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Inspection on 29/07/05 for Yew Tree House Residential Care Home For The Elderly

Also see our care home review for Yew Tree House Residential Care Home For The Elderly for more information

This inspection was carried out on 29th July 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Yew Tree House provides an individual service that caters for the specific needs of residents. The home continues to evidence a great empathy and direct responsibility for the residents living there. Residents indicated a high regard for the home and the care they receive and said, "this is a wonderful home, they are angels" and "the staff are very friendly and really care for me" People are given the information they require before moving in to the home. Residents have a comprehensive care plan and their heath needs are well recognised and met. Residents are able to make individual choices and felt their views were always listened to. The home was decorated and furnished to a good standard. All of the resident`s rooms, including communal rooms received good levels of natural light and bedrooms were clean, comfortable and personalised to the individual. The home retains strong links with resident`s relatives and the local community Staff are encouraged to undertake training and were committed to providing a good service.

What has improved since the last inspection?

Members of staff have gained NVQ qualifications and undertaken additional core training this year. Further training opportunities are planned and the home manager has secured additional exterior funding to ensure this takes place. A new system of staff supervision and appraisal is being implemented. Existing and new staff have current Criminal Record Bureau clearance checks, to ensure the homes recruitment systems protect residents from risk of abuse There have been improvements to care plans and the way individual residents personal information is managed and recorded. Accidents and incidents in the home are now recorded in a format that conforms to the demands of the Health and Safety Executive. A process for ensuring that all staff know and understand the homes policies and procedures has been implemented Quality assurance audits are being planned.

What the care home could do better:

The home must be more proactive in adopting a risk assessment culture to protect people`s health and safety generally and whenever the home is faced with a potential hazard on which they need to act promptly. Whilst the small, intimate and homely nature of the home is appreciated, basic standards of health and safety need to be consistently met. The exterior grounds of the home should be as free from hazards and obstructions as possible and risk assessments undertaken for people using them. The homes fire evacuation procedures require review and revision in light of the current building work and the recent security risk that the laundry fire door poses. The homes medication policy and procedure document requires minor updating to reflect the homes procedures. Further consideration must be given to the use of a Controlled Drugs register and improved procedures adopted for the administration of Controlled Drugs to residents. The home should regularly record hot water temperatures in hand washbasins as well as baths and take action when the temperature is excessive. The residents would benefit from radiators being covered or have guaranteed low temperature surfaces. Staff rosters must be a true record of planned and actual hours worked and evidence that staffing levels were adequate over each 24-hour period.Individual agreement to the use of baby monitors in residents bedrooms should be recorded in care plans to ensure this is a matter of choice for residents and their privacy and dignity is respected. Any future upgrading plans for the building should ensure that the laundry facility is of a more suitable size with equipment that meets health and safety demands and infection control measures. The provision of a suitable passenger lift would greatly benefit the less mobile residents to have access to all parts of the home.

CARE HOMES FOR OLDER PEOPLE Yew Tree House Residential Care Home for the Elderly Yew Tree House 9 Station Road Headcorn Kent TN27 9SA Lead Inspector Marion Weller Unannounced 29 July 2005 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Yew Tree House Residential Care Home for the Elderly Yew Tree House 9 Station Road Headcorn Kent TN27 9SA 01622 890112 Address Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Michael Francis Discombe CRH 10 Category(ies) of DE(E) Dementia - over 65 (2) registration, with number OP Old Age (8) of places Yew Tree House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6 July 2004 Brief Description of the Service: Yew Tree House is a detached property with accommodation on two floors. There are 8 single bedrooms and 1 double Each room has a call point and a television point. The home does not have a shaft or stair lift installed, which therefore limits the use of the upstairs bedrooms to those who are physically able. Communal areas are a large lounge with integrated dining area. The homes kitchen is located on the first floor with meals being served via a dumb waiter to the dining room below. This arrangement allows for more bedrooms to be located on the ground floor..The home is located in the middle of Headcorn village near to Headcorn Station, with very good access to shops and other amenities. Car parking at the front of the home is currently unavailable due to building work taking place. Mr Discombe has owned and run Yew Tree House for the past sixteen years and in addition to Mr Discombe, the home employs a further 13 care staff, working full and part-time hours, one trainee manager, one cook/ administrator and another part-time cook. Application to extend services at Yew Tree has been submitted to the Commission, with new proposals for an additional 2 single en-suite bedrooms being built to the front of the property. The proposed building will not be attached. to the current accommodation. The work is proposed to be completed by the end of 2005. Yew Tree House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Regulatory Inspectors Helen Martin and Marion Weller carried out an unannounced inspection of Yew Tree House between 10.40 and 19.10. Management, staff and residents agreed to speak with the Inspectors. Feedback from the inspection was given to the Owner and the Trainee Manager who assisted the Inspectors throughout the day. The last inspection report together with progress and achievements made by the home since the last inspection were discussed. Some judgements about quality of life for residents were taken from conversations held with them in private and in public areas and observations. Some records, staff files, staff rosters, training records and care plans were inspected. A tour of the premises was carried out which included the exterior grounds. All staff were very helpful during the visit. What the service does well: Yew Tree House provides an individual service that caters for the specific needs of residents. The home continues to evidence a great empathy and direct responsibility for the residents living there. Residents indicated a high regard for the home and the care they receive and said, “this is a wonderful home, they are angels” and “the staff are very friendly and really care for me” People are given the information they require before moving in to the home. Residents have a comprehensive care plan and their heath needs are well recognised and met. Residents are able to make individual choices and felt their views were always listened to. The home was decorated and furnished to a good standard. All of the resident’s rooms, including communal rooms received good levels of natural light and bedrooms were clean, comfortable and personalised to the individual. The home retains strong links with resident’s relatives and the local community Staff are encouraged to undertake training and were committed to providing a good service. Yew Tree House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: The home must be more proactive in adopting a risk assessment culture to protect people’s health and safety generally and whenever the home is faced with a potential hazard on which they need to act promptly. Whilst the small, intimate and homely nature of the home is appreciated, basic standards of health and safety need to be consistently met. The exterior grounds of the home should be as free from hazards and obstructions as possible and risk assessments undertaken for people using them. The homes fire evacuation procedures require review and revision in light of the current building work and the recent security risk that the laundry fire door poses. The homes medication policy and procedure document requires minor updating to reflect the homes procedures. Further consideration must be given to the use of a Controlled Drugs register and improved procedures adopted for the administration of Controlled Drugs to residents. The home should regularly record hot water temperatures in hand washbasins as well as baths and take action when the temperature is excessive. The residents would benefit from radiators being covered or have guaranteed low temperature surfaces. Staff rosters must be a true record of planned and actual hours worked and evidence that staffing levels were adequate over each 24-hour period. Yew Tree House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 Page 7 Individual agreement to the use of baby monitors in residents bedrooms should be recorded in care plans to ensure this is a matter of choice for residents and their privacy and dignity is respected. Any future upgrading plans for the building should ensure that the laundry facility is of a more suitable size with equipment that meets health and safety demands and infection control measures. The provision of a suitable passenger lift would greatly benefit the less mobile residents to have access to all parts of the home. 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 House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Yew Tree House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1.3. 4. 5. Prospective residents have the information they need to make an informed choice about moving to the home. Residents know the home will be able to meet their needs before they move in. EVIDENCE: In conversation with residents they commented that they were given adequate information and had also been encouraged to visit the home prior to moving in. They were satisfied that the home was meeting their needs. Resident’s records contained the homes pre admission assessments, together with information that would reliably inform the home as to whether they could meet the person’s needs. The pre admission information is used as the basis for resident’s care plans. Residents explained how helpful staff had been in assisting them to settle in. One resident said that the manager had arranged to collect her from her home. She felt that the home had “gone to great lengths” to make her welcome and to develop a better understanding of her needs. They had also helped her become familiar with staff and fellow residents. Yew Tree House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 Page 10 The manager demonstrated a clear understanding regarding the category and needs of residents that the home could meet. There was evidence that Care Management had previously been involved in helping to appropriately place some resident’s However, the home currently caters predominately for privately funded service users. The home does not provide intermediate care. Yew Tree House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 8 9 10. Residents can expect a high quality service, which promotes their health and welfare with evidence of good multi disciplinary working. Resident’s safety is unnecessarily compromised by the homes failure to comprehensively meet good practice recommendations in the administration of medication. EVIDENCE: There was evidence of comprehensive care plans that inform and guide staff as to how resident’s health and welfare needs should be met. Care plans are updated and reviewed regularly The home continues to improve their content and ease of use. Fragmentation and duplication of information had almost been eliminated and staff were recording information about activities undertaken and personal care appropriately. The home could evidence excellent and effective working relationships with local health care professionals who readily and fully support residents in their health care needs. One resident described access to a Chiropodist, Optician, arrangements for a hospital visit and treatment. Records of professional visits were recorded and advice acted upon. Residents seen showed care and attention had been given to personal hygiene and staff were observed attending to this during the day. Residents were encouraged to self medicate if it was appropriate and had the resources to enable them to do so. The CSCI Pharmacy Inspector visited the Yew Tree House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 Page 12 home in 2004. The pharmaceutical standards in the home were seen to be satisfactory at that time. Recommendations were made however to enhance practice. Some items identified still require attention, particularly around accurate recording of medicines leaving and being returned to the home when residents go on social leave. Medication administration records seen had not had hand written changes confirmed in writing by the doctor. Some residents are currently prescribed Controlled Medicines. The administration of these medicines are not always witnessed by a second person The home does not use a Controlled Drugs register for recording the receipt, administration and disposal of Controlled drugs. The homes policy and procedures document needs minor adjustments to accurately reflect procedures within the home. From speaking with residents and staff it was clear that the service has at its heart the welfare of the residents living there. Staff treated residents with respect and promoted their privacy and dignity. They also had a very good understanding of preferences in care and the individual support needed by residents. Yew Tree House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12.13.14.15. Residents have a good standard of living in the home. Links with the local community are excellent and as a result, support and enrich residents’ social, cultural and religious interests. EVIDENCE: The home is close to the village and operates very much around the residents and village life, thus offering good community involvement. Residents discussed people from the village waving as they go by or stopping to chat to them. One resident said she is treated very well when she visits the local shops, “They are very protective of us you know, I always joke with them and they make me laugh in return, I know they would see me safely home if I was in trouble or worried.” Other residents described receiving visitors, going to visit relatives and friends or going out to church or for a meal on special occasions. Activities are arranged in the home covering leisure and hobbies such as board games, word games, bingo knitting, and sewing, playing the piano. One resident said, “ I don’t always want to join in but I sit and listen to the others, we are treated so well. You feel as if you should seem interested when the staff try so hard to please us” Several other residents explained that they return to their bedrooms for a rest after lunch. One declaring, “I like to Yew Tree House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 Page 14 snooze for a while and I feel so safe, best thing I ever did coming here!” All residents spoken with appeared happy and relaxed in their surroundings. The home offers locally purchased food, freshly prepared and cooked. Special diets are accommodated. Meal times are set for practical reasons but this is flexible to accommodate individual residents wishes and proposed activities. Most residents were complimentary of the food served. One resident said food had been discussed at a residents meeting, and she had expressed a view that the vegetables and the teatime menu offered were a bit monotonous at times. She said, “ that had the desired effect, it got better for a while, I would like residents meeting more often, I think they are trying to arrange another one.” The trainee home manager confirmed this. Residents are able to choose where to eat their meals. Some prefer to dine alone in their rooms but many choose to join fellow residents in the dining area. Yew Tree House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16.17.18 Residents can feel confident that if they have any complaints or concerns they are responded to quickly, taken seriously and acted upon. EVIDENCE: The home has a policy for dealing with complaints and keeps records No complaints have been received since the last inspection. Without exception all the residents spoken with were happy with the service they received and had no complaints or concerns they felt had not been addressed. They were confident that the home took their welfare seriously and concerns would be investigated and resolved as quickly as possible. Residents explained that the home supports them in exercising their legal rights and to vote if they so wish. One resident explained how she had been helped to go to the local polling station during a previous election. The home has an Adult Protection and Whistle blowing policy. The manager was clear that advise would be sought from Social Services immediately on an allegation being made before any investigation took place in the home. The home has a copy of Kent and Medway Adult Protection procedures. Yew Tree House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 Page 16 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 standard(s) 19.20.21.23.24.26. Residents were potentially put at risk by poor health and safety practices. EVIDENCE: On the day of inspection building work was taking place at the front of the premises. Other exterior areas of the home, such as the entrance, pathways and the gardens were also suffering some disruption. Residents were being observed closely by staff and confirmed that they had been verbally advised as to the protection of their safety when going outside or leaving the home. However, in light of the amount of disruption seen, it was recommended that the home manager review the current fire procedures in case of the need for emergency evacuation. The usual muster point at the front of the premises was not accessible and one fire door to the side of the building had been locked. It was further recommended that the exterior grounds of the home should be as free from hazards and obstructions as possible. Risk assessments should be undertaken for people using the exterior grounds of the home during the remaining course of the building work and reviewed and updated Yew Tree House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 Page 17 thereafter. Fire risk assessments and actions decided should be checked with the Fire Officer. The home manager confirmed that this had been discussed and would be undertaken immediately. Evidence was seen of obstructions caused to the exterior grounds by two washing machines, a cooker hood, a broken panel of glass and various other old household items, together with bottles containing chemicals and a container for soaking commode pots filled with diluted bleach. The items had been placed along one side of the access path to the back garden and had been there for some time. On the access path at the other side of the premises, bricks and debris from the building work had been stacked. Some areas of the access path were uneven and in a poor state of repair. One resident had previously stated that she regularly accessed the back garden to use the greenhouse, which she, “enjoyed immensely”. The greenhouse was seen. It was unlocked with garden chemicals on view. A garden shed, also unlocked, with a broken pain of glass in the door, was also viewed. A variety of chemicals could be accessed and were seen to be haphazardly stored within. The laundry room on the ground floor contained a domestic washing machine with no sluicing cycle, a tumble dryer and a sink unit. The room is small and cramped. No soap or hand towels were supplied. The home manager stated that the exterior door from the laundry was kept locked due to a recent security incident. As the door is a fire exit and is to remain locked for security reasons, it was recommended that safe egress from the building is discussed with the Fire Officer and advice recorded and actioned. The interior of the home was well presented, clean and well ventilated. New decoration had been completed in some areas internally and more was planned upon completion of the current building work. Previous building work plans discussed with The C.S.C.I. had included enhancements of the current facilities provided by the home. Any future upgrading plans for the building should seek to ensure that current shortfalls in the environmental standards at the home are revisited and addressed. Yew Tree House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27. 28.30. The relationship between staff and residents is good and creates a supportive and caring atmosphere in which the residents feel secure and comfortable. EVIDENCE: Residents spoken with were complimentary about the staff and had nothing but praise for them and the service they receive. Several residents stated that they felt staff were very busy and stretched however and could often do with an extra bit of help. Care staff are responsible for the residents personal washing and all the domestic duties in the home. Separate ancillary staff cover catering duties. No agency staff are used. The manager is aware that the current staffing structure and levels will require revision when additional services are offered. Staff duty rosters were inspected. The documents seen were not sufficiently detailed and did not include the hours worked by the Registered Manager. The home manager stated her intention to rectify this. Staff confirmed that training and proving their competence at work by gaining NVQ qualifications was encouraged and planned for. Records seen confirmed this. A full induction is undertaken with new staff. The home manager spoke of training events she had previously organised and her plans for the future. Records seen confirmed that CRB and POVA Register checks are made for all new staff before they commence employment and have been completed for all existing staff. Staff were very positive about working in the home Yew Tree House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31.32.33.37.38. Current arrangements were not sufficient to fully protect the health, safety and welfare of residents EVIDENCE: The trainee home manager has achieved additional qualifications to prove her competence and worth and has many years experience in care provision. Residents said that she is approachable, kind and caring. Both the home manager and the owner have received satisfactory CRB disclosures. Residents spoke of many opportunities to share their opinions on the service offered by the home and both the home manager and the owner encourage an open and inclusive atmosphere. It was obvious that the residents hold the owner, who many referred to jokingly and fondly as “the boss”, in high esteem for his unfailing commitment to them as individuals and the security he offers them in the home. Yew Tree House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 Page 20 His commitment to residents direct care is commendable and valid but can be detrimental in terms of the available time this leaves him to achieve sound organisational and administrative standards and to both formulate and review policies and procedures in line with good practice demands and recommendations. Development plans exist for many aspects of the homes future but there was no evidence of a formal written annual plan to enable the homes achievements, once realised, to be acknowledged. Much work however has been achieved since the last inspection. Service user and stakeholder quality assurance and audit checks regarding the services offered are planned but have not yet taken place. It was clear that the new role held by the trainee home manager is enabling the further development and quality of the services offered. Evidence was seen of good practice in the displayed ‘Policy and Procedure of the week’ on the staff notice board. The homes manager explained that a procedure is displayed and discussed with all staff to ensure both their knowledge and understanding and to secure their future compliance. A simplistic idea, but staff found it very effective. It was felt that the new role held by the trainee manager would offer valuable support to the owner/manager and give the home an opportunity to achieve as high an organisational standard as it already achieves in direct care. The reduction or elimination of potential hazards and risks to residents’ safety during the current building work had not been sufficiently planned for. No risk assessments were in place. This was particularly necessary for dealing with the safety of residents and staff accessing the exterior grounds, greenhouse and for people who needed to negotiate obstructions to the access pathways to the garden. The homes Fire Procedures had not been revised in light of the usual muster point becoming temporarily unavailable or for the new security procedure adopted of locking the fire exit door in the laundry. It was recommended that the fire door remains unlocked until advice from the Fire Officer is sought. Yew Tree House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 1 2 3 x 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 x x x 3 1 Yew Tree House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 Page 22 NO 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 OP9 Regulation 13 (2) Requirement The Registered person shall make arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the care home. In that: 1. The home is to review and revise the current medication policy to reflect current practice. 2. Records must be kept of all medication taken out of the home for social leave. Records must show the amount leaving the home and the amount received back by the home. 3. The receipt, administration and disposal of Controlled Drugs are recorded in a Controlled Drugs register. 4. The administration of Controlled drugs is witnessed by another designated, appropriately trained member of staff and both sign the administration records. 5. The home records the current procedure for the administration of non –prescription, homely Yew Tree House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 Page 23 Timescale for action To be completed by 14th October 2005 remedies in the medication policy and procedures document. 6. Medication Administration Record sheets must be updated and maintained comprehensively and accurately. Hand written entries by staff must be confirmed in writing and/or signed by the prescribing GP. Hand written entries must be signed by two staff members in order to evidence confirmation of accurate details. “ The Registered Person shall make suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users in that the privacy screen in the double bedroom currently extends only halfway across the shared room; there are occasions that require full privacy screening. Currently the situation has the potential to compromise a residents privacy and dignity. This must be addressed. The Registered Person shall maintain in the care home the records specified in Schedule 4 (7) A copy of the duty roster of persons working in the home, and a record of whether the roster was actually worked. The registered person shall ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated” in that: 1. Fire procedures must be risk assessed, reviewed and if necessary revised in light of the 2. OP10 12(4) 16 (2) Action plan to CSCI by Octber 14th 2005 3. OP27.2 17(2) Schedule 4 (7) to be done by October 14th 2005 4. OP38 13 (4) 23(4) To be done by October 30th 2005 Yew Tree House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 Page 24 building works. 2. Advice must be sought from the Fire Officer as to the current practice of locking the laundry room fire exit door. 3. External Fire Exits and egress pathways must not be obstructed. 4. The exterior garden areas must be safe for service users and access to the greenhouse is to be risk assessed. Any potential risks identified must be reduced or eliminated 5. Radiators must be operated at a low surface temperature or have guards fitted. . 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 OP10 Good Practice Recommendations The home should record in individual plans of care service users agreement to the use of a baby monitor sited in their bedroom during night hours. It is strongly recommended that a suitable passenger lift is provided. I. It is strongly recommended that the home have a sluicing facility. The CSCI is aware from previous action plans received that quotes for sluicing washing machines had been received by the home. In the original plans for the extension work this should have been installed, as agreed in 2004. It is recommended that this should still be installed in light of the client group the home is registered for, the limited sluicing resources in the current cramped laundry and to ensure that infection control is appropriately addressed. H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 Page 25 2. 3. OP22.2 OP26 Yew Tree House Residential Care Home for the Elderly 4. OP29 2. It is strongly recommended that dedicated hand washing facilities are available for staff in the laundry.(NMS 26.3) It is strongly recommended that the provider complete the stated aim of reviewing staff files to comply with the amendments made to the Care Homes Regulations 2001, Schedule 2. This will ensure that the home complies with current recruitment requirements and protects the safety and security of residents It is recommended that there is an annual development plan for the home based on a systematic cycle of planning, action and review, reflecting the aims and outcomes for service users. It is further recommended that results of quality assurance surveys are published and made available to current and prospective service users, their representatives and other interested parties, including The C.S.C.I. Both of these recommendations would be an aid to monitoring and reviewing the good progress made by the home It is recommended that the home develop HACCP procedures and records as suggested by the Environmental Health Officer.e It is strongly recommended that a procedure is set up to regularly monitor and record hot water temperatures to wash hand basins in service user areas. Excessive hot water temperatures, once identified and recorded, require action to protect the health and safety of service user. It is recommended where bedrooms are shared, the residents involved have made a positive informed choice to share with each other. 5. OP33 6. OP38.2 7. OP38.3 8. OP23.6 9. 10. 11. 12. Yew Tree House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection The Oast Hermitage Court, Hermitage Lane Maidstone Kent ME16 7NT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Yew Tree House Residential Care Home for the Elderly H56-H06 S24096 Yew Tree House V223136 290705 Stage 4.doc Version 1.40 Page 27 - 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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