Inspection on 30/10/07 for Yews Hill

This inspection was carried out on 30th October 2007.

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 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Yews Hill 06/11/06

Yews Hill 18/01/06

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 75 & 77 Yews Hill Road Lockwood Huddersfield West Yorkshire HD1 3SG Lead Inspector Alison McCabe K ey Unannounced Inspection 30th October 2007 10:30 Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 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.V353778.R01.S.doc Version 5.2 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.V353778.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Yews Hill Address 75 & 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) lmacdonald@bridgewoodtrust.co.uk Bridgewood Trust Limited Mrs Valerie Broadley Care Home 17 Category(ies) of Learning disability (17) registration, with number of places Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th November 2006 75 and 77 Yews Hill are two care homes that share the same site and are registered with CSCI and managed as one as one establishment. Yews Hill provides care and accommodation for seventeen adults with learning disabilities; one house (known within the service as North Rise) accommodates five individuals whilst the other (Yews Hill Road) accommodates twelve. Yews Hill is owned by the Bridgewood Trust, a voluntary organisation that provides a range of services to people with learning disabilities. The houses are located in Lockwood, a suburb of Huddersfield. They are close to a bus route and there are a small number of community facilities in the area. Both houses are purpose built over two floors. Both houses have single bedrooms and there are good communal facilities and a large garden that both homes share. People living at North Rise have the benefit of en-suite facilities. The current scale of charges at Yews Hill is £301.60 - £692.83. All those living at the homes contribute towards transport costs. The service provider ensures that information about the service is available by way of the home’s Statement of Purpose, the Service User Guide and through CSCI inspection reports. Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out using information supplied by the registered manager in the form of a self assessment, surveys returned from people living at Yews Hill Road and their relatives and professionals involved with people living there. Some of the staff working at the home also completed surveys giving their views about how well the home performs. The inspection included two visits to the home by one inspector. As part of these visits, the inspector had the opportunity to look around the communal areas of both houses, talk to people living at the home, have some discussion with staff, the manager, area manager and training manager, and observe the practice of the staff and manager. A sample of records relating to people living and working at the home was also seen. Feedback was given to the manager and the area manager at the time of the visit. The inspector would like to thank all involved with this inspection for their assistance. What the service does well: What has improved since the last inspection? Procedures in respect of protecting people form harm (safeguarding) have improved since the last inspection. Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 6 Some new furniture has been purchased for the lounge and more furniture is on order. Some areas have been re-decorated since the last inspection. What they could do better: The CSCI is not satisfied that people living at the home are adequately protected from harm. Risk management is generally poor, and communication between staff, managers, and people living at the home needs significant improvement in some areas. Care planning requires significant improvement so that staff can deliver care consistently and in line with best practice. Records must be kept securely and in the event of records going missing there needs to be a clear procedure for staff to follow. Some people living at the home are not given enough opportunities to engage in meaningful activities that are appropriate to their needs, abilities, age or preferences. A much more imaginative and pro-active approach is required to improve practice in this area. There needs to be a much clearer understanding of how the complaints procedure is implemented, particularly in relation to the recording of complaints. An improved understanding of the homes obligation to report certain events or incidents that occur in the home is necessary. Practice in respect of how medicines are given is not safe and must improve. More staff need to complete their NVQ in care so that their skills and knowledge improve. Work needs to be done with some staff to improve and challenge values and attitudes so that people living at the home are confident that their needs will be met in a way that is respectful and has been agreed with them as part of their care plan. The management of the home needs to improve. There is currently a lack of management oversight of the general running of the home. Record keeping is some areas needs significant improvement, and better arrangements for the security of records needs to be arranged. Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 8 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.V353778.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs are appropriately assessed before they move into the home. EVIDENCE: Records relating to three people living at the home were looked at. There was evidence in all the records that individuals’ needs had been appropriately assessed prior to them moving into the home. Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9,10 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home are supported to make some choices and decisions, however individuals’ needs are not met consistently and people are put at risk of harm due to lack of planning and appropriate assessment of risks. Records relating to individuals are not always kept secure. EVIDENCE: Individual care plans for three people were looked at during the inspection. There were parts of the care plans that contained useful, detailed information to enable staff to support people in having their needs met. However, there were some gaps in the care plans where specific needs that individuals have were not described. For example, there was practically no information available regarding an individual’s epilepsy, when there are some very specific ways in which it must be dealt with. The manager explained that the Bridgewood Trust has decided that another revised format is to be introduced. Information regarding one individual had been transferred onto the new format, however upon going through the file it was noted that information in Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 11 the new care plan was not consistent with information in the old care plan or the assessment information. Whilst it is acknowledged that there will be a period of transition from one system to another, it is unhelpful for staff if information is not transferred correctly or in full, as elements of individuals’ care could be missed. Records are kept daily of how individuals needs have been met. It was seen that what has been agreed in the care plan is not always followed through. For example, in one persons care plan it is agreed that support will be given to regularly write to their family, however daily records suggested that this had not been done since the middle of July 2007. The manager understood ‘regularly’ to be monthly and it has since been confirmed that a monthly telephone call had been agreed with the family. Unfortunately there is no record of this in the care plan. Risk management in the home is good in some areas, and needs improving in some areas. There are some good examples of people being supported to take some risks and comprehensive assessments have been made with details of how to minimize risks recorded. Most risks however are recorded using the old risk assessment system, which does not lend itself to providing useful information to staff about the exact nature of the risk and how to minimize this. Risk assessments for an individual regarding the management of challenging behaviour were asked for. These were unavailable for inspection, and the manager was unable to explain where these documents had gone, although she was certain they had been completed and available to staff previously. Following the first day of inspection, the manager informed CSCI that the documents had been located at the Bridgewood Trust head office and had been replaced at the home. In order to ensure that all staff, including agency and casual staff, are aware of how to meet individuals current needs, up to date care plans and risk assessments must be available in the home. Risk assessments in relation to falls and epilepsy did not adequately describe the risks or agreed control measures. This was discussed with the manager at the time. A requirement has been made in respect of risk assessments and care planning. Some examples of individuals making decisions and choices were observed. For example, an individual asked for an alternative evening meal and staff were observed to encourage the individual to choose an alternative from the kitchen. Individuals were observed to choose whether to spend time in communal areas of the home or in their bedrooms. It was noted that an individual was indicating that they would like to go out, however staff said this was not possible as it was raining. This is discussed in more detail under ‘lifestyle’ standards. During the inspection, a number of records asked for were not available. The manager reported that some documents, for example, risk assessments relating to individual service users, and information relating to complaints Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 12 received by the home specific to individuals, had ‘gone missing’. It is concerning that although records are reported to have gone missing, it is unclear when this occurred and no report of this was made until the inspection occurred. Since the inspection, a meeting has been held between the local authority, Bridgewood Trust and CSCI to discuss a number of concerns identified at the inspection. Measures are being taken to increase security of records at the home as a result of this. Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Some people live full and active lifestyles with good contact with their families, however a more imaginative approach is necessary to keep some people occupied. Good food is provided at the home and individuals’ rights are usually respected. EVIDENCE: Some of the people living at Yews Hill Road/North Rise lead active lifestyles whereby they attend day services, college and go to social clubs and events. Some comments from relatives of those living at the home support this, for example, ‘they have a very full, active life in what they do’, ‘the residents social care is wide and varied with trips out to functions, events and holidays etc’. Most of those people living at the home who completed a survey indicated that they could choose how to spend their time. On both days of inspection, a number of people were at home as they did not have day or college Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 14 placements. There are staff employed to work during the day to offer activities to people at home. On the first day of inspection, entertainment had been arranged for the afternoon, and a musician from a local university came to play for people at home, which some individuals seemed to enjoy. There were however long periods of time where individuals were not engaged in any meaningful activities and some were observed wandering around the home, sleeping in the chair, or just sitting. One person was sitting with a jigsaw in front of them, however due to the height of the chair and their position, it would have been very difficult to reach. A member of staff explained that it is actually the staff that do the jigsaw, and the individual likes to chat with the staff as they do it. In a completed survey a relative stated that their relative had been on a waiting list for horse riding for three years, and that this was the only activity they enjoyed. This was raised with the home manager who explained that there was a long waiting list for riding for the disabled. It was suggested that other stables be approached and further attempts be made to arrange this. The manager has since informed the CSCI that riding has been arranged for two individuals at the home. This is positive, however it should not take the intervention of CSCI to encourage a more proactive approach in meeting the needs of people living at the home. Another relative commented that the home is ‘lacking in the way of occupying clients to prevent boredom and its associated problems’. The manager explained that it is difficult to find activities that some people at the home will engage in and enjoy because of the nature of their disabilities. Staff were observed doing some art/craft work, however none of the people living at the home participated in this, as it was not an activity that interested them. A member of staff explained that an individual who was requesting to go out could not do so as it was raining. It was barely raining at the time, and it is not in line with ordinary life principles that people using services cannot go out in the rain. There was nothing in the individuals care plan to suggest that this was the case. It is strongly recommended that the home explore what resources, staff training, publications, other professionals are available to assist in improving practice in this area. Families spoken to as part of this key inspection had not been asked for information about what their relative enjoyed doing. This may also be useful if staff are struggling to meet people’s needs in this area. Most of the families of people living at the home who completed surveys said that the home is good at keeping in touch with them. One relative however expressed concern at the lack of contact stating that they are not informed when there relative is ill or had an accident etc. This had been raised with the home a year previously, however it would seem that this matter remains unresolved. Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 15 Staff were observed to respect individuals’ rights by knocking on bedroom or bathroom doors before entering and supporting people to choose whether to spend time alone, in company, or whether or not to join in with activities. During the inspection, an individual from another Bridgewood Trust home came to use the bathing facilities at Yews Hill, although there was no apparent reason for this. There was no evidence that people living at the home had been asked permission for a visitor to use their bathroom, and the manager said it was unlikely that they would have been asked. Visitors should only have access to the home with the individual and collective consent of the people living there. A cook is employed to work at the home, and records showed that a varied and healthy diet is offered to people. One of the people living at North Rise explained that staff do the cooking, though they all contribute to menu planning, shopping, some preparation and clearing away after meals. All those individuals spoken to said that the food provided was good. Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Peoples health and personal care needs are generally met, however medication administration practice needs to improve to ensure the health and wellbeing of those people living at the home who need support in this area. EVIDENCE: People living at this home require varying degrees of support with their personal care. There is some good information about peoples preferred routines and what support is required within their personal support plans. Examples of staff providing discreet and sensitive support with peoples’ personal care were observed which is positive. It was noted however that personal support plans are not always followed as agreed. For example, on the first day of inspection, an individual’s dentures kept falling out. He explained that staff should help him with adhesive, but that they do not always remember. The inspector asked that this be addressed at the time, as the individual was due to have his lunch. It was also noted in the morning that an individual’s shirt had dried food on and was stained; it was several hours before a member of staff supported them to change. Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 17 There was evidence in the records seen that generally people are supported to have their healthcare needs met. Records show that people attend regular healthcare appointments with support, although some were noted to be overdue. For example, an individual’s last recorded check up at the dentist was October 2005. There was evidence that the expertise and guidance of healthcare professionals is sought. The manager was in the process of completing a new information pack for an individual to carry with him in the event of him going into hospital, as suggested by the community learning disability nurse. This contained really useful information that would support the individual’s needs to be met appropriately. As discussed under standards six and nine, further information needs to be made available to staff with regards to an individual’s epilepsy and action that staff need to take in the event of a seizure or a fall. At the time of the inspection, a complaint from a relative of one of the people living at Yews Hill Road regarding how their relative’s healthcare needs are being met was unresolved. A survey completed by a GP indicates that there is a good working relationship between the home and the GP, and that the GP is satisfied with the overall care provided to people at Yews Hill. Since the last inspection, revised systems are in place regarding medicine management. Excellent information is available regarding what medication individuals are taking, why they are taking it, possible side effects and when they started taking the medication. Clear information about when ‘as required’ (prn) medication should be administered is available, along with a photograph of each individual to ensure the correct medication is given to the right person. Medication administration records were examined along with medication stored. All medication tallied with the records. Unfortunately, despite good systems being in place, unsafe administration practice was observed on three occasions. For example, a staff member measured out almost double the prescribed dose of medicine for an individual. The staff member reported that she had never been shown the correct technique for measuring out liquid medicines. The inspector intervened and the correct dose was then administered. Although staff have received training in the Boots monitored dose system, there are clearly gaps in peoples knowledge. The training manager reported that she has developed a course regarding medication and that she would be arranging for staff to attend this. In the meantime, the manager must ensure that arrangements are made for the safe administration of all medication and a requirement has been made in respect of this. The poor medication administration practice has affected the overall rating of this outcome group. Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People using the service experience poor outcomes in this area. This judgement has been made using a range of available evidence including a visit to this service. Whilst there are satisfactory procedures in place for complaints and protection of individuals, poor record keeping and understanding of procedures does not ensure that complaints are responded to appropriately. Procedures regarding individuals’ financial affairs do not adequately protect people from potential financial abuse. EVIDENCE: A satisfactory complaints procedure is in place. Information received from the manager prior to the inspection indicates that three complaints have been received in the last twelve months, two of which were not upheld and one that is still ongoing. The two not upheld relate to care practice issues and concerns about medication that had been prescribed. However, records of two of the complaints were not available in the home, and the complaints log only referred to one. Photocopies of some documentation in relation to one complaint had been found at Bridgewood Trust’s head office by the second day of inspection, although there were still some documents missing. There is a lack of clarity about how complaints should be recorded and responded to; staff within the organisation are unclear about what constitutes a complaint. Those individuals living at the home and relatives who completed surveys said that they were aware of the complaints procedure and staff indicated that they knew what to do if a complaint was made to them. Most people indicated that any complaints or concerns had been dealt with appropriately, although one Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 19 individual said that this had not been the case. A requirement has been made in respect of how complaints are recorded and responded to. Since the last inspection a revised safeguarding (adult protection) procedure has been implemented. The manager reported that this has been discussed with all staff in one to one support and supervision meetings. Staff spoken to confirmed this. The new procedure clearly instructs staff about multi-agency guidelines and how to make a safeguarding referral to Social Services Information Point (SSIP’s). A safeguarding matter arising a few days after the inspection visit was referred appropriately. Information received prior to the inspection suggests that three incidents where physical intervention was used have occurred in the last twelve months. The Commission For Social Care inspection have not been notified of any of these as required under the Care Homes Regulations 2001. Staff were unable to locate the records detailing these incidents. Behaviour management, physical intervention plans and risk assessments were not available in sufficient detail for an individual requiring support in this area. The CSCI and Kirklees Council’s Contracts Manager have raised this with the home previously. A requirement has been made in respect of this. Licence agreements were examined in relation to three individuals living at the home, and all were signed by the individual. It was queried whether any of the individuals would have an understanding of what they were signing, and the home manager suggested that none would. The licence includes an agreement that individuals’ mobility allowance is taken by the Trust and used to fund vehicles and all transport costs. However there was evidence in an individual’s record that all transport costs have not been covered as agreed. The organisation needs to review its policies and procedures regarding individuals’ money and financial affairs to ensure that people are protected from financial abuse. The Mental Capacity Act must be considered when asking individuals with learning disabilities to sign licence agreements. Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 People using the service experience good outcomes in this area. This judgement has been made using a range of available evidence including a visit to this service. People live in a clean and comfortable home. EVIDENCE: Communal areas of both North Rise and Yews Hill were seen and one individual’s bedroom. All areas were clean, free from unpleasant odour and comfortably furnished. Some of the furniture at Yews Hill has been replaced and staff reported that new sofas, chairs and carpets were on order. The lounge and dining room at Yews Hill had been decorated and looked fresh and homely. People living at the home that completed a survey all indicated that the home is always clean and fresh and those spoken to said they were happy with the maintenance of the home. Laundry facilities at the home are satisfactory and infection control procedures are in place. Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 People using the service experience adequate outcomes in this area. This judgement has been made using a range of available evidence including a visit to this service. People are supported by a well trained staff team that have been subject to thorough recruitment checks before working at the home, although more staff need to achieve a relevant qualification in care and improve some areas of their care practice. EVIDENCE: During the inspection some examples of positive care practice were observed where staff demonstrated a good understanding of the needs of individuals. However, there were also occasions where staff did not demonstrate good care practice or an awareness of the needs of the people living at the home. Whilst staff appeared to have genuinely positive relationships with people living at the home, there was a lack of awareness of basic support that people required. For example, an individual had not been supported to have adhesive put on his dentures, consequently his teeth kept falling out. This went unnoticed by staff and was pointed out by the inspector. Another individual was slumped in a chair whilst trying to complete a jigsaw puzzle. Once pointed out, a staff member attempted to adjust the individual’s position. It is recommended that Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 22 staff be given more guidance and support to ensure that they are aware of how to meet individuals needs. New staff complete the ‘Learning Disability Qualification’ prior to them starting the National Vocational Qualification (NVQ) in Care. At the time of inspection, three staff were working towards this qualification. The staff team are continuing to work towards achieving NVQ qualifications, although there are still less than fifty per cent of staff with this award. It is recommended that the manager review where staff are up to with this award as some staff have been working towards this for a considerable length of time and further support may be required in order to achieve the qualification. Recruitment records in relation to three new staff were examined. All contained the required information and documentation and it was evident that thorough and robust procedures had been followed. Since the last inspection a new training and development manager has been appointed to the organisation. A training and development programme is in place and staff have attended a range of relevant training events since the last inspection. It was noted on the information provided prior to the inspection that only five of fourteen staff have received training in infection control. It is recommended that all staff receive training in this area. Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41,42 People using the service experience poor outcomes in this area. This judgement has been made using a range of available evidence including a visit to this service. The management of the home is weak and requires improvement. The health, safety and welfare of people living at the home are not adequately protected. EVIDENCE: Since the last inspection, the manager has completed the NVQ Registered Managers Award, which is positive. The home has been through an unsettled period as the manager was off work for some months, although has now returned. A new area manager has been appointed who will oversee the running of the home. In June 2006 Yews Hill combined its registration with North Rise, and the manager has taken on responsibility of both homes. North Rise is situated next door to Yews Hill and was previously operated by the Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 24 Bridgewood Trust. The manager reported that the agreed management hours have still not been achieved as she is covering shifts on a regular basis. The area manager reported that she was aware of this and was addressing it with the homes manager to ensure that sufficient management hours were arranged. Through the inspection visit and information received before and after the inspection, it is apparent that a number of policies and procedures have not been implemented, as they should have been. A significant number of concerns have been identified regarding the management of the home. There is a lack of management oversight and consequently a number of serious mistakes have been made that have or could have affected the safety and well being of the people living at the home. The CSCI, Social Services and Kirklees Contracts are in consultation with the Bridgewood Trust regarding these matters. A requirement has been made in respect of the management of this home. Record keeping at the home requires significant improvement in some areas (as discussed previously in this report). It is most concerning that a number of documents and records could not be accounted for and were reported as having gone missing. This does not protect people using the service nor does it ensure the efficient running of the home. A requirement has been made in respect of this. Self-assessment information provided by the home indicates that maintenance of equipment has been conducted at the required intervals. Records sampled confirmed this. A requirement was made at the last inspection that the cupboard used for storing cleaning materials and hazardous substances be kept locked. Although a new lock had been fitted, during the inspection it was observed that the key was kept in the lock and the cupboard door was left open. This is unsafe and must be addressed with staff. The CSCI is not satisfied that people living at the home are adequately protected from harm. Risk management is generally poor, and communication between staff, managers, and people living at the home needs significant improvement in some areas. For example, an individual was dropped off at his day placement and left for the day, despite the home having been notified that the day placement was closed for the day. This put the individual at serious risk of harm. Records examined do not demonstrate that adequate care was given following this incident. An individual from another service within the organisation was observed to use the bathing facilities at Yews Hill on the day of inspection. When asked, nobody at Yews Hill knew why this had been arranged or with whom and the manager reported that it was unlikely that people living at Yews Hill would have been consulted. As previously discussed under standard 20, medication administration practice observed was unsafe. The CSCI have not been notified of three incidents referred to in the selfassessment completed by the homes manager in relation to physical intervention being used. It is a requirement of this inspection that in future incidents are reported in accordance with the Care Homes Regulations 2001. Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 25 Since the inspection, the area manager has been working closely with the homes manager to address the most urgent areas of concern including risk management and ensuring compliance with health and safety matters. 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 also sought during the review process. Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 26 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 3 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 1 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 1 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 1 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 X 1 X 3 X 1 1 X Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 27 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 YA6 YA23 Regulation 15 Requirement Each person living at Yews Hill and North Rise must have an up to date, detailed care plan setting out their individual needs in sufficient detail so that staff supporting them provide consistent and appropriate care. Where necessary, the individual plan should contain a behaviour management plan and physical intervention plan. Suitable arrangements need to be in place to ensure that staff implement the agreed care plan. In order to protect people from harm, where there are identified risks to people living at the home, these must be recorded on a risk assessment. There must be detailed information about measures that must be taken to reduce the identified risk. Risk assessments must be kept under review and updated or added to where necessary. Timescale for action 31/12/07 2. YA9 YA23 13(4) 15/12/07 Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 28 3. YA20 13(2) 4. YA22 22, Schedule 4(11) 5. YA23 YA42 13(8) 37 6. YA41 17(1)b 37(f) 7. YA42 13(4) So that people are given the correct medication at the correct dose, arrangements must be made to ensure that medication is administered safely. In order to ensure that people living at the home, or their relatives/advocates views or complaints are listened to and acted upon, the registered person must ensure that any complaint made is investigated fully and that records are kept of the complaint. Additionally, a record of any action taken by the registered person in respect of the complaint must be kept. In the event of physical intervention being used with an individual, the manager must ensure that the Commission for Social Care Inspection is notified and a record of this must be kept at the home. The manager must ensure that records at the home are kept securely. If it is suspected that theft of records has occurred, this must be reported to the appropriate agencies, including CSCI and the police. The cupboard that contains cleaning and hazardous products at Yews Hill must be kept locked to protect people living at the home from harm. This matter was raised with the home at the previous inspection. 05/11/07 30/11/07 30/11/07 30/11/07 30/11/07 Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 29 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 YA12 YA13 Good Practice Recommendations People should be supported to participate in a range of fulfilling, valued activities appropriate to their needs and wishes both in and outside of the home so that a good quality of life can be maintained. In order to support people to keep in touch with their family or friends, where agreements have been made with about how often they will keep in touch, these need to be recorded in the care plan. If the agreement is not kept to, there needs to be a record of the reasons why not. Where there is doubt that people living at the home are able to make an informed decision when being asked to sign agreements relating to the use of their benefits, the manager needs to ensure an assessment of capacity is undertaken by the relevant professional. Where it is felt that people do not have the capacity to make such a decision, appropriate steps should be taken to reach agreement about what is in the individuals best interests, including consultation with a multi-disciplinary team. In order to ensure the smooth running of the home and protect people living at the home from harm, the manager needs to have a better oversight of the overall running of the home. The manager and staff need to be more vigilant about protecting people from harm, and adhering to policies and procedures so that mistakes that put people at risk of harm are significantly reduced. Staff should continue working towards obtaining NVQ 2 or above. Action should be taken to ensure the registered manager is allocated the agreed management hours. 2. YA15 3. YA23 4. YA23 YA37 YA42 5. 6. YA32 YA37 Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Yews Hill DS0000026331.V353778.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!