Inspection on 20/02/08 for Yew Tree Cottage Residential Home

This inspection was carried out on 20th February 2008.

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

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 Cottage Residential Home 10/02/09

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Yew Tree Cottage Residential Home Hornsbury Hill Chard Somerset TA20 3DB Lead Inspector Ms Sue Hale Unannounced Inspection 10.10 20 February 2008 th 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 Cottage Residential Home DS0000070525.V358200.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 Cottage Residential Home DS0000070525.V358200.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Yew Tree Cottage Residential Home Address Hornsbury Hill Chard Somerset TA20 3DB 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) 01460 64735 01460 64735 sarah.ambridge@virgin.net Ambridge Estates Ltd Mrs Sarah-Jane Ambridge Care Home 5 Category(ies) of Dementia (5), Old age, not falling within any registration, with number other category (5) of places Yew Tree Cottage Residential Home DS0000070525.V358200.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Dementia (Code DE) Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 5. First inspection – new service. 2. Date of last inspection Brief Description of the Service: Yew Tree Cottage is a care home offering personal care for up to 5 older people. Included in this registration the proprietor may provide personal care for older people with dementia. The home is a substantial domestic property situated on the outskirts of Chard, Somerset. There are also large, very attractive gardens offering considerable privacy to the front and the rear of the home. In the main house the accommodation consists of three single bedrooms with en-suite facilities all situated on the first floor. A stair lift is available for people with lesser mobility. On the ground floor there is a lounge, dining room/conservatory, kitchen and toilet. Attached to the main house is an annex with lounge, kitchenette and twin bedroom with en-suite facilities. This facility is aimed for a more independent person or couple. The owner and manager Mrs Ambridge lives on-site. The home also provides day care for up to three people Monday to Friday. Day care facilities are not inspected under the jurisdiction of the CSCI. Yew Tree Cottage Residential Home DS0000070525.V358200.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this key inspection was to inspect relevant key standards under the Commission for Social Care Inspections ‘Inspecting for Better lives 2 Framework. This focuses on outcomes for residents and measures the quality the service under for general headings. These are; excellent, good, adequate and poor. These judgment descriptors for the seven chapter outcomes are given in the report. The inspection took place over the course of one day in February 2009 by one inspector (5 hours). The inspector spoke to the registered provider/manager, Mrs Sarah Ambridge, two members of staff, two people who live in the home and two people who were visiting the home for day care. The inspector looked at three residents care files, two staff files and other records relevant to the running of a care home. The home completed an Annual Quality Assurance Assessment (AQAA) and surveys were sent out to residents, relatives and staff. The results of surveys are incorporated into this report. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The current fees range between £550 and £600. As a result of this inspection one requirement and two recommendations have been made. What the service does well: The service user guide/statement of purpose is clearly written in plain English and gives readers a good picture of what services are provided at the home. It is available in the entrance hall to residents and visitors alike. All residents are given a terms and conditions of residency that tells them what will be provided for the fees payable. All residents have an individualised care plan that promotes their right to independence and details how their health, social and care needs will be met in a way that meets their agreement. Residents have ready access as necessary to medical and health professionals and any equipment necessary such as walking frames or pressure relieving equipment is provided. Yew Tree Cottage Residential Home DS0000070525.V358200.R01.S.doc Version 5.2 Page 6 Medication policies and procedures were in place, medication records were well kept and individuals supported to retain their own medication as far as possible following a satisfactory risk assessment. All staff has undertaken training in administering medication so that they can do this safely. The routines of the home are flexible and take into account individuals choices, preferences and needs. People are seen as individuals and the activities organised in conjunction with residents to offer a stimulating atmosphere that encourages independence and retention of existing skills. Visitors to the home are encouraged and able to visit at any time. Contact with residents family and friends is encouraged and supported by Mrs Ambridge and the staff. Meals are well balanced and cater for individual’s likes and dislikes. Mealtimes are flexible and relaxed and an opportunity for residents to socialise together. The home has a copy of the locally agreed Somerset wide procedures on safeguarding vulnerable adults and ensures that robust recruitment practices are in place to safeguard the people who use the service. A whistle blowing and gifts and wills policy was in place to provide robust safeguards for residents. The environment is furnished and fitted to a very high standard and provides a very clean, comfortable and safe place to live. All equipment provided and used in the home is well maintained and serviced regularly. Mrs Ambridge is developing a training programme and all staff has completed training in fire safety, infection control, manual handling, food hygiene and first aid. All this training has been achieved since Mrs Ambridge took over the home. Mrs Ambridge has the skills, experience and training to manage the home and provide leadership and support for staff. Health and safety is taken seriously and all equipment for use by residents and staff is regularly serviced to make sure it is safe. Accident records are well kept and stored securely. What has improved since the last inspection? First Inspection new service. Yew Tree Cottage Residential Home DS0000070525.V358200.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Yew Tree Cottage Residential Home DS0000070525.V358200.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 Cottage Residential Home DS0000070525.V358200.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): 1,2,3. Standard 6 is not applicable to this service. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home produces clearly written information about the home so that people can make informed choices about residency. All residents are given a terms and conditions of residency. Pre admission assessments are not routinely undertaken for people have a respite care. EVIDENCE: The home produces a joint service user guide and statement of purpose. This is clearly written and gives a good range of information about the services the home provides. It includes information about the fees and the terms and Yew Tree Cottage Residential Home DS0000070525.V358200.R01.S.doc Version 5.2 Page 10 conditions of residency. Both of the residents surveyed said they had received a contract about their residency at the home. Both residents and relatives surveyed said that they had received enough information about the home. One resident said’ within a month of taking over Sarah Ambridge gave me comprehensive documents outlining the aims of Yew Tree Cottage detailing everything a relative needs to know’. There has been one new permanent admission to the home since Mrs Ambridge took over. Pre admission assessment documentation is in place that meets the national minimum standards and assessments are undertaken by Mrs Ambridge to make sure that the home can meet prospective residents needs before they move in. However, one person who goes to the home on a regular basis for day care recently stayed overnight on an emergency basis. Mrs Ambridge was advised that even though there are detailed records kept for people who attend for day care should they stay for respite care, a preadmission assessment should be completed as soon as practicable. The home produces a terms and conditions of residency that includes the number of the room to be occupied, what is included in the fee and some general information about the home. The contract refers to the provision of nursing as well as residential care services. The information attached to the contract about complaints refers to the nurse in charge and the Nursing and Midwifery Council. This has now been revised and addressed by Mrs Ambridge. It does not made clear who would be responsible if there was a breach of contract. Yew Tree Cottage Residential Home DS0000070525.V358200.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): 7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive individualised personal and health care that respects their right to independence and their own decision-making. Medication is administered safely by qualified staff. Residents right to be treated with respect and their right to privacy is an integral part of the culture of the home. EVIDENCE: We (the Commission for Social Care Inspection) looked at the care plans of three residents. All the care plans contained a photograph of the resident, their preferred name, personal information of their family in next of kin and a detailed life history. The care plans were all signed by the residents giving their agreement about the care needed and how it should be provided. The care Yew Tree Cottage Residential Home DS0000070525.V358200.R01.S.doc Version 5.2 Page 12 plans covered all the necessary topics and gave clear guidance and information to staff on how care should be delivered. The care file also includes a record called ‘things I am able to do’ that is completed by a member of staff with the resident and focuses on their skills and abilities and asks a resident to tell staff what level of assistance they need and how they can promote individual choice and independence. All the care plans had been written in October 2007 when Mrs Ambridge took over the home and had been reviewed once since then. The service user guide/statement of purpose states that the ‘care plan will be reviewed monthly’. A member of staff surveys said that they felt that the home provided’ good quality individual holistic care that promoted independence as much as possible ’. Risk assessments in relation to pressure care, falls, moving and handling and nutrition were in place and have been reviewed regularly. A record of contact with the GP, district nurse or any other health or medical professional was in place. All residents have access to medical and health care professionals as required. Records show that the home respects the rights of people to make their own decisions about medication and health care. We looked medication practice in the home. Residents are encouraged and supported to have responsibility for their role medication as far as they are able. Risk assessments in relation to this were on file and will be subject to regular review. Medication was stored safely and securely, controlled drugs were kept in accordance with guidelines on when checked were found to be correct. A sample staff signature list was seen; there were no gaps on the medicine administration record (MAR), homely remedies were recorded and patient information leaflets kept for reference. All staff administer medication have undertaken training. A medication policy was in place. Staff were observed to be respectful of people living and visiting the home. Residents spoken to confirmed that they were very satisfied with the way that Mrs Ambridge and the staff provided their care. Yew Tree Cottage Residential Home DS0000070525.V358200.R01.S.doc Version 5.2 Page 13 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): 12, 13, 14 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service actively supports people to be independent and to have as much control as possible over their lives. People are very satisfied about the quality and variety of the food served at the home. Visitors are made welcome to the home and family and friends of residents are closely involved with the home. EVIDENCE: The home has a weekly programme of activities that includes the opportunity to go out of the home. Activities include quizzes, hangman, Jenga to retain manual dexterity and memory games with cards. Residents are able to accompany Mrs Ambridge into town to collect shopping. Some residents Yew Tree Cottage Residential Home DS0000070525.V358200.R01.S.doc Version 5.2 Page 14 recently went to the theatre at Yeovil to see a show. People who attend the home for day care are included in trips out if they want to join in. Residents told us that a Christmas party has been held for the first time at the home and that resident’s family and friends were invited. All the residents spoken to said that they had really enjoyed the party. Mrs Ambridge has two pet dogs that are an integral part of life in the home for residents. The details on care plans about individual’s life history include past and current interests, likes and dislikes. Residents are able to have a personal telephone fitted at their own expense. However, they are able to use the telephone after 6 p.m. at the homes expense. Visitors to the home are made welcome at any time and most people have frequent visitors and also the opportunity to go out with their family and friends. A relative surveyed said that ‘they (the home) treat each person as an individual and are genuinely concerned with their well-being’. The routines of the home are flexible to reflect the choices and preferences of people who live there. These are recorded in individuals care files and respected by staff in the way that the home is organised and care delivered. Local clergy visit the home and residents are supported to continue with their religious worship if they want to. All food at the home is freshly prepared and homemade. The cook keeps records of individuals likes and dislikes and this is taken into account when planning menus. There was a wide variety of good quality food available. The main meal of the day is at lunchtime and people choose what they would like for their supper on an individual basis. All people spoken to said that they enjoyed the food. People can choose to eat in their rooms or with other people in the dining area in the conservatory. Tablecloths, paper napkins, tablemats and condiments are provided. A cold drink is provided with the meal and people can choose to have a hot drink afterwards if they want to. A birthday cake is provided by the home for both permanent residents and people who come for day care. All food stored in the refrigerator was covered and labelled. Yew Tree Cottage Residential Home DS0000070525.V358200.R01.S.doc Version 5.2 Page 15 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): 16,17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints policy is clear, readily available and residents and relatives are confident their concerns would be taken seriously. The home takes steps to safeguard people who live there and use its services. Staff will all undertake training in adult protection. EVIDENCE: The home has not received any complaints since Mrs Ambridge took over in October 2007. The home has a complaints policy that includes timescales and makes clear that complainants can contact the Commission for Social Care Inspection at any stage for complaint. All residents surveyed knew who to speak to if they had any problems and all had of them knew how to make a complaint. Please refer to outcome group one in relation to the complaints policy attached to the terms and conditions of residency. The home has a copy of the Department of Health No Secrets guidance and an up to date copy of the Somerset safeguarding adult’s guidance. The managing physical aggression by resident’s policy was dated 2002 and should be revised to reflect current good practice advice. Yew Tree Cottage Residential Home DS0000070525.V358200.R01.S.doc Version 5.2 Page 16 The advocacy policy says that the homes policy is self-advocacy. This is not possible for all residents or families. A whistle blowing policy that includes the contact details of the Commission for Social Care Inspection and Public Concern at work was in place. A gifts and will policy making it clear staff cannot accept gifts or give advice or benefit from residents wills was in place. People living at the home are protected from the risk of abuse by the homes recruitment practices. The training matrix supplied by the home showed that none of the staff have undertaken training in adult abuse. However, Mrs Ambridge told us that a training programme has been set up since she took over and this is currently being arranged. Yew Tree Cottage Residential Home DS0000070525.V358200.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): 19,20,21,22,23,24,25,26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. All areas of the home are furnished and fitted to a very high standard and the home is clean, tidy and very well maintained. Aids and adaptations are supplied as necessary according to individuals needs. The laundry service offered to residents is efficient and well organised. EVIDENCE: Accommodation at Yew Tree Cottage is clean and very attractively presented. Bedrooms in the main house are all on the first floor, en-suite and for single occupancy. The furnishings and fittings of the home of a very high standard and very well maintained. Residents are able to bring in small items of Yew Tree Cottage Residential Home DS0000070525.V358200.R01.S.doc Version 5.2 Page 18 furniture and personal possessions and arrange these in their rooms to personalise it. Mrs Ambridge and staff encourage residents to see the home as their own home. There is a stair lift to the first floor. In the annex is an en-suite twin room with lounge and small kitchen. The grounds are accessible and well maintained. Mrs Ambridge has employed a regular gardener and improvements are planned including the building of a summerhouse. Residents were fully aware of the plans and are looking forward to being able to watch the gardens progress. Communal space is adequately proportioned for up to five residents and three day care clients in the week. Suitable aids and adaptations for older people have been made to the building. Sinks are fitted with anti-scald mixer valves and radiators are covered with low surface temperature guards. Emergency lighting is provided. The home was clean, tidy and free from odours on the day of the inspection, the standard was a credit to the housekeeper and other staff. Mrs Ambridge told us it was planned to redecorate the whole home in the near future. The laundry facilities are adequate for the number of residents. Hand washing facilities are available for staff and protective clothing readily available to reduce the risk of infection. The home has policies and procedures on infection control. Information provided by the home showed that all staff has completed training in infection control. Mrs Ambridge told us that the floor covering in the laundry is due for replacement and will be non permeable. Yew Tree Cottage Residential Home DS0000070525.V358200.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): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels are sufficient to meet the needs of residents and residents have confidence in the people that look after them. Staff have access to training to give them the skills and knowledge necessary to meet residents needs. Staff recruitment procedures are robust and safeguard the people who live at the home. New staff complete appropriate training. EVIDENCE: Mrs Ambridge is the registered provider/manager and lives on the premises. The home also employs a deputy manager, a cook, three carers and a housekeeper. Minimum staffing levels are one carer plus Mrs Ambridge who is on call on the premises. Currently none of the residents require assistance at night. That there is no one on duty awake at night should be made clear in the service user guide/statement of purpose. The housekeeper is currently on an NVQ to the course relevant to their work. The deputy manager has started to undertake the registered managers award. The deputy manager has recently completed nurse training, and one care is Yew Tree Cottage Residential Home DS0000070525.V358200.R01.S.doc Version 5.2 Page 20 currently registered on an NVQ level 2 course. This means that 33 of staff are qualified to NVQ level 2 or above with this rising to 66 in July 2008. We looked at the recruitment files for two new members of staff, both contained all the documentation required. Staff are given individual copies of the General Social Care Council code of conduct. Mrs Ambridge was advised to review all the policies and procedures relating to employing staff to make sure they are up to date and reflect current legislation and good practice. All new staff had completed the skills for care common induction standards and these were seen on files checked. T Yew Tree Cottage Residential Home DS0000070525.V358200.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): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Mrs Ambridge has the skills and experience to manage the home. The health and safety of residents and staff is taken seriously and people kept safe. Many policies and procedures need reviewing to make them relevant and reflective of good practice. EVIDENCE: Yew Tree Cottage Residential Home DS0000070525.V358200.R01.S.doc Version 5.2 Page 22 Mrs Ambridge is a qualified nurse and has worked in the care sector for many years. She has completed the registered managers award and continues to undertake relevant training to keep up to date. All the residents spoken to were very positive about Mrs Ambridge and the changes she had brought about in the home. Staff spoken to said that Mrs Ambridge was always approachable and offered support and encouragement to them. The AQAA contains clear, relevant information that is supported by a range of evidence that tells us about the planned changes at the home. The accident book was completed correctly and we cross checked entries with care files and they were found to be consistent. The home does not manage personal allowances for any residents or hold valuables on their behalf. Mrs Ambridge told us that formal residents meetings did not take place as she saw and spent time with all the residents on a daily basis. However, the service user guide/statement of purpose states that residents meetings are held quarterly, this should be clarified. The majority of the policies and procedures were several years old and did not reflect current good practice advice or in some cases the national minimum standards. Mrs Ambridge told us that she had started to review and update these. Records were seen that evidenced that all the equipment and facilities at the home are regularly serviced and safe. All staff have completed health and safety training and policies and procedures in relation to this were in place, including infection control. Yew Tree Cottage Residential Home DS0000070525.V358200.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 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 2 18 3 4 3 3 3 3 4 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Yew Tree Cottage Residential Home DS0000070525.V358200.R01.S.doc Version 5.2 Page 24 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 OP3 Regulation 14(1) Requirement People should not be admitted to the home unless a pre admission assessment has been completed. Timescale for action 10/03/08 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 OP7 OP33 Good Practice Recommendations All care plans should be reviewed monthly. All policies and procedures should be reviewed and updated to reflect the national minimum standards and current good practice advice. Yew Tree Cottage Residential Home DS0000070525.V358200.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South West Regional Office Colston 33 33 Colston Avenue Bristol BS1 4UA 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. Extracts may not be used or reproduced without the express permission of CSCI Yew Tree Cottage Residential Home DS0000070525.V358200.R01.S.doc Version 5.2 Page 26 - 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. 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