Inspection on 15/11/05 for Yews Hill

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 Poor. 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Yews Hill 30/10/07

Yews Hill 06/11/06

Yews Hill 18/01/06

Yews Hill 17/11/04

Yews Hill 22/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Yews Hill 77 Yews Hill Road Lockwood Huddersfield West Yorkshire HD1 3SG Lead Inspector Alison McCabe Unannounced Inspection 15th November 2005 11:55 Yews Hill DS0000026331.V268360.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 Yews Hill DS0000026331.V268360.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. Yews Hill DS0000026331.V268360.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Yews Hill Address 77 Yews Hill Road Lockwood Huddersfield West Yorkshire HD1 3SG 01484 430329 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) Bridgewood Trust Limited Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Yews Hill DS0000026331.V268360.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th November 2004 Brief Description of the Service: Yews Hill is a care home providing care and accommodation for twelve adults with learning disabilities. It is owned by the Bridgewood Trust, a voluntary organisation providing a range of services to people with learning disabilities. The home is located in Lockwood, a suburb of Huddersfield. It is close to a bus route and there are a small number of community facilities in the area. The home is purpose built over two floors. All service users have single bedrooms and there are good communal facilities in the home and a large garden that is shared with the home next door, North Rise. The Bridgewood Trust also owns North Rise. Yews Hill DS0000026331.V268360.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted between 11.55am and 5.55pm by one inspector. The inspector had the opportunity to meet with service users, staff, the manager and service manager. A tour of the communal areas and two service users’ bedrooms was conducted, and records were sampled. Service users spoken to said they were happy at the home and that they liked the staff. Service users looked well cared for. The findings of the inspection are generally positive. A new manager has been appointed since the last inspection and there has been a period of settling in and adjustment. The manager demonstrated a clear sense of direction and leadership. What the service does well: What has improved since the last inspection? Service users are offered a choice of meals. A menu using photographs of food is being made to help all service users make a choice about what they would like to eat. Records of fire alarm testing have improved. Temperature regulators have been fitted to the showers so that service users are not scalded. Yews Hill DS0000026331.V268360.R01.S.doc Version 5.0 Page 6 What they could do better: 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. Yews Hill DS0000026331.V268360.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 Yews Hill DS0000026331.V268360.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): EVIDENCE: Not assessed on this occasion. Yews Hill DS0000026331.V268360.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): 6 Some areas of individual care plans are clear and detailed whilst some areas require further development. EVIDENCE: Two individual plans were examined as part of the inspection. Since the last inspection, care staff have completed personal support plan assessments with service users. These provide good detail about how service users’ needs are to be met. It was noted that not all areas had been completed in full. The information from the assessment is transferred onto a daily support needs plan. Some of this information was clear and easy to follow, however some information on the support plans was contradictory to the information in the assessment. This was discussed with the manager who explained that staff were still in the process of learning how to use the new systems correctly. Yews Hill DS0000026331.V268360.R01.S.doc Version 5.0 Page 10 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): 12,13,14,15,17 Service users are offered opportunities to access community facilities on a regular basis. This includes day services, educational facilities and leisure pursuits. Service users receive good support to enable them to maintain links with their families. Service users are offered a healthy diet and say that they enjoy their meals. EVIDENCE: Service users attend a range of day services, some of which are provided by the Bridgewood Trust. Two day care officers are employed to support service users at home on days that they do not attend day services. There was evidence in the records examined that service users are supported to access a range of community activities. Staff and a service user spoken to as part of the inspection confirmed this. Service users contribute to the cost of a vehicle that is regularly used for accessing the community. Yews Hill DS0000026331.V268360.R01.S.doc Version 5.0 Page 11 Service users have access to a range of leisure activities both in and outside of the home. Most service users have their own TVs, stereo and other activities in their bedrooms. Service users are supported to maintain links with family and friends. This was confirmed by service users, staff and within records examined. Staff were observed to support a service user to understand when he would next be seeing his family. Menus were inspected and demonstrated that a varied and nutritionally balanced diet is offered to service users. Two cooks are employed to work at the home on a part time basis. A record is kept of service users’ likes and dislikes. Service users do not have many opportunities to participate in food preparation and cooking, although the manager reported that there has been an increase in opportunities offered to make snacks and drinks. Service users take responsibility for setting the tables and clearing up after meals, with appropriate support from staff. The manager reported that service users are now offered a choice of meals, which is positive. The cook is in the process of compiling a menu made up of photographs of food to enable all service users to make a choice about what they would like. Yews Hill DS0000026331.V268360.R01.S.doc Version 5.0 Page 12 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 Storage of medication is good at this home. Administration and recording of medication needs to improve. EVIDENCE: Only staff that have received ‘Boots’ medication training administer the medication. Since the last inspection, the manager has introduced a system for counting in and recording medication received into the home. Upon checking medicines kept against the records, it was noted that not all medication could be reconciled with the corresponding records and action must be taken to address this matter. It was positive to note however that medication is checked against the medication administration records on a regular basis making it easier to pinpoint when errors have occurred. For those services users that require their medication during the day and attend day services, there is a system in place whereby medication is given to the escort who comes to collect the service users. Records in this area need to improve; there was no record of amount of medication given to the escort, dose to be given or any record of who the medication had been handed to. A number of service users are written up for as required medication (PRN). Clear written guidance must be available to staff to enable them to make a Yews Hill DS0000026331.V268360.R01.S.doc Version 5.0 Page 13 judgement about when this medication should be administered. This was raised at the previous inspection. At the previous inspection, concerns were raised in respect of PRN medication being given to a service user to manage challenging behaviour when there was no evidence of agreed behaviour management techniques having been implemented. It is positive that since the last inspection de-escalation techniques have been used successfully resulting in the medication no longer being used. Medication is stored securely at this home. Yews Hill DS0000026331.V268360.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): EVIDENCE: Not assessed on this occasion. Yews Hill DS0000026331.V268360.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): 24,30 Service users live in a clean, comfortable home that has adequate private and communal space. Some repairs/adaptations are necessary in order to maintain the standards in the home. EVIDENCE: The inspector had the opportunity to view all communal areas of the home and two service users’ bedrooms. Each service user has a single occupancy bedroom with a wash hand basin. There are sufficient toilets and bathrooms on both floors of the home. There is a large, well-maintained garden to the rear of the property that is shared with the home next door; this is also a care home operated by the Bridgewood Trust. There is a large sitting room with a dining room off that service users can use. All areas were clean and free from unpleasant odours. Some items of furniture in the sitting room looked worn and need to be replaced. The inspector was informed that it had been several years since the communal areas on the ground floor had been decorated. There should be a rolling programme of renewal and redecoration in place. It was noted that the lock to the upstairs toilet was broken and this must be repaired to ensure the privacy of service users is maintained. A service user told the inspector that he liked his bedroom and had everything he needed. Yews Hill DS0000026331.V268360.R01.S.doc Version 5.0 Page 16 Water temperatures were sampled and found to be at the recommended level. The manager stated that temperature regulators had been fitted to the showers as required at the last inspection. The shower trays in both shower rooms are set quite high from the floor. The occupational therapist has recommended that the ground floor shower is adapted so that service users with mobility difficulties can access this safely. A recommendation is repeated regarding this matter. The home has adequate systems in place for the disposal of clinical waste. Yews Hill DS0000026331.V268360.R01.S.doc Version 5.0 Page 17 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): 32,35 In general, staff and service users have positive relationships. Relevant training is provided to staff. More staff need to be qualified in NVQ level 2 or above in care. EVIDENCE: Most of the interaction between staff and service users was positive. Since the last inspection, a new manager has been recruited. She is still in the process of getting to know service users and staff. The manager is working with the staff team to improve their understanding of challenging behaviours displayed by service users and positive ways of responding to this. Generally, service users appeared to be relaxed in the company of staff. Of eleven care staff, including two senior carers, day care staff and night staff, four have achieved NVQ level 2 or above. Both senior carers are in the process of completing NVQ level 4, one carer is completing NVQ level 3, and two carers are in the process of completing NVQ level 2. The manager and service manager confirmed that the home would not have achieved the recommended 50 of all care staff with NVQ level 2 or above by the end of 2005, however the organisation is working towards achieving this standard. A recommendation has therefore been repeated in this matter. Yews Hill DS0000026331.V268360.R01.S.doc Version 5.0 Page 18 The home has a comprehensive training plan, and training needs are identified through the annual training needs assessment. All new staff complete the learning disabilities award framework induction and foundation training. Yews Hill DS0000026331.V268360.R01.S.doc Version 5.0 Page 19 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): 37,42 This home does not have a registered manager and the provider must address this. The acting manager is experienced and is working towards the necessary qualification. The home is maintained in line with safe working practices. EVIDENCE: The new manager is still to apply to CSCI to become the registered manager of the home. The manager is currently working towards the registered managers award and stated that she had completed four units towards this, although the assessor has signed none off as yet. The manager has had previous management experience and has worked with people with learning disabilities prior to coming to this home. The provider must arrange for the acting manager or other appointed person to submit an application to the CSCI for registration and a requirement has been made in respect of this. Records regarding health and safety matters were in good order. There was evidence in the records that the required checks and maintenance of safety equipment is carried out. The fire alarm is tested weekly as required, and staff Yews Hill DS0000026331.V268360.R01.S.doc Version 5.0 Page 20 are recording which point has been checked each week as recommended at the last inspection. Fire training is delivered to staff at least every twelve months. Yews Hill DS0000026331.V268360.R01.S.doc Version 5.0 Page 21 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 X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Yews Hill Score X X 1 X Standard No 37 38 39 40 41 42 43 Score 1 X X X X 3 X DS0000026331.V268360.R01.S.doc Version 5.0 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) Requirement Timescale for action 20/12/05 2 3 YA24 YA37 The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. 23(2)(b)(c) The lock to the upstairs toilet must be repaired. 8(1)(a) The provider must arrange for the acting manager or another appointed person to apply to CSCI to be the registered manager. 20/12/05 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA24 YA27 Good Practice Recommendations Further development of care plans is necessary to ensure that all aspects of service users’ health and welfare needs are described in sufficient detail. The home should explore how recommendations made by the Occupational Therapist in relation to the height of DS0000026331.V268360.R01.S.doc Version 5.0 Page 23 Yews Hill 3 YA32 shower trays can be addressed. 50 of care staff (including agency staff), should have achieved NVQ level 2 or above by 2005. Yews Hill DS0000026331.V268360.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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. 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