out on 2nd August 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

Yew Bank 07/12/09

Yew Bank 08/08/07

Yew Bank 11/01/07

Yew Bank 08/02/06

Yew Bank 31/01/05

Yew Bank 15/06/04

Yew Bank 01/03/04

Yew Bank 05/11/03

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

CARE HOME ADULTS 18-65 YEW BANK 19 Hucklebury Close Purley-on-Thames Berkshire RG8 8EH Lead Inspector Steve Webb Unannounced 2 August 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. YEW BANK H52-H01 S11170 Yew Bank V235287 080805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Yew Bank Address 19 Hucklebury Close Purley-on-Thames Berkshire RG8 8EH 0118 9427608 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) Purley Park Trust Limited Bernadetta Johnson Care Home 5 Category(ies) of Learning Disability LD registration, with number of places YEW BANK H52-H01 S11170 Yew Bank V235287 080805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: One designated person aged 65 years of age or over is accommodated by prior agreement. Date of last inspection 31/01/05 Brief Description of the Service: Yew Bank is one of the three original ‘outlying houses’ within the Purley Park Trust, and is now one of eight separate small units within the estate. The unit now accommodates five adults of either gender, 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. YEW BANK H52-H01 S11170 Yew Bank V235287 080805 Stage 4.doc Version 1.40 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 2.30pm. The inspection included discussion with staff and service users, examination of key records, inspection of the premises and discussion with service users. The inspector also had lunch with service users. The manager was on leave but called in briefly towards the end of the inspection. This was a positive inspection. Service users were relaxed and chatty, and going about their business. Two were very happy to show the inspector their rooms and they talked about their holiday to Weymouth, and the recent wedding between to service users from other units on site. What the service does well: All service users have access to a wide range of on and off-site activities and are part of both the on-site and wider community. They are supported to engage in work if they wish. Contact with family is supported and encouraged. The health needs of service users are well monitored and an effective medication management system is now in place. Staff have responded effectively to health issues, in terms of the service users putting on a lot of weight, and have worked with them to improve eating habits. Appropriate specialist fire alarm warning equipment has been obtained for one resident who is very deaf. Service users are effectively supported to take risks within a risk assessment framework and creative planning has taken place to address identified concerns. The training needs of staff are well met, and the unit has a full and settled staff team, which is positive in terms of continuity and consistency. The organisation has an effective assessment process and consults relevant parties when making significant decisions about service users. The organisation has an effective complaints system and service users can also express their views within resident meetings or directly to the head of care or chief executive. The unit is homely and is maintained on an ongoing basis. However some works remain necessary. YEW BANK H52-H01 S11170 Yew Bank V235287 080805 Stage 4.doc Version 1.40 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. YEW BANK H52-H01 S11170 Yew Bank V235287 080805 Stage 4.doc Version 1.40 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 YEW BANK H52-H01 S11170 Yew Bank V235287 080805 Stage 4.doc Version 1.40 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 Though it was not possible to examine current evidence of the unit’s assessment system, the system was explained and is applied in all of the units within the service. EVIDENCE: There have been no recent admissions to the unit, as the service user group have been together for a long time, with one new person coming into the unit in June 2004, who swapped units with a service user from this unit in order to better address both of their needs. The service users, their relatives and funding authorities were appropriately involved in the decision making process at the time. An effective assessment system is in place within the organisation if it is required in future. The process would include visits to the unit by the prospective service user and their family, and would also involve a comparison of their needs with those of the existing resident group to try to ensure compatibility. There is a detailed Purley Park Trust assessment format, which is completed as well as obtaining the care manager’s assessment. The process would include risk assessments, and the completion of an essential lifestyle plan, which identifies details about care preferences, likes, dislikes and interests. YEW BANK H52-H01 S11170 Yew Bank V235287 080805 Stage 4.doc Version 1.40 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 standard(s) 9 Service users are supported to take risks within a risk assessment context, and individual freedom is not unnecessarily restricted. However, an overall fire risk assessment for the unit should be compiled. EVIDENCE: Relevant individual risk assessments are in place for each service user and these are held both within individual files, and collectively for ease of staff access. The risk assessments are reviewed annually or sooner if necessary and staff are required to sign a form to confirm they have read these documents, which is good practice. Some risk assessments relate to service users from other units on-site, where they have significant involvement with this unit. Given the level of ability of service users in the unit, and the fact that they go to the pub some evenings unaccompanied, and return after the day staff have gone off duty, an effective system has been established for them to report their return to the night staff. There are individual fire risk assessments in place for each service user, but no overall fire risk assessment for the unit. A unit fire risk assessment should be compiled, which would include the individual assessments, but also address wider aspects of the building, staffing etc. YEW BANK H52-H01 S11170 Yew Bank V235287 080805 Stage 4.doc Version 1.40 Page 10 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) 12,13,14,15 Service users take part in a range of on and off-site activities and employment, and are part of both the local and on-site communities. All but one have regular contact with family or significant others. EVIDENCE: Service users access a wide range of activities both on and off-site. Some are part of their weekly activities plan and others are of a spontaneous nature. One service user was at work for the first part of the inspection, and returned for lunch, and one was at horticultural therapy on-site. Each service user has an individual activities plan for regular scheduled activities. Available activities include karaoke, pub visits, bowling, shopping, swimming, computing, stage shows, bible studies, on and off-site horticultural therapy, attending church and church-run events such as coffee mornings, Monday Club, trips to Beale Park and on-site art and craft sessions run by Reading College. Service users freely visit each other in the other units on site. Service users who visit the pub may do so un-escorted, and report themselves back on-site, to the night staff on their return. YEW BANK H52-H01 S11170 Yew Bank V235287 080805 Stage 4.doc Version 1.40 Page 11 Four of the service users have regular family contact via visits or telephone, one receives cards at Christmas and birthdays but has no other contact. One service user is being taught to use e-mail so that he can maintain contact with family who are moving abroad. The possible benefits of a webcam should perhaps be considered. Service users have had a holiday to Weymouth earlier in the year and showed the inspector the photographs. Other individual holidays were being planned and a boat trip on the Thames was coming up. All of the service users recently attended the wedding between two service users from other units. There are several vehicles available for taking service users out to activities or for visits to family. YEW BANK H52-H01 S11170 Yew Bank V235287 080805 Stage 4.doc Version 1.40 Page 12 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) 19, 20 Service users physical and emotional health needs are met in the unit and staff showed awareness of, and responded to, general health issues. Though neither of the service users on regular medication manages this for themselves, it is effectively managed on their behalf by staff, who receive training on this role, within an effective medication management system. It would be good practice to obtain the medication information sheets on prescribed medication and file them in the medication file for staff reference. EVIDENCE: Records of service user accidents are now recorded both on their individual files and collectively for monitoring purposes. Recent accident records were detailed and indicated a number of falls by one service user. There are plans to move him to a ground floor room as the result, and this has been appropriately consulted upon. Recently it was noted, through regular weight checks that several service users were gaining weight, primarily through eating inappropriate snacks late at night on return from the pub. A range of appropriate snacks is now made available, and other items are secured. Some work has also been done with service users on healthy eating issues and they have begun losing the excess weight gained. YEW BANK H52-H01 S11170 Yew Bank V235287 080805 Stage 4.doc Version 1.40 Page 13 One service user is very deaf and has a flashing fire alarm warning light and vibrating pillow pad to alert him to the fire alarm sounding at night or when in his bedroom. Two of the service users are on regular medication, but neither is felt able to manage this themselves. The staff manage medication on their behalf. They receive in-house training on medication and external pharmacist training is also being arranged. There is a detailed medication procedure in place with appropriate guidance provided within the administration file. There is a photograph of the service user with their Medication Administration Record (MAR) sheet. However, there was little information available about the prescribed medication for one service user, and nothing about that prescribed for the other. It would be good practice to obtain the medication information sheets for these items and include them in the file for staff reference. This is understood to be an organisational expectation anyway. The quantities of medication coming into the unit are recorded and the system has been improved by providing a second signatory to verify each administration. Medication returns forms were also in place appropriately. YEW BANK H52-H01 S11170 Yew Bank V235287 080805 Stage 4.doc Version 1.40 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 standard(s) 22 The views of service users are sought through various forums, including a quality assurance survey, and via regular residents meetings. Complaints would be recorded in the unit’s complaints log. EVIDENCE: The unit has an appropriate complaints procedure in text and symbol formats, and there is now a complaints log in the unit, which has no entries to date. Service users attend regular monthly resident meetings, where issues of group living, holiday plans, activities and news are discussed and minuted. The meetings are sometimes called in response to a service user’s request. Service users also have access to the head of care and chief executive, who are both based on site and known to them. Service users have also been consulted as part of the organisations quality assurance system, though the resulting report has yet to be published. YEW BANK H52-H01 S11170 Yew Bank V235287 080805 Stage 4.doc Version 1.40 Page 15 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 Service users live in a homely and comfortable environment, which protects their wellbeing for the most part, though a self-closer should be fitted to the laundry door to maximise safety. EVIDENCE: The unit is homely and on a domestic scale. The lounge/kitchen/diner had been redecorated and had new blinds and a new dining suite. New sofas were also on order. Bedrooms had also been fitted with new blinds, and were pleasantly decorated and individualised, reflecting the personality and interests of their occupant. A new washing machine and tumble drier were also present. There is an ongoing problem with the worktop over the dishwasher, which has begun to deteriorate owing to either water or steam damage. It is suggested that the worktop be replaced and thoroughly sealed prior to installation. The dishwasher door seal also appeared to need replacement. Self-closers had been fitted to the lounge and bedroom doors in response to the fire officers recent visit, but the laundry door had not been fitted with one. YEW BANK H52-H01 S11170 Yew Bank V235287 080805 Stage 4.doc Version 1.40 Page 16 This should be addressed as a priority. A risk assessment is also recommended on the fitting of an approved holdback device for the lounge door so that it can be retained open during the day to facilitate ease of movement about the unit, whilst remaining free to close in the event of the fire alarm sounding. The device must be tested for correct operation in situ. The yale-type locks on bedroom doors have been disabled in response to the fire officer’s visit. The upstairs toilet had been redecorated and part-tiled since the last inspection, to address a previous inspection requirement. YEW BANK H52-H01 S11170 Yew Bank V235287 080805 Stage 4.doc Version 1.40 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) 35 The needs of service users are met by a well trained and stable staff team. EVIDENCE: The unit has a settled team now with one staff having left and one having transferred into the unit from another unit on site. The organisation now has one post dedicated to coordinating the training across all of the units, which ensures a consistent approach and a good overview of cyclical needs. Spreadsheets of training needed or completed, for units or individuals can be produced as required. A spreadsheet of unit training in 2005 was available in the unit, and a copy of the details of individual staff cyclical training needs was provided. A thorough range of core training is now provided to all staff. The manager has obtained her NVQ level 4 and registered manager’s award, one staff has level 3, and one each are starting levels 2 and 3. YEW BANK H52-H01 S11170 Yew Bank V235287 080805 Stage 4.doc Version 1.40 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 service users is protected, for the most part, though this will be further improved once the identified works and practice improvements are addressed, and the fire risk assessment is completed. EVIDENCE: The required safety certification/service records were available for the unit, apart from records of the annual testing of electrical appliances, which remains outstanding from previous inspections. This is understood to be in hand, but should be done as a priority and the resulting report copied to the inspector. All staff have current first aid and food hygiene certificates in place, and receive other safety-related training. Regular fire drills are recorded, but fire alarm testing has not been done weekly on a consistent basis as it should be. As already noted under standard 24, a fire door self-closer needs to be fitted to the laundry door and a risk assessment is suggested on the fitting of an appropriate hold-back to the lounge door. An overall fire risk assessment is also required for the unit. YEW BANK H52-H01 S11170 Yew Bank V235287 080805 Stage 4.doc Version 1.40 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 x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 YEW BANK Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x H52-H01 S11170 Yew Bank V235287 080805 Stage 4.doc Version 1.40 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. 2. Standard 9 24 Regulation 23 23 Requirement Compile a unit fire risk assessment and copy document to the inspector. A self-closer should be fitted to the laundry door. This requirement remains from the previous inspection. A risk assessment should be carried out on the use of suitable hold-back device on the lounge door. The device should be tested in situ, for effective operation. Carry out the tesing of portable electrical appliances and copy resulting report to inspector. This requirment remains from previous inspetions. The fequency of in-house fire alarm testing should be increased to weekly testing. Timescale for action 4/10/05 4/9/05 3. 24 23 4/9/05 4. 42 13 4/10/05 5. 6. 42 - 23 - 4/9/05 - YEW BANK H52-H01 S11170 Yew Bank V235287 080805 Stage 4.doc Version 1.40 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. 2. Refer to Standard 20 24 Good Practice Recommendations Consideration should be given to obtaining the medication information sheets for any prescribed medication and filing these in the medication file for staff reference. Consider the replacement of the damaged worktop and the sealing of the new one before installation. YEW BANK H52-H01 S11170 Yew Bank V235287 080805 Stage 4.doc Version 1.40 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. Extracts may not be used or reproduced without the express permission of CSCI YEW BANK H52-H01 S11170 Yew Bank V235287 080805 Stage 4.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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