Inspection on 12/10/05 for Yew Tree Nursing Home

This inspection was carried out on 12th October 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 Nursing Home 28/06/07

Yew Tree Nursing Home 30/01/06

Yew Tree Nursing Home 29/03/05

Yew Tree Nursing Home 31/08/04

Yew Tree Nursing Home 30/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Yew Tree Nursing Home Yew Tree Place Romsley West Midlands B62 ONX Lead Inspector N Richards Unannounced Inspection 12th October 2005 08:40 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Yew Tree Nursing Home DS0000004156.V252136.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Yew Tree Nursing Home DS0000004156.V252136.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Yew Tree Nursing Home Address Yew Tree Place Romsley West Midlands B62 ONX 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) 01562 710809 01562 710592 Yew Tree Nursing Home Limited Mrs Sharen Ellen Guise Care Home 29 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (29), of places Physical disability (4), Physical disability over 65 years of age (29) Yew Tree Nursing Home DS0000004156.V252136.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. An age limit of 55 - 65 years applies to people with needs in category PD. 29th March 2005 Date of last inspection Brief Description of the Service: Yew Tree Nursing Home is a 29-bedded care home providing 24-hour nurse care. It is situated in Romsley, northwest of Bromsgrove. Located within a “green-belt” area, the home benefits from large, accessible grounds that can be accessed by service users. The home is located on two floors, which are accessed via a central passenger lift, or two staircases. The home provides in-house catering and laundry services. Accommodation and communal space is provided on both floors of the home. The village of Romsley provides local resources (shops, public houses et cetera) that are accessible to service users. Yew Tree Nursing Home DS0000004156.V252136.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 4 hours, and was carried out to examine the homes physical environment and estates-related issues in advance of building work being undertaken to increase the homes potential occupancy level from 29 to 35 residents. A tour of the premises took place and staff and records were inspected. Three staff on duty, one relative and three of the twenty-nine residents were spoken to. What the service does well: What has improved since the last inspection? What they could do better: Opportunity could be taken to further enhance health and safety within the home to further minimise the potential risk of residents sustaining accidental injury through accidental scalding. Yew Tree Nursing Home DS0000004156.V252136.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 Nursing Home DS0000004156.V252136.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Yew Tree Nursing Home DS0000004156.V252136.R01.S.doc Version 5.0 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 the following standard(s): 1 and 2. Residents and their representatives are provided with suitable information prior to admission to ensure that an informed choice can be made. EVIDENCE: The homes Statement of Purpose and Service User Guide are satisfactory and readily available to people – providing residents and prospective residents with details of the services the home provides, and enabling an informed decision about admission, and the suitability of the home to meet individual residents’ needs to be made. The Service User Guide was available in audio format to assist people with vision problems. The home does not contract to provide Intermediate Care. Therefore Standard 6 is not applicable to the home. Residents’ files contain copy terms and conditions of residency (“contract”). The contracts examined were clear and easy to understand. Yew Tree Nursing Home DS0000004156.V252136.R01.S.doc Version 5.0 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 the following standard(s): These Standards were not examined on this occasion. EVIDENCE: These Standards were not examined on this occasion. The Standards in question were fully complied with at the time of the previous inspection in March 2005. Yew Tree Nursing Home DS0000004156.V252136.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Meals are well managed, creative and provide daily variety and flexibility for people living in the home. Contact with family and friends was openly maintained. EVIDENCE: A number of people living in the home were spoken to and everyone who commented on the food said how good it was and that they welcomed the daily choices offered. Menus were inspected and found to be balanced and interesting, and mealtime arrangements are also flexible enough to accommodate individual preferences. The home operated a four-week menu system. The menus demonstrated alternative choices that residents could select from, and a choice of food that had been developed to specifically reflect the preferences of residents. The main meal provided on the day of inspection was a choice between gammon and pineapple or chicken and vegetable pie with cauliflower, broccoli and roast or boiled potatoes. Dessert was lemon meringue. Residents have the opportunity to partake of up to three cooked meals a day. Catering staff demonstrated a detailed knowledge and understanding of individual residents’ dietary preferences and requirements. Yew Tree Nursing Home DS0000004156.V252136.R01.S.doc Version 5.0 Page 11 Care staff were seen providing direct assistance to people with their lunch in a sensitive and relaxed manner. Since the time of the previous inspection, the home has increased its activity organiser input from 15 to 30 hours each week, and a five-day activity programme was available with activities that were specific to the interests and preferences of residents. During the inspection, it was noted that an external facilitator was undertaking a “movement to music” activity with residents. During the inspection, some relatives were seen visiting people, and staff greeted visitors politely. Residents spoken to say that they could receive visitors at any time of the day, thereby maintaining links with family members. Residents confirmed that there were “no restrictions” on visiting. Yew Tree Nursing Home DS0000004156.V252136.R01.S.doc Version 5.0 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 the following standard(s): 16, 17 and 18. Complaints are handled objectively and residents are confident that their concerns will be listened to, taken seriously and acted upon. A vulnerable adults procedure is available to ensure a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has a simple and clear complaints procedure. A copy of the complaints procedure had been given to all residents, and was available to visitors and relatives. Residents spoken to were confident that concerns could be raised with the home. A procedure for responding to allegations of abuse is available. The home promotes residents’ legal right to vote by ensuring that everybody is placed on the register of electors. Residents are given the opportunity to vote during local and national elections through either the use of postal voting or by visiting a local voting booth with the assistance of staff from within the home. The home does not promote any political party. Yew Tree Nursing Home DS0000004156.V252136.R01.S.doc Version 5.0 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 the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Investment within the home continues to ensure that a positive environmental standard is maintained, creating a comfortable and safe environment for those living there and visiting. EVIDENCE: Yew Tree Nursing Home DS0000004156.V252136.R01.S.doc Version 5.0 Page 14 The bedrooms are predominantly single occupancy, and have en-suite toilet facilities. Communal toilets and bathrooms are available throughout the home. Lounge and dining room facilities are provided throughout the home. Systems were in place for the management of infection control, and the home was clean, tidy and free from offensive odours. Each bedroom seen had been furnished with residents’ personal possessions, thereby generating ownership and a sense of autonomy for individuals. The standard of the environment within the home is satisfactory, providing residents with an attractive and homely place to live. Residents confirmed that they appreciated the physical environment. To a certain extent, the home is a victim of its own success in as much as, due to the high occupancy levels (currently 100 with a waiting list), the redecoration of bedrooms is difficult once they become vacant. The inspector was shown one bedroom that had been redecorated and re-carpeted over a weekend period to ensure that a new resident could take up occupancy on the Monday morning. The standard of the décor was impressive given the very tight timescale available for the purposes of redecoration. Hot water temperatures have been risk assessed and had been regulated to prevent people being accidentally scalded when they have a bath, and radiators had been guarded and restricted to prevent people being accidentally burnt through intentional or unintentional contact All the windows located above first floor level had been restricted to prevent people from being injured through falling out of the windows (accidentally or deliberately). After a period of approximately two years, the home has successfully attained planning permission to build a single-storey extension to the rear of the building. The extension will provide a further seven bedrooms, and enable the home to accommodate a further six residents. Building work is planned to start at the end of October 2005, and should last for approximately 30 weeks. A third party with experience of care home development will undertake the management of the building work. Several areas within the home have floor coverings that need replacing due to fatigue, and some bedrooms would benefit from the provision of replacement furnishings. The home has already identified these issues and is ready to implement a replacement programme. Opportunity was taken to discuss one internal lounge area located within the central part of the home. The lounge has no external windows, and it is suggested that this area is reviewed with consideration given to widening the adjacent corridor and making the area an open-plan sitting area to enhance usage by residents and visitors. Yew Tree Nursing Home DS0000004156.V252136.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Staffing levels and competencies are suitable to ensure that residents’ needs are identified and effectively met. EVIDENCE: There were suitable nursing and care staff on duty to provide care and support for the 29 people who were resident in the home at the time of inspection. In addition to nursing and care staff, there were also ancillary staff on duty to support service provision. During the visit, call bells were activated, and staff responded speedily to them. The duty rotas confirmed that the staffing levels were stable, with little evidence of staff being absent through short-term sickness. Agency usage was minimal. Training has been provided to staff, and includes infection control, first aid and moving and handling. Training was identified as a result of the needs of residents, to ensure that care delivered was appropriate to and in response to the needs of residents. Many staff had undertaken and completed National Vocational Qualification Level 2, and at the time of the inspection, almost half of the care staff within the home had been trained to NVQ level 2 or 3. A further five staff are to commence NVQ level 2. Once these staff have Yew Tree Nursing Home DS0000004156.V252136.R01.S.doc Version 5.0 Page 16 completed their training, the home will exceed the Standard relating to staff qualification. There is a qualified first-aider on duty throughout the entire 24-hour period. At the time of inspection, five of the staff on duty held a first aid certificate. Yew Tree Nursing Home DS0000004156.V252136.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34 and 38. There is clear leadership, guidance and direction to staff to ensure residents receive consistent care, resulting in practices that promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: The registered manager is competent and appropriately qualified and experienced to manage the service. Staff and residents spoke very highly of her, and significant diligence and action has been undertaken to maintain and further improve the quality of the service provided by the home since the time of the previous inspection. Residents clearly expressed their opinion that the home was being run in their best interests. The home is undertaking regular quality assurance exercises on various aspects of the homes functioning to ensure that (a) quality is maintained and Yew Tree Nursing Home DS0000004156.V252136.R01.S.doc Version 5.0 Page 18 (b) to improve standards whenever possible – thereby enhancing residents’ quality of life and well-being. The home ensures that it does not become involved in the management of residents’ finances. It is the unofficial policy of the home to promote residents’ financial independence by enabling residents to manage their own finances, where applicable, or facilitate advocacy services to manage residents’ finances on their behalf. The registered manager proficiently promotes and safeguards the health and safety of staff and residents within the home. Maintenance and service contracts are in place in relation to; (a) (b) (c) (d) The homes electrical and gas systems, The passenger lift, Mobile hoists and Water systems (including the control of legionellae) All radiators are suitably guarded to prevent accidental injury through contact burns, and all baths are fitted with thermostatic mixer valves (TMVs) to prevent residents sustaining accidental injury through scalding. Although TMVs are used, staff were not testing and recording the water temperatures when baths were being used. This action will ensure that, should the TMVs fail, staff can identify (and rectify) the problem at an early stage. The home audits accident records every three months. When patterns are identified, action is taken to reduce or eliminate accidental occurrences. Yew Tree Nursing Home DS0000004156.V252136.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 X X X 2 Yew Tree Nursing Home DS0000004156.V252136.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? No 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 38 Regulation 12(1)(a) Requirement Water temperatures must be tested and recorded when residents are bathed. Remedial action must be taken if water temperatures exceed 44°C. Timescale for action 12/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Yew Tree Nursing Home DS0000004156.V252136.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Nursing Home DS0000004156.V252136.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. 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