Inspection on 15/08/05 for Yew Trees

This inspection was carried out on 15th August 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 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 Trees 22/05/09

Yew Trees 05/04/07

Yew Trees 10/01/06

Yew Trees 22/03/05

Yew Trees 03/07/04

Yew Trees 02/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Yew Trees Off Long Lane Chadderton Oldham OL9 8BR Lead Inspector Michelle Haller Announced 15 August 2005 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 Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Yew Trees Address Off Long Lane Chadderton Oldham OL9 8BR 01616816204 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 Karen McCarley Susan Fitton CRH Care Home 16 Category(ies) of OP Old Age - 16 registration, with number of places Yew Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 Service users to include up to 16 OP. Date of last inspection 22nd March 2005 Brief Description of the Service: Yew Trees Rest Home is a comfortable residential home registered to provide for 16 older people over two floors. The home is situated within walking distance of convenience stores, take-away restaraunts and a video rental shop. The garden area is easily acessible and pleseantly landscaped with raised beds and planted pots. The accommodation consists of 12 single rooms, eight of which have en-suite facilites and two double rooms. Bathing and toilet facilties are adapted to meet the needs of the service users. There is a choice of two large lounges and a dining room. Yew Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The report relates to an announced inspection completed in one day, over a period of 10.15 hours. Over the course of the inspection a tour of the home was undertaken, five service user files where examined, participation in discussions with six service users individually and in a group, discussion with three relatives, the district nurse, an employee of the local authority and an advocate from Age Concern. In addition, one member of staff was interviewed. During the day the interactions between service users, staff, relatives and other visitors to the home were also observed. Reports, records, files and other documents pertaining to the care and support of service users and the running of the home were also examined. From these observations it is possible to conclude that the home provides a good level of physical and emotional care, employing staff who are well trained, well supervised and caring. The manager listens to service users and their representatives and leads by providing a good example to staff. What the service does well: Yew Trees provides information and opportunities for potential service users to make an informed choice about moving into the home. The manager ensures that sufficient information is received about service users prior to their admission into Yew Trees. Following admission, the manager ensures that additional assessment of all aspects of the service users’ needs and wishes is completed, demonstrating a keen interest meeting psychological as well as physical needs. The service has a good relationship with nurses, doctors and other health care and social service professionals. This assists in maintaining a good standard of health and social support, when required, for service users. Staff support and training is excellent. Opportunities for learning new skills and updating practice is regularly provided and fully funded. Yew Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 Page 6 The home is comfortably furnished and provides an environment that helps to maintain the independence of service users for as long as possible. The manager of the home is approachable and interested in the lives of the service users. Positives comments from service users and their representatives included: ‘I have no complaints whatsoever’; ‘The staff are very attentive and show great patience. My father is overwhelmed by their kindness, communication has been excellent to date.’ ‘The home is very supportive- there is a family atmosphere here.’ ‘My family can come and see me at any time.’ ‘The girls are really kind - we’re looked after very well.’ What has improved since the last inspection? What they could do better: The home could be cleaner if a plan of maintenance was developed which included the deep cleaning of all equipment and areas in the home and a plan for replacing stained and worn-out carpet in one of the corridors. The task of covering all radiators to safeguard service users must be completed. The CSCI should be provided with a copy of the refurbishment plans for the home. The home’s quality monitoring system should be more fully developed. Yew Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 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. Yew Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 Page 8 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 Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 Page 9 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) 1, 2, 3, 4 & 5 Service users have sufficient information to make informed decisions prior to moving into Yew Trees. A contract concerning residency at Yew Trees is provided to all service users. Service users are only admitted following completion of a comprehensive care needs assessment. The home states that it will meet the needs of service users. Prospective service users and their representatives are able to visit the home prior to admission. Yew Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 Page 10 EVIDENCE: Evidence for this announced inspection was gained from examination of six service user files, discussion with service users, their representatives and staff, and examination of records, reports and other documents concerning the running of the home. Nine comment cards were received, eight from service users and one from a general practitioner. The home’s Statement of Purpose was found to contain adequate information about the philosophy of care, staffing, facilities and services available at Yew Trees. All service user files contained signed contracts detailing the specific services and condition of residency. The contract also indicated that admission was initially on a trial basis of one month. Service user files also contained comprehensive pre-admission assessments completed by the referring agency or the home’s manager. When interviewed, service and relatives stated that they had the opportunity to visit the home prior to taking up residency. Yew Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 Page 11 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 & 11 The health, personal and social care needs for all service users are set out in care plans. The health needs of service users are fully met. The medication policies and procedures are safe. Service users are treated with respect and their dignity and rights are upheld. EVIDENCE: In the course of this inspection six service user files were fully examined. Detailed care plans had been prepared for all service users. These care plans provided sufficient instruction to staff in how to meet the needs of service users. Files also contained records, reports and correspondence confirming routine and specialist health checks and treatment was provided when required and in line with relevant guidelines. Care plans were reviewed on a monthly basis. Yew Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 Page 12 Comment cards returned by district nurses and one GP confirmed that appropriate health care is received in the home. Discussions with service users and their representatives also indicated that health care is of a good standard. All staff who administer medication have received appropriate training. Examination of the medication guidelines, the medication record sheets and observation of medication being administrated indicated that home’s system is safe. Discussion with service users, relatives, a representative from social services and an advocacy agency confirmed that service users were treated with respect and their rights respected. All examinations take place in private and service users could receive guests in private. Observation of staff and service user interaction throughout the day and the positive manner in which reports concerning service users were written also supported these findings. The admission process into the home includes information about the service user’s final arrangements. Discussion with the manager confirmed that all care and support is provided in the home at this time and certificates confirmed that staff had attended training about caring for a person who is dying. Yew Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 Page 13 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) 12, 13, 14 & 15 Service users live in a home with flexible routines, providing a lifestyle that meets their preferences and expectations. Contact with family, friends and the local community is encouraged and maintained. Service users are supported in exercising control over their lives. Mealtimes in the home are varied and meals are wholesome. EVIDENCE: Service users, their representatives and staff stated that routines such as mealtimes, getting up and going to bed, bath times, outings and activities were flexible. All those interviewed confirmed that visiting could take place at any time. Yew Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 Page 14 Staff stated that they are encouraged to support service users to go out individually, however it was difficult to identify the activities in which service users participated. Discussion with relatives and service users indicated that efforts were made to maintain the social skills of service users and to prevent or alleviate boredom. Everyone interviewed stated that staff were routinely given the opportunity to sit and talk with and develop a positive relationship with service users. Activities such as reminiscence games, bingo, entertainers, reading the paper and arts and crafts did occur in the home, and services users stated that they could choose whether or not to participate. Comment was made that there were not many outings, although service users were encouraged to attend local clubs and groups, such as luncheon club and church based activities when possible. Visitors were observed freely attending service users throughout the day. Service users are also encouraged to go out with friends and family. The manager asserted that many service users have retained their own bank accounts and these are managed with support as required. Records demonstrated that meals and snacks were varied, plentiful and wholesome. The menu was varied and included traditional Lancashire dishes such as sausage casserole, mince and onion pie and corned-beef hash. Other meals included chilli-con-carne with garlic bread, pizzas and other less traditional meals. The meal on the day of inspection was cottage pie, carrots, cabbage and cauliflower, followed by rhubarb and custard. It was also noted that hot and cold drinks were offered to all service users throughout the day. Service users stated that there was ‘good food here’. Assessment charts also demonstrated that service users dietary needs were fully assessed and met. The manager and cook are currently completing and NVQ I catering. Meals are served in a pleasant and comfortable dining room. Adapted knives forks, spoons and plates are provided to assist service users in maintaining their independence. Staff were observed supporting service users who required assistance with meals in a caring, patient and dignified manner. Yew Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 Page 15 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, 17 & 18 Complaints are taken seriously. The service users’ legal rights are protected. The home protects service users from abuse. EVIDENCE: The home’s complaints procedure is comprehensive and detailed, informing all concerned of how complaints could be made and the expected response. The service users and their representatives have signed to confirm that the manager has informed them about the complaints procedure. At the time of the inspection no complaints had been received by home; however, service users and their representatives confirmed that any issues they had were quickly resolved. An Age Concern advocate is visiting the home and currently completing ‘life story’ books with service users. In addition to this, she supports service users in exercising their civil rights. Staff have received training in the prevention and detection of adult abuse. Staff who were interviewed were knowledgable about actions and omissions that constitute abuse and confident in the actions they would take if any abuse were to come to their attention. Yew Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 Page 16 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) 19, 20, 21, 22, 23, 24, 25 & 26 Some areas of the home require additional maintenance. The communal areas are accessible and comfortable. There are sufficient lavatories and washing facilities to meet the needs of the service users. Specialist equipment is available for service users. The bedrooms and other private facilities meet the needs of the services users. Not all areas in the home are pleasant and clean. Yew Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 Page 17 EVIDENCE: In the course of this announced inspection a tour of the communal and private areas of the home was undertaken. The gardens are fully accessible and well maintained, allowing easy access to service users. There are two sitting areas and a large dining room. Some furniture in the dining room was worn. The manager stated that she was in the process of developing a refurbishment plan and this would include new dining furniture. The seating and flooring in the lounge area was clean and free from stains and unpleasant odours. The bathing areas were also clean and moving and handling equipment was available for use. Aids and adaptations, such as high toilet seats, grab rails and other portable moving equipment, were observed. While inspecting the bedrooms it was found that although they were furnished to the service users’ specification, many of the en-suite toilets smelled unpleasant. In addition, the carpet in one corridor was ruffled and held an unpleasant smell. The flooring in a number of bathroom and toilet areas was cracked and discoloured. These findings were discussed with the manager who indicated that replacement flooring and deep cleaning would be included in her refurbishment plan. The manager is planning to replace the dining room furniture. The programme of covering all radiators in order to reduce surface temperature continues. Service users were observed accessing all parts of the home independently using Zimmer frames and walking sticks. Staff were also observed offering support to service users in accordance with instructions provided in the care plans. Yew Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 Page 18 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, 29 & 30 Staff are provided in sufficient numbers and skill mix to meet the needs of the service users. Service users’ safety is safeguarded by procedures of the home. The home’s recruitment and selection process provides protection to the service users. Effective staff training is provided to staff. EVIDENCE: On the day of this announced inspection 15 service users were being supported by two care staff and the manager. Ancillary staff, namely, one part-time domestic and a part-time cook, were also on duty. The home’s admin worker was also on site. The staff rota indicated that there were experienced care assistants on duty in sufficient numbers at peak times. The training documentation confirmed that the majority of staff have completed NVQ level 2 and many have commenced level 3. Staff are also completing an NVQ level 1 in catering. ‘Induction into care’ training is provided through Learn Direct. Yew Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 Page 19 Examination of the staff files confirmed that all staff had completed application forms when applying for a post, two references are gained and CRB and POVA checks completed prior to new staff being employed in the home. Staff files also contained records of supervision and copies of an extensive array of training certificates. Training included: prevention of adult abuse; foundation in food hygiene; certificate in essential care practice; working in care and administration of drugs. All staff, including the domestic, are encouraged and expected to engage in NVQ and other certificated training. The manager is actively involved with the local authority’s training unit as a means of accessing up-todate and relevant courses for staff at Yew Trees. Yew Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 Page 20 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, 32, 33, 36, 37 & 38 The manager of Yew Trees is competent and qualified. The ethos of leadership and management is enabling, leading to positive outcomes for service users and staff. The home has not yet fully developed its quality assurance monitoring systems. Staff at Yew Trees are well managed and supervised. The home has adequate recording systems. The health and safety of service users and staff are promoted. Yew Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 Page 21 EVIDENCE: The manager at Yew Trees has recently completed the Registered Manager’s course. Her training record indicated that she kept herself updated by attending courses with her staff or as a means of gaining knowledge that she would cascade to senior staff. Other recent courses completed by the manager included ‘Supervising Staff’ and training regarding being an Appointed Person. The manager is also completing an NVQ in Catering. Staff records confirmed that regular staff supervision was in place and discussion with staff indicated that they felt supervision improved their understanding of the care process. Records of accidents, fire-checks and maintenance of equipment in the home was examined and were up to date. A refurbishment plan is currently being developed and a copy is to be sent to CSCI for examination. The insurance certificate confirmed that adequate public liability insurance was in place. The manager is in the process of developing a quality assurance monitoring system with a specialist agency. Staff have received extensive health and safety training, including moving and handling, food hygiene and fire safety. Staff were observed using aprons and gloves appropriately and, on the day of inspection, safe practice was observed by all staff supporting the service users. Policies and procedures in the home were not fully examined, however they have been found to be satisfactory on previous inspections and health and signage was observed throughout the home. Yew Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 Page 22 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 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 3 3 3 3 2 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 Standard No 16 17 18 Score 3 3 3 3 3 2 x x 3 3 3 Yew Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 19 & 26 Regulation 23 Requirement The registered person must ensure that all parts of the home are kept clean and resonably decorated. The registered person must ensure that all radiators are covered to prevent accidental burning. The registered person must develop a system of monitoring the quality of care in the home that takes into account the opinion of service users, their representatives, staff and other interested parties. Timescale for action 01/01/06 2. 25 13(4) 01/01/06 3. 33 24 01/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Yew Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 2nd Floor, Heritage Wharf Portland Place Ashton-under-Lyne OL7 OQD 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 Trees F54 F04 s5548 Yewtrees an v239510 150805 Stage 4.doc Version 1.40 Page 25 - 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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