Inspection on 18/08/08 for Yew Tree Care Home

This inspection was carried out on 18th August 2008.

CSCI found this care home to be providing an Adequate service.

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 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 11/10/05

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 09/11/2008.

CARE HOMES FOR OLDER PEOPLE Yew Tree Care Home 60 Main Road Dowsby Bourne Lincs PE10 0TL Lead Inspector Dawn Podmore Unannounced Inspection 18th August 2008 09:30 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.V370311.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 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.V370311.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Yew Tree Care Home Address 60 Main Road Dowsby Bourne Lincs PE10 0TL 01778 440247 01778 440858 yewtree.gallac@btconnect.com 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 Patricia Gallagher 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.V370311.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th August 2007 Brief Description of the Service: Yew Tree Care Home is a former rectory and is situated next to the church in the village of Dowsby. It is six miles from the town of Bourne, in Lincolnshire, which has shops, banks, post office, pubs and leisure facilities. The home is registered to provide residential care for eighteen people of both sexes over the age of 65 years, twelve of whom may have the diagnosis of dementia. A single storey extension provides accommodation for ten residents; the first floor accommodation in the main building is accessed via a stair lift. There are twelve single rooms, two of which have en-suite facilities, and three shared rooms. The home is set back from the road and has large enclosed gardens with spaces for car parking. The home has a conservatory, which leads to the garden and patio. At the time of the inspection the manager confirmed that the weekly fees ranged from £379 - £509 depending on the residents assessed needs. Additional charges are made for hairdressing and chiropody. Information about these costs as well as the day-to-day operation of the home, including a copy of the last inspection report, is available in the manager’s office. Yew Tree Care Home DS0000060593.V370311.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This key inspection was unannounced and took any previous information held by C.S.C.I. about the home into account. The manager and the proprietor were both at the home on the day of the visit to assist with the inspection process. The main method of inspection used was called case tracking. This involved selecting a proportion of residents and tracking the care they receive through the checking of records, discussions with them and the staff who care for them and observation of care practices. A partial tour of the home was also conducted which included looking at some bedrooms, communal areas, bathing and toilet facilities. Documentation was sampled and the care records of three residents were examined. We spoke with three residents and a relative, as well as three members of staff. They shared their views about how the home operated on a day-to-day basis and the care and facilities provided. Prior to the visit the providers had returned an Annual Quality Assurance Assessment (AQAA) and this document will be mentioned throughout this report. We sent out some ‘have your say’ surveys to residents and staff, but none had been returned in time to be included in this report. On the day of the visit 10 residents were living at the home. What the service does well: Residents are cared for in a friendly, homely environment by staff who are aware of their needs and preferences. Staff were observed interacting with residents in a respectful and responsive manner. People are happy with the facilities provided, the way staff deliver their care and the management of the home. They told us, ‘they are all nice and seem to be very loving and respectful’, ‘I am happy with my room and everything’ and ‘I chose it as it is a secure place for him to live, he is happy here’. People are offered a varied menu that takes into consideration their likes and dislikes. Comments added to recent surveys issued by the home included, ‘the food is always appetising and good, even on pureed diets, ‘it’s always cooked fresh’ and ‘mum enjoys the meals, lovely and home cooked’. Yew Tree Care Home DS0000060593.V370311.R01.S.doc Version 5.2 Page 6 Leadership in the home is good and quality assurance systems are in place to help to make sure that the home is run for the benefit of the people who live there. Staff have access to a training programme which offers them a variety of courses. What has improved since the last inspection? What they could do better: The information collated as part of the assessment process needs to be formulated into individualised person centred care plans. These will then help to make sure that staff have better guidance on their role in supporting individual residents and how they prefer their care to be delivered. This also needs to include the arrangements for meeting peoples social needs. Although the environment of the home has been greatly improved outstanding issues, such as the repair and painting of external windows, need to be completed. All staff need to receive regular documented appraisals and supervision sessions to show that they are being supported to carry out their role. Yew Tree Care Home DS0000060593.V370311.R01.S.doc Version 5.2 Page 7 Other areas that would benefit from some attention included the following. The pre-admission assessment form should be reviewed to ensure that it provides sufficient space to enable the assessor to record their assessment in enough detail. Care plans should contain information about recent legislation that is designed to protect people’s rights and choices. This is so the home can show they have looked at the effects the legislation has on the resident’s lives and planned their care accordingly. The activities available to residents should be reviewed to make sure that the home is providing appropriate stimulation that meets people’s needs, with particular importance being given to people with dementia. 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. Yew Tree Care Home DS0000060593.V370311.R01.S.doc Version 5.2 Page 8 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.V370311.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People coming into this service have access to a range of information to help them make a decision about moving into the home. Procedures are in place to ensure that people are only admitted after a full needs assessment has been carried out to make sure that the home can meet their needs. EVIDENCE: The Statement of Purpose and the Service Users Guide had been amended so that they contained the information that people need about how the home intends to operate. Copies of the Service Users Guide were available in people’s rooms. A review of all information available prior to this visit, and the content of people care records, showed that the home does not admit residents without an assessment of their needs being completed. The pre-admission assessment seen contained basic information about the residents needs, but the manager Yew Tree Care Home DS0000060593.V370311.R01.S.doc Version 5.2 Page 10 had recorded other information on the back of the form due to the limited space provided. A relative and staff spoken with confirmed that needs assessments had taken place, either at people’s homes or in hospital before they moved in. The relative told us, ‘I chose it as it is a secure place for him to live’. The manager confirmed that the home does not currently cater for people with intermediate care needs. Yew Tree Care Home DS0000060593.V370311.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s care and health needs are being met by staff who understand their needs and deliver care in a respectful manner. However care plans do not provide enough guidance to staff about their role in supporting individual residents or people’s preferences as to how they want their care delivering. EVIDENCE: We looked at the care records for 3 people living at the home, each with differing needs. Information contained in the files outlined people’s main needs, but they lacked guidance for staff regarding what their role was in supporting individual residents. For example one said that the resident needed supervision to wash. However it did not detail what support was needed from staff or her abilities. It said that she wore dentures, but not whether she could attend to cleaning them herself, or if staff should do this and if so how. There was some good information contained in the plans, but this consisted of lists of possible areas of need, such as the time they liked to get up and whether they needed help with washing. Additional notes had been added such as ‘needs help with zips and buttons and that they preferred 2 pillows, Yew Tree Care Home DS0000060593.V370311.R01.S.doc Version 5.2 Page 12 but this information had not been developed into a person centred plan of care. The proprietor and manager said that this had been discussed and that they were considering how to make plans more person centred. Staff comments and actions showed that they knew all about the people they supported and did things the way they wanted them doing. For example one resident had requested to be left in bed until lunchtime as she was tired and they respected her wishes. Social assessments were completed, but again this information had not been developed into a plan of care regarding meeting peoples social needs. They did not clearly tell staff about what residents wanted to do or how to facilitate it. A new history profile form was being introduced with 3 completed to date; this provided a profile of the resident and some of their preferences. Assessments for potential risk areas had been completed in topics such as, nutrition, pressure risk and manual handling. However this information was not fully reflected in the care planning process. One resident who was tracked and was at risk of pressure damage was being turned 2 hourly and had a specialist mattress in place. Body maps were also being used to record any injuries or wounds that people had. A daily record of how people were progressing was being maintained and people’s care had been evaluated monthly. These had been improved since the last visit to contain better information about any changes in peoples care requirements. The home has not yet included the content of the Mental Capacity Act in their care planning process. This is new legislation that is aimed at protecting people’s rights. Records and peoples comments showed that residents had access to outside health professionals, such as their G.P, opticians and chiropodists. People’s health care was being monitored, which included monthly checks on their weight. One person, who had a nutritional assessment that indicated that they were at risk, was receiving nutritional supplements. Equipment such as hoists, air mattresses and bed rails were also in use. The provider’s Annual Quality Assurance Assessment (A.Q.A.A.) demonstrated that the home has satisfactory policies and procedures concerning the receipt, storage, administration and disposal of medications. Records and a discussion with the care worker responsible for the morning medications showed that medications were being handled safely. People were appropriately dressed and looked well cared for. Observations showed that staff respected people’s dignity and encouraged them to make Yew Tree Care Home DS0000060593.V370311.R01.S.doc Version 5.2 Page 13 decisions about their daily lives. Staff interacted well with residents, relatives and each other. People said that they were happy with the level of support provided, as well as the way in which it was delivered. Their comments indicated that they received support at the right level and it met their individual needs. A relative told us, ‘my husband seems very happy here’. Other people said, ‘I feel his needs are met’ and ‘it is very nice here, they look after us well’. Yew Tree Care Home DS0000060593.V370311.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home enables residents to maintain and develop social interests and relationships of their choice, but this is not reflected in care plans. Residents receive a nutritious, varied diet, which meets their individual preferences and health requirements. EVIDENCE: Currently the home does not have an activities coordinator so staff provide stimulation for the residents. A formal programme of activities is not provided because most people who live at the home prefer one to one interaction. One person told us. ‘I like to do my crochet and jigsaws and I really enjoyed the fete this weekend’. Records and peoples comments demonstrated that residents had taken part in activities such as, singing and dancing, jigsaws, folding laundry, hand massages, walks in the grounds, ball games to aid coordination, movement to music and reminiscence therapy. People said that visitors and staff took them out for walks sometimes, but otherwise there were no organised outings. They told us that entertainers also visited the home sometimes. Yew Tree Care Home DS0000060593.V370311.R01.S.doc Version 5.2 Page 15 The dining room provided a comfortable, airy environment for people to eat in, tables were set with tablecloths and flowers. Information provided in the AQAA and what people told us showed that the menus were varied and choice was offered. The cook outlined the menu options and specialist diets, which included pureed diets. Drinks and homemade buns and cakes were served during the afternoon of the visit One resident said, ‘it was casserole today, it was delicious’. The content of surveys undertaken by the home said that the food was either excellent or good. Comments included, ‘the food is always appetising and good, even on pureed diets, ‘it’s always cooked fresh’ and ‘mum enjoys the meals, lovely and home cooked’. Yew Tree Care Home DS0000060593.V370311.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by clear policies and procedures for handling complaints and allegations of abuse. Staff have received training in these subjects to help them protect the people they support EVIDENCE: The home has a complaint procedure, which is displayed in the home and included in the Service Users Guide. Details contained in the AQAA and records held at the home, showed that they had received no complaints over the last year. Surveys used by the home in June 2008 to gain peoples views showed that all 12 who responded knew how to raise concerns, but were happy with the care provided. People spoken with confirmed that they knew how to make a complaint, but said that they had nothing they wanted to complain about. One person said ‘I have no complaints at all’ and another told us, ‘I don’t need anything, I’ve got everything I want’. The home has procedures concerning the protection of vulnerable adults. Staff demonstrated a satisfactory knowledge of what to do if they suspected abuse could be occurring. They said that they had also received training about the types of abuse that might occur and the procedure for reporting any incidents. Yew Tree Care Home DS0000060593.V370311.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a clean, comfortable and homely environment, which offers a satisfactory standard of décor and furnishings, but some areas are in need of attention. EVIDENCE: We took a partial tour of the home, which included looking at the bedrooms of the residents we were case tracking. The lounge and dining areas had a homely feel to them with pleasant décor and furnishings. Bedrooms had been personalised by the residents or their families with photographs, mementoes and small items of furniture. People told us that they liked their rooms and the communal facilities. One person said, ‘I am happy with my room and everything’. The home has a three year plan for improving the environment, which started in 2005. A part time handyman is employed to maintain the home. Yew Tree Care Home DS0000060593.V370311.R01.S.doc Version 5.2 Page 18 There had been a leak in the flat roof over the stairs area so the corridor beneath it had been stripped of paper to allow it to dry out before redecoration could take place. The manager said that currently there were no residents living upstairs to be affected by the damage. Various equipment was available including, hoists, specialist mattresses, raised toilet seat and grab rails. Gardens and the car park were well maintained. Improvements had been made to the outside of the building, which included a large ramp leading to the front door. The front downstairs windows had been repaired and painted, but the upstairs windows and those at the rear of the building still need attention. The manager said that there were plans to address this. A fence has been erected around the back and the side of the home to provide an enclosed area for residents to wander. Gravel has been laid to the side of the house to provide a path. The manager said that there were plans for raised flowerbeds and other improvements in the near future. Yew Tree Care Home DS0000060593.V370311.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is enough staff on duty to meet the needs of the people living at the home. Procedures for the recruitment of staff are robust and therefore offer protection for people living at the home. Staff have access to training to help them meet the needs of the people they care for. EVIDENCE: Staffing rotas and peoples comments indicated that there was enough staff on duty to meet the needs of the people currently living at the home. As there are currently only 9 people living at the home 2 care staff, plus management and ancillary staff are on duty during the daytime. At night there are 2 care staff. Staff spoken with told us that they thought that the staffing levels were satisfactory. Residents and a relative spoken with confirmed this. Residents and the relative told us that they were happy with how care was delivered. Comments included, ‘the staff are very good’, ‘the girls are kind’ and ‘they are all nice and seem to be very loving and respectful’. No new staff had been recruited since the last inspection. However the home has a recruitment procedure, which includes essential checks such as written references and C.R.B. (Criminal Records Bureau) checks being undertaken. Yew Tree Care Home DS0000060593.V370311.R01.S.doc Version 5.2 Page 20 At the last visit overseas nurses had not had a C.R.B check done, although the manager had police checks from their own country on file. Since that visit the manager has arranged for the staff concerned to undergo a C.R.B check. The home has an induction programme to orientate new staff to the home and its policies and procedures. Records and peoples comments showed that the company has a programme in place to ensure that staff received adequate training. Training that had taken place included, manual handling, protection of vulnerable adults, infection control, fire safety, dementia care, health and safety and sensory deprivation awareness. The manager said that plans for the future included mandatory updates and challenging behaviour. Staff said that they felt that they were well trained and supported. The company encourage staff to complete an N.V.Q. (National Vocational Qualification) in care. Records and staff comments confirmed that out of 10 care staff 2 have completed an NVQ and 2 are currently undertaking the award. One person told us that she had completed her level 2 NVQ and was now going to do the level 3. Observation of care practices at the home demonstrated that staff were caring for people in an appropriate manner. They were visible in communal areas and responded well to peoples needs. The day seemed unrushed with staff having time to chat to residents. Yew Tree Care Home DS0000060593.V370311.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is good management, guidance and direction provided to staff to ensure that care is delivered in a consistent manner. The home is managed in the best interest of the residents. There are systems in place to ensure that the health, safety and welfare needs of residents are met. EVIDENCE: The manager has the necessary experience and qualifications to run the home. She has been in post since January 2005 and has completed the Registered Managers Award, which is aimed to provide managers with the essential skills and knowledge they need to manage a care home. She said that she has an open door policy to encourage people to speak to her as they wish. Yew Tree Care Home DS0000060593.V370311.R01.S.doc Version 5.2 Page 22 Residents and relatives told us that they were happy with the management of the home. One person told us, ‘it is very nice here’, someone else said, ‘they do everything I want, I have no complaints’. Staff spoken with said they were happy working at the home and felt that it was well managed. They told us that they felt the home provided a safe, caring and homely environment for people to live in. Comments included, ‘I’m very comfortable here, all the staff, especially the manager and the proprietor, are very supportive’, ‘I get job satisfaction working here’ and ‘the manager always listens to you’. The home has a quality assurance system so that it can gain the views of the people who use the service. We reviewed the results of surveys returned in 2008, which showed that people thought the home was providing either a good or excellent service in all areas covered by the set questions. Addition comments included; ‘very friendly staff’, ‘everything that can be done is done with a smile’, ‘I am delighted with how contented mum is’ and ‘I am more than happy with all the services that are provided’. There is a system in place for resident’s monies to be held in safe keeping by the home. This includes keeping a running total of all transactions and obtaining receipts and two signatures. Records samples showed that these were being maintained. Records and staff comments showed that staff were receiving supervision, but this had not always been recorded on a regular basis. They said that informal support was regularly given and that they felt supported by the manager. The manager said that she had not done any staff appraisals this year, but would soon be doing so. The home has a range of health and safety policies and procedures available to guide and instruct staff. There is a programme in place to service and maintain equipment in the home on a regular basis. Information provided in the AQAA, demonstrated that regular checks on equipment such as hoists and fire fighting equipment had taken place. During the visit the staff appeared to work well together and peoples individual needs were considered throughout the day. A visit by the Environmental Health Officer last year had resulted in the kitchen being awarded a 4 star rating for cleanliness and facilities. They had visited again the week before this inspection and verbally confirmed that the rating would remain the same, but no report had been received. Yew Tree Care Home DS0000060593.V370311.R01.S.doc Version 5.2 Page 23 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 X 2 X X 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Yew Tree Care Home DS0000060593.V370311.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 (1) 16 (2) Requirement The information collated as part of the assessment process must be used to formulate care plans that provide appropriate guidance to staff about their role in supporting individual residents. This must include how staff will meet people’s social needs. The fabric of the building must be maintained in a good state of repair, externally and internally. This requirement has been met in part. Although considerable work has been completed there are still some windows that need attention. Therefore the timescale of 31/10/07 was not fully met. All staff must receive an annual appraisal and regular formal supervision. Timescale for action 01/11/08 2. OP19 23 (2) (b) 01/12/08 3 OP36 18 01/10/08 Yew Tree Care Home DS0000060593.V370311.R01.S.doc Version 5.2 Page 25 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 OP3 Good Practice Recommendations The pre-admission assessment form should be reviewed to ensure that it provides sufficient space to enable the assessor to record their assessment in enough detail. Care plans should contain information about peoples individual preferences so that they provide a more person centred approach to caring for residents. It is recommended that support plans include reference to the Mental Capacity Act, 2007 and the effects it has upon the service users lives. This is to ensure that their rights and choices are protected. The activities available to residents should be reviewed to make sure that they are providing appropriate stimulation that meets people’s needs, with particular importance being given to people with dementia. It should also give residents the opportunity to go into the community on outings if they so wish. 2. 3. OP7 OP7 4. OP12 Yew Tree Care Home DS0000060593.V370311.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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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