Inspection on 11/10/05 for Yew Tree Care Home

This inspection was carried out on 11th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Yew Tree Care Home 18/08/08

Yew Tree Care Home 20/08/07

Yew Tree Care Home 05/03/07

Yew Tree Care Home 24/07/06

Yew Tree Care Home 06/02/06

Yew Tree Care Home 20/12/04

Yew Tree Care Home 24/08/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Yew Tree Care Home 60 Main Road Dowsby Bourne Lincs PE10 0TL Lead Inspector Julie Western Unannounced Inspection 11th October 2005 10:00 X10015.doc Version 1.40 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 Yew Tree Care Home DS0000060593.V249208.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 Older People. 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. Yew Tree Care Home DS0000060593.V249208.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Yew Tree Care Home Address 60 Main Road Dowsby Bourne Lincs PE10 0TL 01778 440247 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Yew Tree Residential Care Home Limited Care Home 18 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (6) of places Yew Tree Care Home DS0000060593.V249208.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Yew Tree Care Home is a former old rectory and is situated next to the church in the village of Dowsby, which is one mile from the village of Billingborough, with shops and a pub and six miles from the small town of Bourne, which has a full range of amenities including shops, banks, post office and pubs. Formerly known as the Old Rectory, the home is registered to provide residential care for 18 service users; 12 with dementia, and 6 older people. A single storey extension provides accommodation for 10 service users, and first floor accommodation in the main building is accessed via a stair lift. There are 12 single rooms, and 3 are shared. Two of the rooms have en-suite facilities. The home is set back from the road, and has large enclosed mature gardens laid to wooded areas, lawns and flowerbeds. There is also a large conservatory with an adjoining patio area. Yew Tree Care Home DS0000060593.V249208.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 4 hours. A partial tour of the building took place and care records were inspected. The main method of inspection used was called ‘case-tracking’; this involved selecting three residents and tracking the care they received through the checking of their records, discussions with residents and care staff and observation of practices. Some policies and procedures were examined and records concerning the safety of the home were also seen. 3 of the 18 residents, 3 of the 8 care and ancillary staff and two visitors were spoken with. The Manager was present throughout the inspection. What the service does well: What has improved since the last inspection? Since the new Manager has been in post, she has worked very hard to reorganise the home’s records, including the introduction of many policies and procedures. A new induction handbook has been developed and staff files have been reviewed. Care plans are also being gradually reviewed. Following the last inspection report, Room 6 has been completely redecorated, including new carpeting. Room 15 has also been re-carpeted and the dining room has been re-arranged to allow more accessibility for wheelchair users. Yew Tree Care Home DS0000060593.V249208.R01.S.doc Version 5.0 Page 6 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 Tree Care Home DS0000060593.V249208.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Yew Tree Care Home DS0000060593.V249208.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home clearly sets out what it intends to do for its residents and this information is freely available to residents. Prospective residents are encouraged to take time before making the decision to move into the home on a permanent basis. EVIDENCE: The statement of purpose and the residents’ handbook were examined and were very comprehensive. The service user guide was easy to read and was retained in each room. Terms and conditions were clear and comprehensive. The Manager said she usually made pre-assessment visits to prospective residents, either visiting them in their own homes or in a care or hospital setting. Some residents had been to the home for respite care before moving into the home and visitors said they were invited with their relative to spend a day at the home, including a meal, before moving in. Yew Tree Care Home DS0000060593.V249208.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home’s records give a clear indication of the needs of residents and enable staff to meet their needs with sensitivity and regard for their privacy and dignity. EVIDENCE: The three care plans looked at in depth contained clear and comprehensive assessments, were reviewed regularly and were signed where possible by the service user or relatives/advocates. The Manager said that some of the care plans were still being reviewed. A safety gate was noticed outside one room and the Manager explained that this was not a form of restraint, but was to keep other people, including staff, from going into the room, on the resident’s wishes. Although there were risk assessments on moving and handling and on specific issues such as the provision of bed rails, risk assessments on the whole need to be documented more fully. There was a clear medication policy and the last visit report from the pharmacist’s visit on 24/5/05 was satisfactory, with no outstanding issues. Residents said they felt safe and well looked after; one said ‘I’m well looked after here’. The staff team were observed carrying out their duties with kindness and sensitivity towards the residents, especially when attending to their personal needs. Staff confirmed that they had training on medication. Yew Tree Care Home DS0000060593.V249208.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Social activities create a variety of events which residents are informed about. The residents exercise choice about which activities, if any, they wish to participate in and what meals they want to eat. EVIDENCE: The home employs an activities organiser who works 2-4 pm on Tuesdays and Fridays; she is responsible for seeking the views of residents about what they wish to take part in. One resident spoken with said that she did not wish take part in a lot of activities but preferred peace and quiet. Staff and visitors confirmed that there was choice regarding the activities and events at the home. The Manager said and that that recent events had included a garden fete and visiting entertainers, while regular activities included carpet bowls, hoop-la, war-time quizzes, photographs and coffee mornings. There was, however, no formal record of these events having taken place and during discussions it was recommended that the activities co-ordinator kept a diary of all events at the home. The Manager said that she took three residents to vote and then for a drive, stopping for coffee at the local supermarket. Future events included a harvest festival service. The midday meal was nutritious and residents said how much they enjoyed the food. Not all staff handling food had their basic food hygiene certificates. Six meals were pureed and there were four diabetic meals. Yew Tree Care Home DS0000060593.V249208.R01.S.doc Version 5.0 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home’s complaints procedure is clear and gives residents and their relatives the confidence that comments and concerns will be listened to; there is a robust adult protection procedure. Staff need formal training on adult protection issues. EVIDENCE: Visitors and residents spoken with said they did not wish to complain but knew how to make a complaint. The home had received no complaints in the last twelve months. There was a clear complaints procedure and an adult protection procedure, which was linked to the Local Authority procedures. The Manager had arranged for training on challenging behaviour and staff had watched a video on adult protection issues, but recognised that external training on adult protection should be given to all staff. Yew Tree Care Home DS0000060593.V249208.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The residents live in a comfortable and pleasant environment with both private and communal space, which is generally suitable for their needs. EVIDENCE: The home has a rolling maintenance rota and recent improvements have included the complete redecoration of Room 6, including new carpeting. Room 15 had also been re-carpeted and the dining room had been re-arranged to allow more accessibility for wheelchair users. The home was free of odours throughout and hygiene procedures were in place. The entrance hall and the corridors did not present a welcoming atmosphere; this was commented upon by two visitors, who said it was dingy. The paintwork and the floor in the entrance hall is dark brown and scuffed and the paint to the corridors is in need of redecoration to make it lighter. The Manage said she had plans to introduce pictures of the residents’ choice to the walls. The standard of decoration in residents’ rooms was generally good and afforded residents a great degree of choice over how they personalised their rooms. The grounds were attractive and offered seclusion and peace. Yew Tree Care Home DS0000060593.V249208.R01.S.doc Version 5.0 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Staff numbers are in sufficient quantity on the staff rota for them to be able to care for the residents, but the actual complement of staff is quite small. Staff members are suitably qualified and competent; they undergo a thorough induction programme before commencing their duties. EVIDENCE: The residents were positive about the care they received from the staff; one resident said ‘they are very kind and friendly’. The most recent staff member to be appointed confirmed that she had given two references, which were followed up, a CRB check and undertaken an induction programme before commencing work and staff records confirmed this. Training records showed that statutory training was still in the process of completion and some staff members had not received training in basic food hygiene or adult protection; this needs to be external. A staff member did not understand the reason for the ban on bleach in homes; it was recommended that a training update was given on COSHH substances. One staff member had National Vocational Qualification at Level 2 with one currently undertaking it. The staff rota showed that there were enough staff numbers according to the staffing matrix and shifts were staggered to accommodate the needs of residents, but the actual staff complement was small. The care staff team included six overseas workers who lived in a cottage adjacent to the home; these were nurses in their own countries. Yew Tree Care Home DS0000060593.V249208.R01.S.doc Version 5.0 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home is managed competently and the staff are supported and supervised in carrying out their respective roles. The views of residents are listened to and they are involved in decisions affecting them. EVIDENCE: The home sends out questionnaires to residents and relatives and regularly asks residents for their views on the running of the home. It was recommended that all questionnaires were collated in a ‘quality assurance’ folder rather than retained in individual residents’ files. The manager has worked hard to update all the home policies and procedures and is still in the process of reviewing them. Yew Tree Care Home DS0000060593.V249208.R01.S.doc Version 5.0 Page 15 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 2 X 3 3 3 3 X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 2 3 3 Yew Tree Care Home DS0000060593.V249208.R01.S.doc Version 5.0 Page 16 Are there any outstanding requirements from the last inspection? no 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 OP7 Regulation 13[4](b,c) 15[2] Requirement The registered person must thoroughly document all aspects of risk in care plans. Where there are no family/friends, an independent advocate must be appointed. The registered person must ensure that all staff receive external training on adult protection issues. The registered person must have a plan for redecorating the entrance hall and corridors. The registered person must ensure that all staff members handling food receive 1] basic food hygiene training and 2] an update on COSHH procedures The registered person must ensure that the policies and procedures manual is updated and old policies and procedures are removed. Timescale for action 07/11/05 2 OP18 13[6,7,8] 07/11/05 3 4 OP19 OP30 23[2](b) 18[1] 07/11/05 07/11/05 5 OP36 17 07/11/05 Yew Tree Care Home DS0000060593.V249208.R01.S.doc Version 5.0 Page 17 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 12 Good Practice Recommendations It is a recommendation that the activities co-ordinator keeps a diary of all events and activities carried out at the home Yew Tree Care Home DS0000060593.V249208.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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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