Inspection on 13/11/06 for Yew Tree Lodge

This inspection was carried out on 13th November 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Yew Tree Lodge 15/04/08

Yew Tree Lodge 15/11/05

Yew Tree Lodge 10/05/05

Yew Tree Lodge 04/11/04

Yew Tree Lodge 24/06/04

Similar services:

21 High Street

Vale House

Chestnut Walk

The Old Vicarage

Cherwood House Care Centre

Ashley House

Ascot Nursing Home

Fountain View

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

CARE HOME ADULTS 18-65 Yew Tree Lodge 17-19 Redlands Road Reading Berks RG1 5HX Lead Inspector Sally Newman Unannounced Inspection 13th, 14th & 16th November 2006 09:15 Yew Tree Lodge DS0000011256.V318561.R01.S.doc Version 5.2 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 Lodge DS0000011256.V318561.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 Adults 18-65. 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 Lodge DS0000011256.V318561.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Yew Tree Lodge Address 17-19 Redlands Road Reading Berks RG1 5HX 0118 931 3534 0118 931 3529 manager.yewtreelodge@careuk.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Care (UK) Mental Health Partnerships Limited Mr Derek Bouldin Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Yew Tree Lodge DS0000011256.V318561.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can provide a service to one named respite service user over the age of 65. 15th November 2005 Date of last inspection Brief Description of the Service: Yew Tree Lodge is registered to provide care for adults (18-65yrs) with mental health issues. Accommodation is in single rooms with full en suite facilities and both male and female residents are eligible for admission to the home. Yew Tree Lodge provides personal care to residents to meet all identified needs as assessed. This means supporting individuals to do as much as they are willing and able to do for themselves and to provide help in those areas in which individuals have identified needs. Individual care is planned and delivered following a comprehensive assessment of need which involves the resident, their family/representative/advocate and other health professional who knows the individual. Fees range between £865 and £1036 per week. This includes accommodation, food and laundry. Yew Tree Lodge DS0000011256.V318561.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an annual inspection, which was conducted over the course of 4 days and included a visit to the home of 5¼ hours duration. The deputy manager assisted the inspector with the inspection and demonstrated competence and professionalism. 5 staff were spoken to in private and 6 service users provided their views to the inspector. A range of records was seen and information provided prior to the visit by the service was used in the formulation of this report. In addition, a service user survey was undertaken by the Commission and of 16 surveys 7 completed questionnaires were returned. Verbal feedback was provided following the site visit and a follow up telephone discussion was held with the manager. The manager has been in post since August 2006. A handover was arranged with the previous retiring manager. Already there was evidence that the new manager had made a positive impact on the running of the home. Both service users and staff spoke highly of her approach and management style. There was a positive sense about prospects for the future of the home. Developments have included major works including the installation of a new roof, extensive redecoration and a programme of furniture replacement. A significant number of records had been reorganised and will be ongoing. Activities and opportunities for outings had been increased which all service users spoken to welcomed. During feedback to the manager it was apparent that she was well aware of where deficits in the home existed and where her efforts needed to concentrate. The home is already considered to be good but the prospects for improvement are considered to be high. What the service does well: This service provides a good standard of care for its service users. The standard of staff training is high. The standard of home cooked food provided in the home is very good. Yew Tree Lodge DS0000011256.V318561.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 Lodge DS0000011256.V318561.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Yew Tree Lodge DS0000011256.V318561.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users’ needs and aspirations are appropriately assessed prior to a place being offered. EVIDENCE: Evidence was provided from discussion with the deputy manager, service users and care plans. There is a robust assessment procedure for all prospective service users which involves visits to the prospective service users by either the manager or the deputy manager. These visits are conducted either in the service user’s own home or in hospital. The interview is designed to ascertain whether the service can meet the needs of the individual. The prospective service user is encouraged to participate in the process and to determine their aspirations and goals. Documentation is completed at this time that is then used as the basis for the care plan. A service user who was in the home for a week’s respite care confirmed that he had been visited prior to his admission to the home. Yew Tree Lodge DS0000011256.V318561.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ assessed and changing needs are documented in care plans. Service users are encouraged and supported to make decisions. Risk taking is seen as an essential part of an independent lifestyle. EVIDENCE: Evidence was obtained from perusal of care plans, from discussion with the deputy manager and staff and from service users. Six care plans were seen. These documents have been reorganised and has made accessing information much easier. New documentation has been introduced and key workers are in the process of using the new formats for all service users presently resident in the home. Information seen provided an overview of each service user’s needs and regular reviews and updates were in evidence. A new format has been introduced which is designed to capture Yew Tree Lodge DS0000011256.V318561.R01.S.doc Version 5.2 Page 10 salient information for feedback to formal Care Programme Approach meetings and ensures that any staff attending have the necessary information to hand. Four staff members were spoken to in private. Each provided a sound understanding of the philosophy of the service and the importance of supporting service users in making decisions about their lives and aspirations. It is accepted that the aim of the home is to enable all service users to eventually move on to independent living. Therefore staff understood that their role was to support service users to maintain and enhance skills associated with daily living. Risk assessments were in evidence within care plans. Formats are used to capture information and to determine the action required to minimise the identified risks. In some instances, with the agreement of the service user, restrictions are placed upon them. For example, the allocation of cigarettes or money can be monitored to safeguard a service user who is inclined to over indulge thereby rendering themselves without money or cigarettes. Service users are encouraged to take managed risks in order to move forward and develop. Staff spoken to demonstrated a sound understanding of the positive impact that encouraging managed risks can have on service users. Yew Tree Lodge DS0000011256.V318561.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged and supported to attend activities and to be part of the community. Appropriate relationships are supported and rights and responsibilities are promoted. The food provided is of a high standard. EVIDENCE: Evidence was obtained from discussion with staff, service users the deputy manager and from care plans. Service users are encouraged to attend a range of activities outside of the home and in accordance with their needs and wishes. Service users spoken to confirmed that they attend a range of community facilities including day centres, leisure centres, college and pubs, restaurants etc. On some care plans weekly activity charts detailing programmes of activities were in Yew Tree Lodge DS0000011256.V318561.R01.S.doc Version 5.2 Page 12 evidence. Since the new manager has been in post service users and staff confirmed that a variety of activities had been arranged involving service users. These included a day trip to Bournemouth, a trip to a Christmas pantomime and parties over the festive season. It was apparent that those service users spoken to were enthusiastic about the prospect of more outings and activities. One service user survey did indicate that they would like the opportunity to attend more activities both within and outside the home. The deputy manager informed the inspector that it was being proposed that an activities organiser be appointed to co-ordinate activities, which would include accompanying service users to medical appointments. All service users are encouraged to maintain relationships outside of the home. In discussion with service users it was apparent that a variety of family members are visited on a regular basis according to the individual’s particular circumstances. Appropriate friendships are also encouraged and supported. The revised care plans included an information sheet, which included details of all significant parties and their contact details. Service users are responsible for keeping their kitchen areas and bedrooms clean and tidy. Rotas are in place for a variety of domestic duties including cooking and preparing for meals. These are developed with individual needs in mind. There are now regular residents meetings which have been timed to facilitate maximum attendance. Minutes of these meetings are maintained and are made available to all residents. Overall the food provided in the home was described by service users as good. The deputy manager confirmed that only fresh ingredients are used in meals and everything is home cooked. Service users are encouraged to cook for themselves and with staff assistance can purchase food which is then prepared in the small kitchens sited throughout the home. Yew Tree Lodge DS0000011256.V318561.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive appropriate support and their health care needs are met. Service users are protected by the service’s policies and procedures for dealing with medicines. EVIDENCE: Service users are asked about the support they wish to receive. Due to the nature of the home very little is required with regard to personal care other than prompts. Currently there are no males on the staff team. However, the inspector was informed that a male staff member is due to commence employment at the home which will provide service users with greater choice with regard to their support needs. The manager has introduced full health screening for all service users and it is hoped that all service users will have received this service within the near future. This initiative has resulted in several significant health care needs being identified and appropriate treatments being secured. There is close Yew Tree Lodge DS0000011256.V318561.R01.S.doc Version 5.2 Page 14 liaison with community psychiatric services and all service users receive visits from various professionals. The arrangements for medication have been reviewed by the manager. In response new storage arrangements are to be implemented and competency assessments for all staff as supplied by the provider organisation are to be commenced. There are arrangements for those service users assessed as appropriate for self-medicating. The manager is currently reviewing these systems to ensure that they are robust and protect all service users. Yew Tree Lodge DS0000011256.V318561.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are confident that their views are listened to and acted upon. Service users are protected from abuse, neglect and self-harm. EVIDENCE: Evidence was provided from talking to service users, staff and the deputy manager and from the perusal of records. There are now regular residents meetings where service users are encouraged to raise issues and ideas. All service users have an allocated key worker from within the staff group who they can speak to about concerns or worries. In addition there are formal processes for review to which service users contribute and where necessary changes to the care plan can be made. The complaints procedure is robust and information is now provided in all bedrooms which includes information to guide service users if they are not happy with something. The complaints record included 2 complaints where information about the investigation and outcome were not made clear. These complaints pre-dated the appointment of the current manager. The manager undertook to review the system operating within the home to ensure that complaints are recorded and stored appropriately. Service users spoken to indicated that they would speak to either their key worker or the manager if they were not happy about anything. All stated that they were confident that action would be taken as a result of them raising concerns. Yew Tree Lodge DS0000011256.V318561.R01.S.doc Version 5.2 Page 16 All staff receive training in protection of vulnerable adults issues. This training is updated on a regular basis. Staff spoken to demonstrated a sound understanding of the principles of protecting vulnerable adults and were clear about what action they would take should an allegation or suspicion arise. There are clear procedures in place when a service user is at risk of self-harm which are linked to comprehensive risk assessments. Yew Tree Lodge DS0000011256.V318561.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable and safe and provides a homely environment for service users. The home is clean and hygienic. EVIDENCE: Evidence was provided from a tour of the premises, from discussion with the deputy manager and from records. During the site visit the home was undergoing redecoration of the hallways, stairwells and office. A new roof has been fitted since the last inspection of the home. The home is visited weekly by a handyman who undertakes small repairs and maintenance. The inspector was informed that all soft furnishings were due to be replaced following an intensive fire safety inspection which identified that some furniture was not fire retardant. As bedrooms become vacant redecoration is undertaken as needed. Yew Tree Lodge DS0000011256.V318561.R01.S.doc Version 5.2 Page 18 The home throughout was seen as clean and tidy. Service user surveys indicated that the home is usually or always clean and fresh. Shared space on each floor is the responsibility of service users to keep clean. However, a domestic is employed to ensure that standards of cleanliness are maintained. The laundry facilities were seen. Industrial standard facilities are available for service users to use with support from staff if required. Yew Tree Lodge DS0000011256.V318561.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by well trained staff and they are protected by the home’s recruitment policies and practices. EVIDENCE: Evidence was obtained from discussions with staff, the deputy manager and from records. The staff group as a whole are well trained. Training is provided for all staff in a range of areas with the expectation that regular updates are attended. Staff spoken to thought highly of the range and quality of training provided by the company. Recent courses attended include medication, POVA and managing challenging behaviour. Future training includes person centred planning and one staff member advised that she had suggested some sort of counselling training would be beneficial for staff. A programme of NVQ training is in place with all staff being encouraged to undertake at least level 2. Four staff have undertaken level 3 NVQ training and the deputy manager was working towards Yew Tree Lodge DS0000011256.V318561.R01.S.doc Version 5.2 Page 20 level 4. It was noted that no written record of induction training was being undertaken whilst the company reviews its induction requirements for new staff. It will be recommended that a recording system be implemented in the interim to ensure that written records reflect all the areas addressed for new staff. Three staff files were seen which included the most recently employed staff. All documentation required by regulation was in evidence. It was noted that a recruitment checklist and a record of interview are maintained. Yew Tree Lodge DS0000011256.V318561.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home is well run and the ethos encourages service users to express their views. The health, safety and welfare of service users are promoted and protected. EVIDENCE: The manager has been in post since August. She has now applied for registration. It was clear from discussions with both staff and service users that she is highly regarded and has made a positive impact on the home. Staff spoken to felt that their views were welcomed and that they now had greater participation in the running of the home. Service users were also complimentary and quoted the improvements to the decoration of the home Yew Tree Lodge DS0000011256.V318561.R01.S.doc Version 5.2 Page 22 and the increase in opportunities for activities and outings as particularly welcomed. Service users spoken to felt that their views were sought and that they are provided with opportunities to express their opinions on the day to day running of the home. The deputy manager advised that attendance at the residents meetings had improved. A formal annual survey of service users’ views is undertaken in the form of questionnaires which service users are invited to complete. A recent survey had been undertaken but the results had not yet been collated. Health and safety checks are undertaken regularly throughout the home and include fire safety checks and appliance checks and servicing. Water temperatures are monitored and fridge and freezer temperatures are recorded. All staff are trained in health and safety matters and regular updates are provided. A new fire safety risk assessment had been undertaken since the last inspection. Risks and hazards throughout the home have been identified and risk assessments are in place to manage those hazards considered to be significant. The inspector was informed of a theft from the safe in the home which had not been reported to the Commission. The manager undertook to inform the Commission in writing as a matter of urgency and apologised for the oversight. It will be a requirement that such incidents are formally notified to the Commission in the future. Yew Tree Lodge DS0000011256.V318561.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 Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Yew Tree Lodge DS0000011256.V318561.R01.S.doc Version 5.2 Page 24 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 YA42 Regulation 37(1)(f) Requirement To notify the Commission of any theft in the home. Timescale for action 14/11/06 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 YA35 YA22 Good Practice Recommendations To consider introduction of recording for induction training within the home. To ensure complaints are recorded appropriately including details of investigation and outcomes. Yew Tree Lodge DS0000011256.V318561.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Lodge DS0000011256.V318561.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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