Inspection on 18/01/06 for Yews Hill

This inspection was carried out on 18th January 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 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 15/11/05

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 18th January 2006 2:30pm Yews Hill DS0000026331.V271252.R01.S.doc Version 5.1 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.V271252.R01.S.doc Version 5.1 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.V271252.R01.S.doc Version 5.1 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.V271252.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2005 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.V271252.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted between 2.30pm and 7.05pm by one inspector. The inspector had the opportunity to meet with service users, staff and managers. Service user and staff records were examined and all communal areas of the home were seen. Service users spoken to as part of the inspection expressed their satisfaction with the service delivered. What the service does well: What has improved since the last inspection? What they could do better: All service users must have an up to date assessment completed before they move into the home. Current care plans need to be developed for all service users. Yews Hill DS0000026331.V271252.R01.S.doc Version 5.1 Page 6 There needs to be more staff qualified to a minimum of NVQ level two in care. 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.V271252.R01.S.doc Version 5.1 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.V271252.R01.S.doc Version 5.1 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): 2 Pre-admission assessments are not always conducted as required. EVIDENCE: Since the last inspection, a service user from the Bridgewood Trust home next door to Yews Hill has been admitted. There was no evidence that an assessment was completed prior to the admission and it is a requirement of the inspection that this be completed prior to service users moving in. Yews Hill DS0000026331.V271252.R01.S.doc Version 5.1 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): 6,7,9 Individual care plans and risk assessments do not address all service users’ needs although this is in the process of being addressed. Service users are supported to make choices. EVIDENCE: Keyworkers are still in the process of completing individual care plans with service users, using the revised care planning system that has been introduced. The care plans of two service users, including the service user most recently admitted, were examined. Good progress had been made in one of the plans, however it was noted that the service user most recently admitted to the home did not have an up to date individual care plan, only the information passed from the previous home. A requirement has been made in respect of this. Further information is necessary about how service users prefer to be supported with their personal care. This is particularly important for those service users who cannot easily communicate their needs. It was positive to note that daily records are now kept in respect of service users making it possible to monitor if service users’ identified needs have been met. The Yews Hill DS0000026331.V271252.R01.S.doc Version 5.1 Page 10 manager anticipates that all service user plans will be completed by the end of February. Service users are supported to take some risks as part of an independent lifestyle; for example, a service user is supported with cooking/baking in the kitchen. Risk assessments are in place in respect of identified risks. Evidence that risk assessments are reviewed was seen in the records. There was evidence that service users are supported to make decisions about their lives. Service users were observed to choose how to spend their evening, when to have a bath, get ready for bed etc. Yews Hill DS0000026331.V271252.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Service users’ rights are respected. EVIDENCE: The daily routines of the home promote individual choice and freedom. Service users have access to all parts of the home with the exception of the office which is kept locked if there are no staff members present. Service users were observed to choose when to spend time alone or in the company of others. Staff were observed to knock before entering service users’ bedrooms. A door bell that activates a flashing light has been installed for a service user with hearing impairment so that he is aware if someone is at his door. Staff were observed to interact with service users some of the time although there were a number of occasions where staff interacted exclusively with each other. This includes staff having their meals together after service users have eaten. The manager reported that this is an opportunity for staff to have a break. It is recommended that this be reviewed so that there is adequate supervision at all times. Yews Hill DS0000026331.V271252.R01.S.doc Version 5.1 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): 18,19,20 Service users are offered sensitive support with personal care. Staff are good at supporting service users to have their healthcare needs met. Medicine management is good at this home. EVIDENCE: Staff were observed to offer personal support discreetly and with sensitivity. Some of the information about how service users prefer to be supported with their personal care was detailed and clear although some areas need more detailed information. A keyworker system is used at this home. Service users spoken to at the time of inspection were aware of who their keyworkers were. Evidence was seen in records that service users are supported to attend healthcare appointments. These included GP, community nursing, psychology and hospital appointments. Records are kept of any health related consultations and appointments. Medication examined was found to tally with records kept. Draft guidelines are in place for the administration of ‘as required’ (prn) medication. Prn medication is now recorded on the medication administration record rather than a separate record, and this is good practice. Yews Hill DS0000026331.V271252.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 A clear complaints procedure is available in the home. Robust procedures are in place to protect service users from harm or abuse. EVIDENCE: A satisfactory complaints procedure is in place containing all the required information. This is also available in symbol format. No complaints have been received at this home in the last twelve months. Through discussion with some service users, it was apparent that they were aware of how to raise concerns and said they would feel comfortable in doing so. Robust procedures for the protection of vulnerable adults are in place in addition to the Kirklees multi-agency guidelines. An adult protection issue raised at the time of inspection was dealt with in accordance with the home’s own policies and procedures. The manager was clear about her responsibilities in this area. Yews Hill DS0000026331.V271252.R01.S.doc Version 5.1 Page 14 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 Service users live in a clean, comfortable home that has adequate private and communal space. EVIDENCE: Communal areas of the home and one service user’s bedroom were seen as part of this inspection. The home was warm, comfortable and free from unpleasant odour. All areas seen were clean and tidy. 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. The lock on the upstairs toilet has been repaired as required at the previous inspection. The manager reported that the recommendation made by the occupational therapist to make the showers more easily accessible had been passed to the senior area manager. This recommendation has therefore been brought forward. Yews Hill DS0000026331.V271252.R01.S.doc Version 5.1 Page 15 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): 32,34 Service users have positive relationships with staff. Around 33 of the staff team are appropriately qualified and a number of staff continue to work towards their NVQ level two. Recruitment practice at this home is generally good. EVIDENCE: Care practice observed was mostly positive. Service users appeared to be relaxed in the company of staff. The inspector observed a staff member make positive attempts to interact with service users using appropriate communication methods. Staff spoken to and observed, demonstrated that they understood the needs of service users. Of twelve care staff, 4 are qualified to NVQ level two in care or above. In addition, five care staff (including senior staff) are working towards levels two, three or four. In order to meet standard 32, 50 of all care staff should be qualified to NVQ level two or above. Recruitment records of all staff were examined. These were found to be in good order containing all the records required by regulation with the exception of an application form and reference being unavailable in respect of the newly appointed cook. The service manager reported that these documents would be available at the organisation’s head office but had not been transferred to the Yews Hill DS0000026331.V271252.R01.S.doc Version 5.1 Page 16 home. The member of staff confirmed that an application form had been completed. It is a requirement of the inspection that staff recruitment records be available for inspection at the home. Yews Hill DS0000026331.V271252.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 The acting manager is experienced and is working towards the necessary qualification. Good quality assurance systems are in place at this home. EVIDENCE: The manager has applied to the CSCI to become the registered manager of the home. Progress with the Registered Managers’ Award has been good since the last inspection. The manager reported that of ten units, 3 have been signed off, 4 have been submitted to the assessor and 3 are in the process of being completed. The manager anticipates that she will have completed the award by June 2006. The manager has had previous management experience and has worked with people with learning disabilities prior to coming to this home. The organisation uses the ISO 9000 quality assurance system. In addition to this formal system, feedback is sought from service users through resident meetings and service user questionnaires that are completed prior to individuals’ annual reviews. The views of family, friends and stakeholders are Yews Hill DS0000026331.V271252.R01.S.doc Version 5.1 Page 18 also sought during the review process. Service users spoken to confirmed that they attend regular residents’ meetings. Yews Hill DS0000026331.V271252.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 1 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 2 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 X 3 X X X X Yews Hill DS0000026331.V271252.R01.S.doc Version 5.1 Page 20 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 YA2 Regulation 14 Requirement An assessment of service users’ needs must be conducted prior to service users moving into the home. A copy of the assessment must be available in the service users’ records. A current individual care plan that includes personal support plans must be in place for all service users accommodated at the home. This must be kept under review. A record is kept in the home in respect of each person employed, which contains all the information stipulated in Schedule 4(6) of the Care Homes Regulations 2001. Timescale for action 28/02/06 2 YA6 YA18 15(1)(2)bcd 12(1)(b) 28/02/06 3 YA34 17(2) 28/02/06 Yews Hill DS0000026331.V271252.R01.S.doc Version 5.1 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA24 YA32 YA37 YA42YA16 Good Practice Recommendations The home should explore how recommendations made by the Occupational Therapist in relation to the height of shower trays can be addressed. Staff should continue working towards obtaining NVQ 2 or above. The manager should continue working towards obtaining the registered managers award. The practice of all staff taking their breaks together should be reviewed. 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