Inspection on 25/04/05 for Yew Tree Lodge

This inspection was carried out on 25th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Lodge 20/03/07

Yew Tree Lodge 17/10/05

Yew Tree Lodge 18/10/04

Yew Tree Lodge 14/04/04

Yew Tree Lodge 18/12/03

Similar services:

Springfield House

The Shelley

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 Lodge Stoke Road Hoo Rochester Kent ME3 9BJ Lead Inspector Robert Pettiford Sue McGrath Unannounced 25 April 2005 09:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Yew Tree Lodge H56-H06 S29005 Yew Tree Lodge V222756 250405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Yew Tree Lodge Address Stoke Road Hoo Rochester Kent ME3 9BJ 01634 251312 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Abida Ali Care Home 28 Category(ies) of Dementi - over 65 (11) registration, with number Old age (17) of places Yew Tree Lodge H56-H06 S29005 Yew Tree Lodge V222756 250405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 18 October 2004 Brief Description of the Service: Yew Tree Lodge is a large detached property. The Proprietors live next door and have day-to-day contact with the home, they employ a number of care staff, domestic staff, tea lady and two cooks. The home is situated in a rural setting on the outskirts of Hoo village. There are transport links with Rochester and Strood, and ample car parking to the rear of the building Yew Tree Lodge H56-H06 S29005 Yew Tree Lodge V222756 250405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Inspection at Yew Tree Lodge took place on 25th April 2005 at 9:00am. The Inspectors agreed and explained the inspection process with Mr and Mrs Ali the Registered Providers. Documentation and records were read, including care plans. Time was spent reading a sample of written policies and procedures, reviewing care plans and records kept within the home. A tour of premises was also undertaken. The focus of the inspection was to assess Yew Tree Lodge in accordance to the National Minimum Standards for Older People. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with which did include a number of residents. What the service does well: What has improved since the last inspection? What they could do better: Yew Tree Lodge H56-H06 S29005 Yew Tree Lodge V222756 250405 Stage 4.doc Version 1.30 Page 6 Residents are potentially at risk from abuse due to lack of staff training in Adult Protection and understanding by the management of Adult Protection and POVA (Protection of Vulnerable Adults) Protocols. However despite the improvement in staff training noted since the last inspection, staff still lack skills in important key areas and basic induction training to National Training Organisation specifications has not been carried out within 6 weeks of appointment. 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 H56-H06 S29005 Yew Tree Lodge V222756 250405 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Yew Tree Lodge H56-H06 S29005 Yew Tree Lodge V222756 250405 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Service user can be confident that their needs will be assessed prior to moving in to the home. EVIDENCE: The acting manager confirmed that she visits prospective residents either in their own home or current setting to complete an assessment of needs to ensure the home can meet those needs. The assessments seen were comprehensive and detailed. One service user confirmed that she was visited by someone prior to coming to Yew Tree Lodge and was ‘asked lots of question’. Care management assessments were also seen that provided information on prospective service users who were funded by Social Services. Yew Tree Lodge H56-H06 S29005 Yew Tree Lodge V222756 250405 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 Care plans confirmed that resident’s personal, social care needs and healthcare needs are being met. Residents are protected by the home’s policy and procedures for dealing with medicines and residents are treated with respect and their dignity is upheld. EVIDENCE: Several care plans were viewed and were much improved from the last inspection. Care staff now complete the daily log manually. The care plans were more comprehensive than before and contained detailed information regarding G.P. visits and outcomes; District Nurse visits and visits from the chiropodist. The Optician also regularly visited. Other professional healthcare care visitors included Physiotherapist’s, Dieticians and Community Psychological Nurses. The home has recently had difficulty in obtaining the services of a Dentist. Care plans are reviewed on a regular basis. Some residents spoken to were aware that care plans were written about them and were also aware of the regular reviews. The Acting Manager confirmed that due to the levels of service users with dementia in the home, few were Yew Tree Lodge H56-H06 S29005 Yew Tree Lodge V222756 250405 Stage 4.doc Version 1.30 Page 10 able to participate in the reviews. There was no evidence that any of the resident’s are suffering from any form of pressure sores. One area of concern was that nutritional assessments are not being carried out and this will be a requirement. All of the residents are registered with a local G.P. and the Acting Manager confirmed that the local District Nurse team supports them very well. One couple spoken to said they were happy with the care given at Yew Tree Lodge. Medication administration has also improved since the last inspection with the acting manager following the advice given by the Pharmacy Inspector after the last inspection. Records were seen that confirmed that medication was counted in and the acting manager monitors the system overall. The register for controlled drugs was seen and was found to be in good order. Prescription are requested and then signed by the acting manage prior to being prescribed by the Pharmacist. Nine members of staff are currently completing the accredited course for the administration of medication. Many residents were spoken to and all who were able to do so confirmed that the staff are very caring and kind to then at all times. The inspector noted that staff spoke to the residents in a respectful and courteous manner. Yew Tree Lodge H56-H06 S29005 Yew Tree Lodge V222756 250405 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 Residents receive a wholesome and balanced diet. EVIDENCE: Discussions with many of the resident confirmed that the food was ‘very nice’ and ‘that there was plenty of it’. The cook described how she had written menus but these were not always followed and were often altered to accommodate the resident’s preferences. The daily menu was not displayed and residents spoken to were unsure what they were having for dinner that day. It is recommended that a menu board containing the day’s meals and choices be prominently displayed. The fridges and freezers were seen to contain plenty of food and fresh vegetables were used. The cook confirmed that specialist diets , such as diabetics diets, could be catered for. Staff were seen offering some resident support to eat their meals. The kitchen was clean and tidy. Yew Tree Lodge H56-H06 S29005 Yew Tree Lodge V222756 250405 Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Residents know that their concerns and complaints are taken seriously. However residents are potentially at risk from abuse due to lack of staff training in Adult Protection. EVIDENCE: The inspector viewed a copy of the Home’s complaints procedures. The procedure included details of how to complain, timescales for response and information for referring a complaint to the Commission for Social Care Inspection A copy of the complaints procedure has been provided and explained to service users. The registered provider at time of inspection was unable to find the complaint record file. He confirmed that he would ensure that it was readily available in future. The home has policies and procedures with regard to abuse, but following a review of staff training only a third of the staff have received any Adult Protection training. The last training was provided in June 2004. No other further training is presently planned. Following discussion with senior management it was identified that there was a lack of understanding of the procedures with regard to Adult Protection and POVA (Protection of Vulnerable Adults) Protocols. Yew Tree Lodge H56-H06 S29005 Yew Tree Lodge V222756 250405 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not inspected on this occasion. EVIDENCE: Yew Tree Lodge H56-H06 S29005 Yew Tree Lodge V222756 250405 Stage 4.doc Version 1.30 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28 and 30 Service Users basic needs are met by the staff. However new staff do not receive an adequate basic induction and other staff do not receive sufficient training in important key areas. EVIDENCE: From discussions with the Management, observations and reviewing the staff rotas sufficient staff were on duty at the time of inspection to meet the service users basic needs. The rota indicates that the home provides six staff for the AM shift with five working on the PM/evening. Four waking night staff are also provided. The home benefits from a number of ancillary staff who carry out important duties such as cooking, cleaning and maintenance. Two staff have been awarded an NVQ Level II in Care. Ten staff have started their course on the 8th March 2005. The home has provided training for all staff that administer medication. This is an improvement since the last inspection. The home has in place a staff training and development programme which meets National Training Organisation (NTO) workforce training targets. Yew Tree Lodge H56-H06 S29005 Yew Tree Lodge V222756 250405 Stage 4.doc Version 1.30 Page 15 However on evidence seen by the inspector staff have not received induction training to these NTO specifications within 6 weeks of appointment to their posts. No evidence was available that all longer serving members of staff have received foundation training to NTO specification within the first six months. Whilst it is acknowledged that additional training has been provided to staff since the last inspection on 18th October 2005 many key areas of training had still not been provided. Many of the staff had not received training in Adult Protection, Dementia Care, Manual Handling, First Aid, Challenging Behaviour, and other important areas. The home was requested to address this as a priority. Yew Tree Lodge H56-H06 S29005 Yew Tree Lodge V222756 250405 Stage 4.doc Version 1.30 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,36, and 37 The home should appoint a competent experienced Registered Manager with the management and care skills to address the identified shortfalls in the National Minimum Standards. Service users have benefited from the services of a good acting manager. EVIDENCE: The Acting manager despite not currently having the qualifications to be the Registered Manager has been instrumental in developing the staff team to work towards improving the quality of care since the last inspection. Evidence of her positive contribution towards the home was given by the staff, service users, relatives and visiting healthcare professionals. Effective quality assurance and quality monitoring systems, based on seeking Yew Tree Lodge H56-H06 S29005 Yew Tree Lodge V222756 250405 Stage 4.doc Version 1.30 Page 17 the views of service users, are in place to measure success in meeting the aims, objectives and statement of purpose of the home. Staff have not benefited from regular formal supervision although the Acting manager has supported staff on a day to day basis. Service users have access to their records and information about them held by the home, as well as opportunities to help maintain their personal records. Individual records and home records are secure, up to date and in good order; and are constructed, maintained and used in accordance with the Data Protection Act 1998. Yew Tree Lodge H56-H06 S29005 Yew Tree Lodge V222756 250405 Stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 2 28 2 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 1 2 x 2 x x 2 3 x Yew Tree Lodge H56-H06 S29005 Yew Tree Lodge V222756 250405 Stage 4.doc Version 1.30 Page 19 Yes 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 18 Regulation 13(6) Requirement Timescale for action 25/07/05 2. 27 18(1) 3. 28 18(1C) 13.—(6) The registered person shall make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. 25/10/05 18.— (1) The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users— (a) ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users; 18.— (1) The registered person 25/10/05 shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users— (c) ensure that the persons employed by the registered person to work at the care home receive— Version 1.30 Yew Tree Lodge H56-H06 S29005 Yew Tree Lodge V222756 250405 Stage 4.doc Page 20 4. 31 9(1) 5. 33 24(1) (i) training appropriate to the work they are to perform; 9.—(1) A person shall not 25/07/05 manage a care home unless he is fit to do so. (2) A person is not fit to manage a care home unless— (a) he is of integrity and good character; (b) having regard to the size of the care home, the statement of purpose, and the number and needs of the service users— (i) he has the qualifications, skills and experience necessary for managing the care home; and (ii) he is physically and mentally fit to manage the care home; and (c) full and satisfactory information is available in relation to him in respect of the following matters— (i) the matters specified in paragraphs 1 to 5 of Schedule 2; (ii) except where paragraph (3) applies, the matters specified in paragraph 7 of that Schedule; (iii) where paragraph (3) applies, the matters specified in paragraph 8 of that Schedule. (3) This paragraph applies where any certificate or information on any matters referred to in paragraph 7 of Schedule 2 is not available to an individual becauseany provision of the Police Act 1997 has not been brought into force. 24.—(1)The registered person 25/07/05 shall establish and maintain a system for— (a) reviewing at appropriate intervals, and Version 1.30 Page 21 Yew Tree Lodge H56-H06 S29005 Yew Tree Lodge V222756 250405 Stage 4.doc (b) improving, the quality of care provided at the care home, including the quality of nursing where nursing is provided at the care home. (2) The registered person shall supply to the Commission a report in respect of any review conducted by him for the purposes of paragraph (1), and make a copy of the report available to service users. (3) The system referred to in paragraph (1) shall provide for consultation with service users and their representatives. 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 15 Good Practice Recommendations It is recommended that menus,offering a choice of meals in written or other formats to suit the capacities of all residents, is given, read or explained to residents be provided. Yew Tree Lodge H56-H06 S29005 Yew Tree Lodge V222756 250405 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection The Oast, Hermitage Court Hermitage Lane Maidstone Kent 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 Lodge H56-H06 S29005 Yew Tree Lodge V222756 250405 Stage 4.doc Version 1.30 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!