Inspection on 15/04/08 for Yew Tree Lodge

This inspection was carried out on 15th April 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Yew Tree Lodge 13/11/06

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 Berkshire RG1 5HX Lead Inspector Jill Chapman Unannounced Inspection 15th April 2008 11:00 Yew Tree Lodge DS0000011256.V360986.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.V360986.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.V360986.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Yew Tree Lodge Address 17-19 Redlands Road Reading Berkshire 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 Susan Carol Reeves Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Yew Tree Lodge DS0000011256.V360986.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. 13th November 2006 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. The home currently has 5 respite care beds and the rest are long stay. Fees per week range between £720 for long stay beds to £900 for respite beds. This includes accommodation, food and laundry. Yew Tree Lodge DS0000011256.V360986.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 11am and was in the service for 4 ½ hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. On the site visit discussion took place with service users, staff and the acting manager. Records relating to care, staff and health and safety were sampled. The premises were looked at. What the service does well: The home makes sure it can meet service users needs before they go to live there. Service users get the chance to try out the home before they decide to live there. Service users are involved in their care planning and these are being developed to be more person centred. Service users are encouraged and supported to attend activities and to be part of the local community. They are supported to maintain appropriate friendships and relationships and to be aware of their rights and responsibilities. Service users are supported to eat healthy and regular meals. Service Users receive appropriate support and their healthcare needs are met. Yew Tree Lodge DS0000011256.V360986.R01.S.doc Version 5.2 Page 6 Service users are protected by the services’ policies and procedures for dealing with medication. Service users are confident that their views are listened to and acted upon. They are protected from abuse, neglect and self-harm. The home is comfortable and safe and provides a homely environment for service users. It is kept clean and hygienic. Service users are supported by confident, trained staff and are protected by the homes recruitment policy. The home is well run and the ethos encourages service users to express their views. The health and safety of service users is promoted and protected, by the homes policies and procedures. What has improved since the last inspection? What they could do better: A written record of respite service users assessments would show that they are carried out. Written care plans and risk assessments would show that the needs of respite service users are carried out. Written risk assessments would show that all risks associated with bathing or showering have been considered. Development of a mandatory programme of Mental Health training would make sure that all staff are fully equipped to meet service users mental health needs. There is not always evidence that monthly Regulation 26 visits are carried out to keep the Registered Provider informed of the conduct of the service. Yew Tree Lodge DS0000011256.V360986.R01.S.doc Version 5.2 Page 7 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.V360986.R01.S.doc Version 5.2 Page 8 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.V360986.R01.S.doc Version 5.2 Page 9 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&4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A robust admissions procedure makes sure that long stay service users needs and aspirations are fully assessed prior to them being offered a place in the home. Further documentation of respite care admissions will show that their needs are fully assessed prior to staying in the home. EVIDENCE: Evidence was provided from pre inspection information (AQAA), surveys, discussion with the acting manager and from sampling assessment documentation. Referrals are made via the Community Mental Health Team and pre assessment paperwork helps the home decide if they can meet the new service users needs. Following that an Initial Assessment is carried out with the service user, home manager and care-coordinator. Assessments include finding out if service users have any cultural or religious needs. Assessment documentation was sampled and shows that the home carries out a written assessment for permanents residents but in the case of respite residents the assessment is not documented. It is recommended that respite care admission Yew Tree Lodge DS0000011256.V360986.R01.S.doc Version 5.2 Page 10 assessments be fully documented to show that their needs are fully assessed prior to staying in the home. Pre placement visits and a four-week trial period give the service user the chance to test-drive the home. 100 of service user surveyed said they were given a choice about coming to the home and enough information to help them decide to live there. One said ‘I was shown around before deciding to come here’, Another service user surveyed said ‘I am very glad to be in Yew Tree Lodge as a permanent resident, I have improved greatly since my admission’ Yew Tree Lodge DS0000011256.V360986.R01.S.doc Version 5.2 Page 11 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, 8 & 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. Development of care plans and risk assessments for respite care service users would show that their identified needs are being met. Service users are encouraged and supported to make choices and decisions. Risk taking is seen as essential as part of an independent lifestyle. Development of bathing risk assessments will evidence that this risk area has been fully assessed. EVIDENCE: Evidence was provided from surveys, pre inspection information (AQAA), and discussion with the acting manager, staff on duty and a sample of care files. The AQAA shows that staff are being trained in person centred care planning to enable service users have more input into their day to day care. Staff Yew Tree Lodge DS0000011256.V360986.R01.S.doc Version 5.2 Page 12 spoken with were enthusiastic about the development of person centred care planning and could see how it would benefit service users. The care files of three permanent and one respite care service users were seen. These were well organised and kept up to date. Care plans are in place and are reviewed monthly or on a needs basis. There was evidence of service users involvement in their care planning and some had signed that they agreed their care plans. It was noted that for respite care service users the home does not draw up care plans but uses the Care Programme Approach Care plan and referral documentation provided by the care manager. It is recommended that the home develop working care plans and risk assessments to evidence the areas of support given by staff for the duration of the stay. A number of respite care service users have regular or more than one stay at the home and so care plans could be reviewed at each new admission. None of the current service users have any specific cultural or religious needs at present but the home has an excellent resource file to help them understand the needs of other cultural groups. Prayer beads and a prayer mat have been ordered in case they are needed for future residents. Service users are encouraged to make choices and residents meetings are held monthly. Information on advocacy services is available. 40 of service users surveyed said they always, 10 said usually and 50 said they sometimes make decisions about what to do each day. One said ‘I go out, watch TV, smoke, help with the dinner and have my tablets in the morning’ Risk assessments highlight if choice needs to be limited to ensure safety or well being. All service users manage their own finances and but the home has a system for the safekeeping of personal money for those who need this support. Files sampled show that risk assessments are carried out for risks to individuals and these include those associated with mental health and support needs. The current risk assessment process does not specifically identify the risks associated with bathing. As service users are mostly independent and most have en suite facilities, it is strongly recommended that individual bathing risk assessments are developed to include the risks of falling, scalding and drowning. Yew Tree Lodge DS0000011256.V360986.R01.S.doc Version 5.2 Page 13 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, 14, 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 local community. Service users are supported to maintain appropriate friendships and relationships and to be aware of their rights and responsibilities. Service users are supported to eat healthy and regular meals. EVIDENCE: Evidence was provided by pre inspection information (AQAA), surveys, discussion with the acting manager and service users. The AQAA states that the home provides sufficient staffing levels to support service users with activities, job opportunities and daily life skills. This was verified in discussion with staff and service users. In house activities include TV, DVD and board games and access to an Arts and Crafts room in another Care UK service in the area. Some service users attend formal activities at local day resources and others prefer to take part in less formal activities such Yew Tree Lodge DS0000011256.V360986.R01.S.doc Version 5.2 Page 14 as church events, shopping, swimming and watching Reading Football Club at ‘home’ matches. The home has a welfare budget, which is used to fund day trips to seaside resorts and a river cruise. Service users spoken with said they enjoyed and looked forward to these outings. Some service users have been on holidays to France and one said he was planning a trip to ‘Centre Parks’ in the Lake District. Visitors are welcome in the home between the hours of 8.30 am and 10pm. Service users spoken with told how staff support them to maintain contact with their families and of regular visits to their relatives homes. It was clear from speaking with staff and service users that there is choice and flexibility in daily routines. This is balanced with the need to give some service users a more structured lifestyle to regain a healthy and independent lifestyle. Service users are encouraged to carry out their own personal care, laundry and room cleaning. They receive their own post and staff will help them deal with this if needed. The arrangements for food help promote independence; service users prepare their own breakfast and lunch in their shared kitchenettes. Staff and service users cook the evening meal in the main kitchen. Menus seen were varied and healthy and include a vegetarian alternative. It was seen that further choices are offered if service users say that neither is suitable. The home carries out food surveys with service users to gain their views and to develop the menu. There is a Development (notice) Board in the hallway that is kept up to date with articles on healthy eating, health and lifestyle information and service users confirmed that they make use of this information. The home does not currently need to provide for specific religious or cultural dietary needs but has demonstrated that these could be met if needed. Service users spoken with said that they enjoyed the meals provided. One service user surveyed said ‘I wish I could cook for myself more’. Yew Tree Lodge DS0000011256.V360986.R01.S.doc Version 5.2 Page 15 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 healthcare needs are met. Development of a mandatory programme of Mental Health training would make sure that all staff are fully equipped to meet service users mental health needs. Service users are protected by the services’ policies and procedures for dealing with medication. EVIDENCE: Evidence was provided by pre inspection information (AQAA), surveys, records sampled, discussion with staff and service users. The AQAA states that service users are involved in the setting up and review of their care plans and this was seen on files sampled. Key workers work with service users regarding their support needs, care plans and meeting their religious beliefs. Staff spoken with were confident in the key worker role and Yew Tree Lodge DS0000011256.V360986.R01.S.doc Version 5.2 Page 16 service users confirmed the support they get from their key workers. The home has policies and procedures to protect service users privacy. These are only overridden for safety reasons. The acting manager said that the home has developed a good working relationship with Reading and Wokingham Community Mental Health teams. During the course of the inspection a care manager carried out a regular visit to a service user. A health care file is kept for each service user that records health care appointments and outcomes. There was good evidence of the monitoring of health care needs; for example weight charts and eating risk assessments were seen on files sampled. The Development Notice Board shows that staff keep service users up to date on health issues. All staff attend a two day Basic Mental Health course that gives staff an overview of Mental Health issues and illnesses. The manager and acting manager have accessed some other Mental Health training for staff locally. In discussion with staff and the acting manager it was found that the organisation has not formally identified mandatory Mental Health training for staff in the home. This should be developed to provide more detailed training relating to the illnesses that affect service users and make sure that all staff are fully equipped to meet the mental health support needs of the service users and to ensure the health and safety of service users and staff. The home has an appropriate system for the storage and administration of service users medication. The Commissions Pharmacy inspector carried out an inspection of this on 9th January 2007 and made three good practice recommendations relating to the filling of dosette boxes, returning unwanted medication and staff training. These have all been carried out. Yew Tree Lodge DS0000011256.V360986.R01.S.doc Version 5.2 Page 17 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 pre inspection information (AQAA), surveys and speaking to staff and service users. The Commission has not received any information about complaints made about the service. No complaints have been received by the home in last 12 months. There is a Complaints procedure and record in place. As recommended from the last inspection the complaints record has been reorganised to make sure it demonstrates appropriate investigation and outcome. 100 of service users surveyed said they knew who to talk to if they are not happy and how to make a complaint. One said ‘Staff have told us we can talk to any staff at any time’ In discussion with service users said they said they know who to talk to if they have a concern. The home keeps a ‘Grumble’ book in the hallway where service users can air day-to-day views and this is reviewed daily. Staff were aware of the Complaints procedure and what to do if they receive a complaint. Yew Tree Lodge DS0000011256.V360986.R01.S.doc Version 5.2 Page 18 The AQAA stated that staff are trained in POVA and there are procedures in place. Staff confirmed their training and were aware of how to protect service users from potential abuse. The Commission has not received any information about any safeguarding referrals relating to the service. The home has appropriately made one Safeguarding Adults referral in the last 12 months. Yew Tree Lodge DS0000011256.V360986.R01.S.doc Version 5.2 Page 19 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 pre inspection information (AQAA), discussion with service users and the acting manager and a tour of the premises. There is an ongoing programme of refurbishment and replacement is underway. This was evidenced in a tour of the premises during the site visit. Furniture and furnishings are being updated, communal flooring is being replaced and some bedroom carpets. En-suites are due to be replaced over the coming months. Bedrooms seen were of a good size and all but one is ensuite. Some service users have purchased their own bedroom furniture and all have the opportunity to personalise their rooms according to their taste. The home and garden are well maintained by a maintenance man who is employed Yew Tree Lodge DS0000011256.V360986.R01.S.doc Version 5.2 Page 20 35 hours per week. Records show that essential maintenance and servicing of equipment is carried out. The acting manager said that the garden is well used during the summer months and service users and staff are planning a vegetable patch in the garden. In line with current legislation and in consultation with service users the home has reviewed the area that service users can smoke. This has changed from the conservatory to an outside covered area. Service who were using this area during the day said they were satisfied with these new arrangements. The layout of the home enables male and female bedrooms to be separate and there are male and female kitchenettes on the 1st and 2nd floor. There is choice for the sexes to mix together in the communal lounge and dining rooms and smoking areas. Service users spoken with were pleased that the kitchenettes gave them independence and flexibility in preparing hot drinks, breakfast and lunch. The home was found to be clean and hygienic and the AQAA states that cleaning schedules are in place. The home has a domestic staff but the post is currently vacant. The home is kept clean by the staff and service users. Infection control training is mandatory for staff and necessary hygiene equipment is supplied. 100 of service users surveyed said that the home is always fresh and clean Yew Tree Lodge DS0000011256.V360986.R01.S.doc Version 5.2 Page 21 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, 33, 34 and 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 confident, trained staff and are protected by the homes recruitment policy. EVIDENCE: Evidence was provided by pre inspection information (AQAA), sampling of staff records and discussion with staff and the acting manager. The AQAA states that the home has good staff ratios, and up to date training. Staff deployment was confirmed on the site visit, there are two support staff on daytime shifts plus one support staff on duty between 9am and 5pm. The manager and deputy are additional to shift unless they have to fill in for unplanned absences or annual leave. There are two waking night staff. Service users confirmed that they receive the support they need. Team leaders carry out a mentoring role. There are monthly staff meetings and two monthly team leader meetings. The AQAA states that previous team problems have been worked on, staff communication has improved and the Yew Tree Lodge DS0000011256.V360986.R01.S.doc Version 5.2 Page 22 team has gelled. Staff were positive about the communication and morale in the team. They were clear about their roles and responsibilities. Staff confirmed that they had completed mandatory training and other training relating to their role. Evidence of this and their induction was seen on staff files sampled. As recommended from the last inspection, the induction is now recorded, in Skills for Care Workbooks. There is a programme of National Vocational Qualification training in place. 84 have or are taking NVQ and two staff are due to start this. There is a recruitment procedure in place, this was evidenced from speaking to staff, the acting manager and from recruitment records sampled. It was seen that relevant checks and references are carried out before new staff are appointed. It was observed that staff relate positively to service users and 100 of service users surveyed said that staff treat them well. 50 said that staff always, 40 usually and 10 sometimes listen to what they say. One said ‘The staff are always pleasant and easy to approach’ ‘Yew tree Lodge is a very nice place to stay as well as the staff’ Yew Tree Lodge DS0000011256.V360986.R01.S.doc Version 5.2 Page 23 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. The home is well run and the ethos encourages service users to express their views. There is not always evidence that monthly Regulation 26 visits are carried out to keep the Registered Provider informed of the conduct of the service. The health and safety of service users is promoted and protected, by the homes policies and procedures. EVIDENCE: Evidence was provided by pre inspection information (AQAA), records sampled and discussion with staff and the acting manager. The AQAA states that the Deputy Manager is interim acting home manager at present. At the site visit the acting manager confirmed that the registered Yew Tree Lodge DS0000011256.V360986.R01.S.doc Version 5.2 Page 24 manager is acting manager locally for another service owned by Care (UK) Mental Health Partnership. The acting manager has NVQ 4 in Health and Social Care and has enrolled for the Registered Managers Award. Staff were positive about the seamless handover between the manager and acting manager and said they both work to the same goals. It was evident during the site visit that the home is well managed and that the manager and acting manager have worked hard to improve the service since they have been in charge of the home. Regulation 26 visits are carried out, as well as the company’s Clinical Governance audits. It was noted however that not all Regulation 26 reports were in place to show that these have been carried out monthly. There were no reports in place to cover March, June, July, August and September 2007. It is a requirement that Regulation 26 are carried out monthly and copies of reports be made available in the home to evidence this. The views of service users are sought in regular meetings and service users, relative and staff surveys and these then form part of the homes development plan. Service users spoken with confirmed that their views are listened to and acted upon. Annual health and safety training takes place as well as monthly audits of the health and safety procedures. The maintenance man carries out a daily health and safety checklist. The AQAA shows that appropriate policies and procedures are in place and regular safety checks are carried out. Some health and safety records were sampled on the site visit and show that they are up to date. A requirement from the last report, to notify the Commission of any theft in the home has been carried out. Yew Tree Lodge DS0000011256.V360986.R01.S.doc Version 5.2 Page 25 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 3 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 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000011256.V360986.R01.S.doc 3 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Yew Tree Lodge Score 3 2 3 X 3 X 2 X X 3 X Version 5.2 Page 26 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 YA19 Regulation 18(1)a Requirement The registered persons must identify suitable mental health training to make sure that all staff are fully equipped to meet the mental health support needs of the service users and to ensure the health and safety of service users and staff. The registered persons must ensure that Regulation 26 visits are carried out monthly and copies of reports of them be made available in the home to evidence this. Timescale for action 15/07/08 2 YA39 26 15/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA2 Good Practice Recommendations It is recommended that respite care admission DS0000011256.V360986.R01.S.doc Version 5.2 Page 27 Yew Tree Lodge assessments be fully documented to show that their needs are fully assessed prior to staying in the home. 2 YA6 It is recommended that the home develop working care plans and risk assessments to evidence the areas of support given to respite care service users for the duration of the stay. It is recommended that written individual bathing risk assessments are developed to include the risks of falling, scalding and drowning. 3 YA9 Yew Tree Lodge DS0000011256.V360986.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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.V360986.R01.S.doc Version 5.2 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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