Inspection on 15/11/05 for Yew Tree Lodge

This inspection was carried out on 15th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Yew Tree Lodge 15/04/08

Yew Tree Lodge 13/11/06

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 15th November 2005 9:45 15/11/05 Yew Tree Lodge DS0000011256.V250286.R01.S.doc Version 5.0 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.V250286.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 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.V250286.R01.S.doc Version 5.0 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.V250286.R01.S.doc Version 5.0 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. 10th May 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. Yew Tree Lodge DS0000011256.V250286.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which was conducted over a morning and early afternoon period for a duration of 5 hours. 4 Service users were spoken to and all staff members on duty were seen in private. A small range of records were seen and discussion took place with the Deputy Manager. What the service does well: What has improved since the last inspection? What they could do better: Professional and equal relationships within the staff team should be promoted and sustained. Yew Tree Lodge DS0000011256.V250286.R01.S.doc Version 5.0 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Yew Tree Lodge DS0000011256.V250286.R01.S.doc Version 5.0 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.V250286.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No standards under this heading were inspected on this occasion. EVIDENCE: Yew Tree Lodge DS0000011256.V250286.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 Service users are supported to take risks as part of an independent lifestyle. EVIDENCE: There was evidence from talking to service users and staff that the management of risks is viewed as an integral part of the service. Risk assessments were clear and focussed. There was some updating required which was noted by the Deputy Manager. In order to assist the management team in monitoring paperwork the inspector recommended that consideration be given to the introduction of an internal management audit tool which would help in identifying deficits in recording and reviewing. Service users provided evidence of their increasing independence with the support of staff. One service user was working and attending a range of leisure facilities, whilst another was preparing to leave the home. It was noted that the smaller residents meetings which had been found to be more successful were not being held on a regular basis. The inspector was informed that it was the responsibility of Team Leaders to arrange these meetings. If these meetings are to be valued by service users staff need to place a priority on scheduling them. Yew Tree Lodge DS0000011256.V250286.R01.S.doc Version 5.0 Page 10 Yew Tree Lodge DS0000011256.V250286.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 & 16 Service users are encouraged to be part of the local community. The rights of service users are promoted and the responsibilities are recognised and reinforced. EVIDENCE: Evidence for these standards was provided mostly from talking to the service users who were present in the home during the course of the inspection. All service users spoken to had regular commitments throughout the week including attendance at day facilities, learning opportunities, work placements and leisure pursuits. It was the aim of all service users spoken to that they would move on from the home at some point in the future. All service users have responsibilities for various cleaning and domestic duties within the home. All those service users spoken to were happy with the extent of those duties and were aware of the need to maintain daily living skills. Staff spoken to understood the need to assist service users with maintaining and enhancing skills which would be required if fully independent living was to be achieved. Yew Tree Lodge DS0000011256.V250286.R01.S.doc Version 5.0 Page 12 Yew Tree Lodge DS0000011256.V250286.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 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. EVIDENCE: A full examination of the medication storage in this home was not undertaken on this occasion. However, extensive discussion with the Deputy Manager, which, concentrated on the arrangements for those service users who self medicate took place. The nature of this home provides for support for service users to regain or learn more independent ways of living. Therefore managing ones own medication is promoted and supported by staff. Several service users were managing their own medication to various degrees. Records were seen which supported this activity together with risk assessments which were updated regularly. It was noted that the in-house training record for medication training for staff was not being used. It will be recommended that this tool is utilised for all future in-house staff medication training. Yew Tree Lodge DS0000011256.V250286.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Service users feel their views are listened to and acted on. EVIDENCE: The complaints record was seen because at the last inspection it was noted that records were not adequately maintained. The inspector found that records were now clearly maintained and individual complaints were easy to access. Service users indicated that they always felt able to approach staff if they had a concern or a query. Yew Tree Lodge DS0000011256.V250286.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No standards were inspected under this heading on this occasion. EVIDENCE: Yew Tree Lodge DS0000011256.V250286.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 & 36 Service users’ individual and joint needs are met by appropriately trained staff. Service users would benefit from a united and cohesive staff team. EVIDENCE: Evidence was obtained from talking to the Deputy Manager and from perusal of staff training records. The inspector was informed that the records were in the process of updating which would result in easier access. The Deputy Manager was aware that considerable updating for most of the staff team was overdue with regard to much of the basic training. A training officer had been appointed to cover the two homes in Reading and arrangements were in hand to ensure that all staff were brought up to date. The Deputy Manager reported that progress had been made with regard to NVQ training. She was due to commence NVQ 4 training and 2 Team Leaders were due to commence NVQ 3 courses. It was evident from talking to staff that there were divisions within the team which had resulted in some discontent and dissatisfaction. It was clear that some discord had resulted from the perception that the manager was favouring certain staff. The inspector will address these issues directly with the manager.. Yew Tree Lodge DS0000011256.V250286.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 & 42 Service users are confident their views underpin all self-monitoring, review and development by the home. The health, safety and welfare of service users are promoted and protected. EVIDENCE: Regular service user surveys are undertaken to obtain the views of service users and to provide feedback on the service. The inspector could not see the results of a survey undertaken in October 2005 because the paperwork was with Head Office for analysis. It has already been mentioned elsewhere in this report that residents meetings are a useful way of obtaining regular service user feedback. The home is encouraged to promote more regular residents meetings. Health and Safety records were seen. It was noted that comprehensive records are maintained however, the fire risk assessment was overdue for review and there is a need to record in-house fire training in a more detailed manner. A review of risk assessments should be undertaken to ensure they Yew Tree Lodge DS0000011256.V250286.R01.S.doc Version 5.0 Page 18 remain relevant. Yew Tree Lodge DS0000011256.V250286.R01.S.doc Version 5.0 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Yew Tree Lodge Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X 3 X DS0000011256.V250286.R01.S.doc Version 5.0 Page 20 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. Standard Regulation Requirement Timescale for action 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 3 4 5 6 7 Refer to Standard YA8 YA42 YA42 YA42 YA9 YA36 YA20 Good Practice Recommendations To review system of residents meetings to ensure they occur on a regular basis. Record the content of in-house fire training for all staff. To review and update fire risk assessment. Undertake a review and update current risk assessments. Consider introduction of an internal management audit tool to monitor record keeping. Consider the implementation of a seniors meeting to address discontent. To implement the use of the medication training and competency record. Yew Tree Lodge DS0000011256.V250286.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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 Lodge DS0000011256.V250286.R01.S.doc Version 5.0 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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