Inspection on 04/01/06 for Yew Tree House Residential Care Home For The Elderly

This inspection was carried out on 4th January 2006.

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 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 House Residential Care... 20/11/07

Yew Tree House Residential Care... 19/07/06

Yew Tree House Residential Care... 29/07/05

Yew Tree House Residential Care... 06/07/04

Yew Tree House Residential Care... 19/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Yew Tree House Residential Care Home For The Elderly Yew Tree House 9 Station Road Headcorn Ashford Kent TN27 9SA Lead Inspector Marion Weller Announced Inspection 4th January 2006 09:50 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 House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Yew Tree House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Yew Tree House Residential Care Home For The Elderly Yew Tree House 9 Station Road Headcorn Ashford Kent TN27 9SA 01622 890112 Address 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) Mr Michael Francis Discombe Care Home 10 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (8) of places Yew Tree House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th July 2005 Brief Description of the Service: Yew Tree House is a detached property with accommodation on two floors. There are 8 single bedrooms and one 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 facilities comprise toilets and two bathrooms and a large lounge with a dining area to one end. The homes kitchen is located on the first floor with meals being served via a dumb waiter to the dining room below. The arrangement allows for more bedrooms to be located on the ground floor. The home is located in Headcorn village near to the railway station. There is good access to shops and other amenities close by. Car parking is currently limited to two spaces at the front of the home due to building work. The homes senior staffing team comprises the owner/ manager, and a trainee home manager. The home also employs 11 care staff working across a 24-hour roster and two part time catering staff. The owner has discussed an application to extend the services offered at Yew Tree House with the Commission. 2 self contained, single en-suite studio bedrooms are being built to the front of the property. It is proposed that the new building will not be attached to the current accommodation. The work is proposed to be completed by February 2006 Yew Tree House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted by Marion Weller, Regulatory Inspector, who visited Yew Tree House from 9:50 am to 5.20 pm. During that time the Inspector spoke with the registered manager, the trainee home manager and some service users. Parts of the home and exterior grounds were seen, some records and documents were inspected and the last inspection report was discussed. Additional information was obtained through the pre-inspection questionnaire, prior to the visit. Comments made during the inspection process included: “Very warm, happy atmosphere-gives the impression of one big family” “The care in this home is always 100 ” “Excellent service.” The manager and staff gave their full co-operation throughout the inspection. What the service does well: What has improved since the last inspection? The home has continued to make improvements to pharmaceutical standards in line with good practice guidance. Care plans record individual service users agreement and satisfaction with the use of listening devices placed in bedrooms overnight. The exterior pathways and rear garden have been cleared of the majority of hazards noted during the last inspection. Safe systems of work, which include revised fire risk assessments and emergency evacuation procedures, will protect service users from harm for the duration of building work taking place at the home. A development plan address’s some Yew Tree House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 Page 6 internal environmental issues and those in the grounds that require resolution. Radiator guards have been fitted to all areas to which service users have access. The home has revised policy and procedure documents this year. A quality assurance exercise has been undertaken regarding the food offered to service users, the results will inform and guide future planning. Infection control is improved; staff now have access to hand washing facilities in the laundry room. The trainee manager has completed work for the Registered Managers Award. The security of the building has been improved by seeking advice from the Fire Officer as to a door that can now safely be locked without compromising service users and staff safety. 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 Yew Tree House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 Page 7 contacting your local CSCI office. Yew Tree House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 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 House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 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 the following standard(s): 13456 Sound systems are in place for prospective service users to decide whether Yew Tree House is the right home for them. EVIDENCE: Service users feel they were given adequate information about the home; both they and their families were encouraged to visit prior to moving in. The manager undertakes thorough pre admission assessments with prospective service users, which form the basis for their individual plans of care. Service users were satisfied that the home was meeting their needs and had been effective in helping them to settle in. One service user commented “ I have no regrets about my decision to move in, the home is warm, clean and cheerful, my friends made welcome …” The managers demonstrated a clear understanding regarding the category and needs of service users that the home could meet. There is evidence that Care Management have recently been involved in helping to appropriately place a service user. The home caters predominately for privately funded individuals. Yew Tree House does not provide Intermediate Care. Yew Tree House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 11. Service users health and welfare needs are fully met by care plans that offer clear guidance for staff and are comprehensively maintained. Service users benefit from good liaison and multi disciplinary working with relevant health care professionals. EVIDENCE: Each service user had a care plan. Those seen were comprehensive, reviewed regularly and guide staff as to how service users health and welfare needs should be met. Service users had signed care plans. Service users access to health care professionals was being maintained and recorded. The home benefits from a very positive relationship with community nurses and local surgeries. Staff were aware of advice received from health professionals in regard to individual service users specific needs and advice was seen to have been acted upon. Service users were encouraged to self medicate if it was appropriate and had the resources to enable them to do so. The home has continued to make Yew Tree House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 Page 11 improvements to pharmaceutical standards in line with good practice guidance. The home currently has no service users who are prescribed controlled drugs. The home does not have a controlled drugs register. The manager stated that should the need occur, a controlled drug register would be purchased and used. The home was seen to have satisfactory medication administration systems in place and medications were seen to be stored in accordance with their instructions. Staff treated service users with respect and promoted their privacy and dignity. Service users individual agreement to the continued use of listening devices, sited during night hours in bedrooms, had been recorded in plans of care. The manager is aware that privacy screening, which extends only halfway across the double room, has the potential to compromise service users dignity and privacy. Efforts are made by the home to manage the effect this has on the individuals who currently share the very limited space in this room. The manager said plans to resolve the issue had been initiated by one service user, resident in the double room, who is seeking alternative accommodation in the new build at Yew Tree House. If this takes place, the future use of the double room as shared provision would be reconsidered as a priority. Discussion took place with the manager about the homes policy on dealing with increasing dependency and death of service users in the home. It was clear that the situation is handled in a sensitive and respectful manner in line with individual service users wishes. The home has written guidance, which informed and supported their practice on this issue. Yew Tree House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Service users have a good standard of living in the home. Links with the local community are excellent and as a result, support and enrich service users recreational interests and needs. EVIDENCE: Yew Tree House is close to the village centre and operates very much around service users expectations of as near normal a lifestyle in the home as possible and village life. There are programmes of activities available for service users that include religious and recreational interests, both inside the home and in the wider community. Within the limitations of group living, activities offered are designed as close to service users recorded preferences as possible. One new service user, who previously had a dog at home and therefore enjoyed the company of a pet and long walks, goes along with the manager when his own dog is exercised. This has helped the individual feel at home quickly and has offered an opportunity to exercise choice, control and the continuation of a life long interest and established routines. Service users confirmed that friends and relatives are always made welcome and they received visitors frequently. It was noted that people from the local area wave as they go by the home. This creates a warm inclusive atmosphere Yew Tree House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 Page 13 that was clearly welcomed by service users who appeared happy and relaxed in their surroundings. Service users were generally complimentary of the meals. The home offers locally purchased food, freshly prepared and cooked. Some comments received prior to the inspection spoke of a lack of variety and repetition in the food offered at times. One comment in particular stated that eggs are rarely offered. Meal times are set for practical reasons, but this is flexible to accommodate individual’s wishes and proposed activities. Service users are able to choose where to eat their meals. Some prefer to dine in their rooms but the majority choose to join fellow service users in the dining area. Yew Tree House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Service users can be confident that complaints and concerns would be listened to, taken seriously and acted upon. EVIDENCE: The home has a policy for dealing with complaints and records those received. No complaints have been received by the home since the last inspection. Service users were confident that the home took their welfare seriously and any concerns would be investigated and resolved quickly. The home has adult protection procedures and a whistle blowing policy for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of service users. The manager demonstrated a clear understanding of adult protection procedures and to whom to refer allegations of abuse to without delay. Yew Tree House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 23 24 25 26 Service users live in clean comfortable surroundings where they could have familiar belongings to help them feel at home. EVIDENCE: Those parts of the home inspected were clean, tidy and free from unpleasant odours. Service user bedrooms were highly personalised, comfortable and arranged to their taste. New decoration to a bedroom had recently been completed. Work to erect a separate two-storey building at the front of the current premises continues. Completion is scheduled for February 2006. The exterior pathways and rear garden had been cleared of the majority of hazards noted during the last inspection. A greenhouse and glass panels await removal. The manager explained future plans for additional parking spaces; a safe walkway and a secure fenced garden area for service users to enjoy in this area. One access pathway to the rear garden situated to the left of the building is to be gated and access restricted to staff only. The area currently Yew Tree House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 Page 16 stores the homes waste bins, recycling boxes and redundant household items. The pathway to the right of the premises will provide safe passage to the rear garden for service users and visitors. Small sections of this pathway have recently been repaired. The manager is keen to enhance the security and safety of the home. It was seen that safe systems are in place for the duration of the building work to ensure service users safety. The laundry room, which is small and somewhat cramped, contains a domestic washing machine with no sluicing facility, a tumble dryer and a sink unit. Soap and hand towels were available for staff use. The manager has plans to install a washing machine with a sluicing cycle in June 2006 to ensure that infection control is appropriately addressed in the home. The Fire Officer had visited to discuss the homes revised fire procedures and risk assessments for the remaining duration of the current building work and to advise the home on the practice of locking the external fire door in the laundry room. The Fire Officer stated that the laundry fire door is not included in the homes evacuation plan and can therefore remain locked. Fire risk assessments and revised procedures were said to be satisfactory. No written evidence at the time of inspection could be provided of the Fire Officers statements and advice. Thermostatic mixer valves have been fitted to hot water outlets on baths. Temperatures of bath water prepared for each service user prior to immersion are kept. Hot water temperatures exceed 43 degrees in hand washbasins in service user areas. No weekly temperature records or actions taken by the home to reduce the risk are currently maintained. An action plan had been prepared by the manager to install thermostatic mixer valves to sinks in July 2006. Radiators in the home have been fitted with guards in all areas to which service users have access. The manager spoke of plans to remove the fire hearth in the service users communal lounge/ dining area to allow for additional living space. Work was said to be scheduled for April 2006. Use of the upstairs bedrooms are limited to service users who are physically able, as no shaft or stair lift is installed. The manager explained that the possibility of installing a chair lift had been investigated with the Fire Officers help. Discussions were said to have confirmed that limited space does not allow for this to be a viable or safe option in the current accommodation. Corridors in the home are of normal domestic width and would be un-suitable for wheelchair users. Careful management and review of service users offered bedrooms on the upper floor and those who might require a wheelchair due to decreasing mobility is undertaken by the home. The practice ensures all Yew Tree House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 Page 17 service users continue to freely access all areas of the home and the facilities offered. Previous building work plans discussed with the CSCI 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 DS0000024096.V263925.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 29 30 The relationship between staff and service users is good and creates a supportive and caring atmosphere in which they can feel comfortable, Closer monitoring of the timely application and receipt of Criminal Record Bureau Checks would protect service users from the potential risk of abuse. EVIDENCE: Service users and their families spoke well of staff and thought they worked hard. Comment cards received prior to the inspection included the statements: • “Staff have a lively sense of humour and do not become dramatic. A balance has been struck with just enough security and ease of access.” • “I am very happy here…Lovely staff, so friendly and courteous.” • “Excellent hard working staff, thankful for them.” Care staff are responsible for the residents personal washing and all the domestic duties in the home. There are two part time staff employed for catering. No agency staff are used by the home. Staffing rosters seen did not clearly show in what capacity staff were rostered and did not include hours worked by the registered manager. New staff are required to undertake induction. A staff training record document was seen. Pre inspection documentation listed staff training events Yew Tree House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 Page 19 planned by the manager for early 2006. A training matrix is however not maintained to give a clear overview of what training staff have completed, events being planned and training update requirements. No awareness training in dementia or challenging behaviour has been listed as undertaken. In view of the homes registration and mental frailty of some service users and the associated behaviours discussed, individuals would benefit from staff being trained in this specialist area. Recruitment processes were discussed with the managers. Pre inspection documentation showed that the home was not in possession of CRB checks for all staff as was previously stated to CSCI. The manager said that two had been applied for and were in the post. Two others had not been applied for as the individuals undertook only minimal working hours. Another staff member had a police check undertaken in another country. Whilst it is acknowledged that the manager knows the individuals involved personally and trusts them implicitly and the inspector is not questioning their integrity and suitability. The current situation does not evidence that the home offers a satisfactory level of safety and protection for people living there that legislation demands. This must be addressed as a priority. The manager stated the intention of applying for CRB and POVA register checks for the staff discussed immediately. The manager is aware that current staffing structure and levels will require revision if additional services are registered by the CSCI on the existing site. Yew Tree House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 35 37 38 Whilst service users can be confident that the quality of their care and welfare is promoted by the philosophies and approach of the home, the effectiveness of some organisational aspect of the home is currently not reliably consistent to fully protect their safety and welfare. EVIDENCE: The Registered Manager and owner of Yew Tree House has worked for many years in a management role and has a wealth of experience in service provision. The trainee manager has recently completed work for the Registered Managers Award and awaits external verification of the qualification. Service users and relatives said they considered the managers to be approachable, understanding and supportive. Yew Tree House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 Page 21 Staff records complied with regulations, except where CRB and POVA checks for some members of staff were not in evidence, as mentioned elsewhere in the report. The manager described how service users and their relatives were asked for their views about the service and spoke of a recent quality assurance exercise which concerned food offered to service users. The manager said a very positive response was received that will inform future planning. Copies of the results were not provided to the CSCI. Some comments received prior to the inspection spoke of items of food not being regularly offered and menus which lacked variety of choice. Service users themselves or their relatives managed their finances. Service users relatives did not express any concerns about the homes management of monies or valuables held on service users behalf. The home has recently reviewed all policies to ensure they complied with current legislation and good practice guidelines. Records and other sensitive documentation were seen to be stored in a manner that preserved privacy and confidentiality. A development plan for 2006 was seen to address environmental aspects both in the home and grounds that have been mentioned elsewhere in the report. The Oxford bath hoist, used for service users in the downstairs bathroom, had a recorded last service date of more than eighteen months ago. This exceeds the accepted period for safety assurance on this type of lifting equipment. The manager was to check this. The home already undertakes many of the individual aspects required to meet the demands of HACCP procedures. The trainee manager said this work is to be consolidated into a procedure document. Records are to be maintained as suggested by the Environmental Health Officer. The home has no Legionella risk assessment and no evidence of monitoring and control measures. The manager stated the intention of seeking advice and implementing the necessary measures to be taken. Fire risk assessments and procedures had been revised in light of the current building work taking place. A fire drill had been undertaken in November 2004. Following the last inspection report the CSCI received no action plan from the manager to show how the home would meet statutory requirements awarded for identified breaches of legislation. This was discussed with the manager. Where it is necessary, receipt of an action plan is expected by the CSCI following the homes receipt of the draft report, as part of the normal inspection process. Yew Tree House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 Page 22 Yew Tree House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 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 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 2 3 3 2 2 STAFFING Standard No Score 27 2 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X 2 2 Yew Tree House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? YES 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 OP10 Regulation 12(4)(a) 16(2)(c) Requirement Timescale for action 27/02/06 2 OP27 17(2) sch. 4(7) “The registered person shall make suitable arrangements to ensure the care home is conducted in a manner, which respects the privacy and dignity of service users.” In that: Privacy screening in the double bedroom extends halfway across both service users shared living space. The limited available space and lack of screening has the potential to compromise standards of privacy and dignity. Action plan for resolution to CSCI within given timescale above. (Previous timescale of October 14th 2005 not met.) “The registered person shall 27/02/06 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.” In that: The staff roster must be comprehensively maintained to show which staff are on duty, during the day and night and in DS0000024096.V263925.R01.S.doc Version 5.0 Yew Tree House Residential Care Home For The Elderly Page 25 3 OP26 23 (2) (k) what capacity. Cover arrangements must be recorded, as must the working hours of the registered manager when part of the rostered staff team. Action completed by given timescale. (Previous timescale of October 14th 2005 not met.) “The registered person shall 27/02/06 having regard to the number and needs of the service users ensure that any necessary sluicing facilities are provided”. In that: The manager should fulfil the stated intention of installing a washing machine with a sluicing facility in light of, the client group registered, the limited sluicing resources in the current laundry and to ensure infection control is fully addressed at the home. Action plan to CSCI by given timescale. “The Registered Person shall not 27/02/06 employ someone to work at the care home unless they are fit to work at the care home and they have obtained in respect of those persons, the information and documents specified in schedule 2.” In that: The home must obtain satisfactory CRB/POVA checks for all staff employed. “The registered person shall 27/02/06 having regard to the size of the home and the number and needs of service users ensure that at all times suitably qualified, competent and experienced persons are working at the home in such numbers as are appropriate for the health and welfare of service users and to ensure that staff employed receive training appropriate to the work they are to perform.” DS0000024096.V263925.R01.S.doc Version 5.0 Page 26 4 OP29 19(1)a,b, i,sch.2(7) 5 OP30 18(1)(a) (c) (i) Yew Tree House Residential Care Home For The Elderly 6 OP37OP38 17(3)b,13 (4)a,b,c 7 OP22 23 (2) (c) In that; In view of the homes registration, the particular needs of service users and the associated behaviours staff deal with, awareness training in dementia and dealing with challenging behaviour must be planned. Action plan to CSCI within agree The registered person shall 27/02/06 ensure that records required by regulation/ schedule are available in the home for inspection. In that: There were no records of hot water temperatures to wash hand basins or records of the actions taken by the home to secure service users 27/02/06 “The registered person shall having regard to the number and needs of service users ensure that equipment provided at the home for use by service users or persons who work at the care home are maintained in good working order” In that Information provided to the inspector showed that the Oxford bath hoist had a last recorded service date of June 2004. Action to be taken and completed by given timescale. 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 OP9 OP15 Good Practice Recommendations It is recommended the home purchase a controlled drug register to further improve pharmaceutical standards. It is recommended that the home should further consult DS0000024096.V263925.R01.S.doc Version 5.0 Page 27 Yew Tree House Residential Care Home For The Elderly with service users with a view to offering a choice of meals that is varied and to their taste. 3 OP19 It is strongly recommended that the home continues to closely monitor the rear garden and walkways and maintains them free from hazards to service users safety. In addition, the stated aim of removing the dismantled greenhouse structure and glass from the rear garden should be fulfilled. It is recommended that the future use of the shared bedroom should be reconsidered with service users offered sole use of the room unless they have made a positive informed choice to share. It is strongly recommended a training matrix be used so as to readily identify training courses attended, identify staff training planned and staff in need of updates. It is recommended that results of quality assurance surveys are published and made available to current and prospective service users, their representatives and other interested parties. Copies should be sent to the CSCI. It is recommended that the manager fulfil the stated intention of installing thermostatic mixer valves to wash hand basins to ensure service users safety. It is recommended that the home develop HACCP procedures and records as suggested by the Environmental Health Officer. It is strongly recommended that advice received from the Fire Officer regarding agreement to the home locking the laundry fire door and the inadvisability of installing a suitable chair or passenger lift in the current accommodation is evidenced in writing to the CSCI. It is strongly recommended that a Legionella risk assessment is undertaken and the home records evidence of monitoring and control measures taken. 4 OP23 5 6 OP30 OP33 7 8 9 OP38 OP38 10 OP38OP37 Yew Tree House Residential Care Home For The Elderly DS0000024096.V263925.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 DS0000024096.V263925.R01.S.doc Version 5.0 Page 29 - 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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