Inspection on 06/11/06 for Yews Hill

This inspection was carried out on 6th November 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 7 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 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 Key Unannounced Inspection 6th November 2006 11:50 Yews Hill DS0000026331.V296163.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.V296163.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.V296163.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) Bridgewood Trust Limited Mrs Valerie Broadley Care Home 17 Category(ies) of Learning disability (17) registration, with number of places Yews Hill DS0000026331.V296163.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th January 2006 Brief Description of the Service: 75 and 77 Yews Hill are two care homes providing care and accommodation for seventeen adults with learning disabilities; one home (known as North Rise) accommodates five service users whilst the other accommodates twelve service users. They are owned by the Bridgewood Trust, a voluntary organisation providing a range of services to people with learning disabilities. The homes 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 homes are purpose built over two floors. All service users have single bedrooms and there are good communal facilities in the homes and a large garden that both homes share. Service users living at North Rise have the benefit of en-suite facilities. The current scale of charges at this home is £301.60 - £692.83. The preinspection questionnaire states that there is an additional charge to the service users for hairdressing, toiletries, activities, magazines, papers and a subsidised charge for holidays. All service users contribute towards transport costs. The service provider ensures that information about the service is available to prospective and current service users by way of the home’s Statement of Purpose, the Service User Guide and through CSCI inspection reports. Yews Hill DS0000026331.V296163.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this key inspection a site visit was conducted at Yews Hill by one inspector between the hours of 11.50am and 7.30pm. In addition to the site visit, information used to inform the inspection includes were notifications received from the home about any accidents, incidents or events that affect the well being of residents; provider monthly visit reports submitted to the Commission for Social Care Inspection (CSCI); the pre-inspection questionnaire submitted to CSCI prior to the site visit and completed questionnaires from service users, relatives and visiting professionals. Questionnaires were sent to eight service users, 1 has been returned; 4 visiting professionals, 1 has been returned; 6 relatives, 3 have been returned and 2 GPs, none have been returned. Comments and feedback have been included within the main body of this report, although the general feedback has been positive with all respondents expressing general satisfaction with the service provided at Yews Hill. As part of the site visit, the inspector had the opportunity to talk to seven service users, four members of staff and the deputy manager. Communal areas of the home were seen and three service users’ bedrooms. Records relating to service users, staff training, staff recruitment and staff rotas were examined and the medication was seen. The inspector also had the opportunity to observe care practice. Since the last inspection, Yews Hill has combined its registration with the Bridgewood Trust run home, North Rise, that is situated next door. The manager has been registered with the CSCI and has management responsibility over both homes. Unfortunately, the manager was on long-term sick leave at the time of the site visit. The residential services manager is temporarily providing management cover supporting the two deputy managers that are in post. The findings of this key inspection are generally positive, although some requirements and recommendations have been made where shortfalls have been identified. The inspector would like to thank the service users and staff for their cooperation and hospitality during the site visit. What the service does well: Before service users move into the home, their needs are properly assessed. Service users are given information about the home before they move in. This helps to make a decision about whether or not to live at Yews Hill. Yews Hill DS0000026331.V296163.R01.S.doc Version 5.2 Page 6 Service users are supported to make decisions and staff respect their rights. Care plans are in place for service users informing staff how to meet individuals’ assessed needs. Service users have regular access to community-based activities. Staff offer good support to service users to enable them to maintain contact with their families and friends. Good food is provided at this home. Service users are supported to have their health and personal care needs met. The home has a clear complaints procedure and service users know how to use this. Service users live in a clean and comfortable environment. An experienced, qualified manager runs the home. Good systems are in place to seek the views of service users and their families about the service they receive. What has improved since the last inspection? What they could do better: Agreed care plans need to be delivered as intended. Medicine management needs to improve. Multi agency protection procedures must be implemented to ensure the protection of all service users. Some furniture is worn and damaged and requires replacement. The lock on the cupboard used to store cleaning materials needs to be repaired to ensure service users do not have access to hazardous substances. Yews Hill DS0000026331.V296163.R01.S.doc Version 5.2 Page 7 There needs to be more staff qualified to a minimum of NVQ level two in care and staff need to attend relevant training. The manager should be allocated more management hours to enable her to complete management tasks. 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.V296163.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.V296163.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): 1,2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are given the information they need to make an informed decision about where to live. Service users’ needs are appropriately assessed before they move into the home. EVIDENCE: One service user survey was returned to CSCI as part of this key inspection. The service user indicated that they were given enough information about the home and were asked if they wanted to move in. Records for three service users were examined as part of this site visit. All contained evidence that individuals’ needs had been assessed prior to them moving into the home. Yews Hill DS0000026331.V296163.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate care plans are in place for service users. Service users are supported to take some risks. Service users are supported to make some choices. EVIDENCE: In each of the service users’ records that were examined, there was an individual care plan setting out how to meet service users’ health, social and personal care needs. There was evidence that service users’ care plans are regularly reviewed. Daily records are kept, detailing how individuals’ needs have been met. It was noted that some elements of service users’ care plans had not been implemented as intended. For example, clear instructions were recorded within a care plan regarding how staff should respond to a service Yews Hill DS0000026331.V296163.R01.S.doc Version 5.2 Page 11 user becoming distressed. Daily records indicated that staff had not responded in the agreed manner. Records showed that physical intervention had been used with a service user. The incident form stated that an urgent review was required and behaviour management strategies were to be developed. Staff spoken to were not aware of any behaviour management strategy, and this could not be located in the service user’s file. The manager spoke to the inspector on the day and explained that the plan had been developed. It is a requirement that the behaviour management plan be located and that all staff are made aware of this document so that the service user’s needs are being met consistently and appropriately. Service users are supported to take some risks as part of an independent lifestyle, for example, participating in cooking/baking with support. 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 some decisions about their lives. Service users were observed to choose how to spend their evening, whether to spend time in their bedrooms or communal areas of the home etc. A completed service user survey stated that the person could choose what they wanted to do at weekends and in the evenings, although not always during the day. Three relatives of service users stated that, if their relative was unable to make decisions, they would be consulted about their care. Yews Hill DS0000026331.V296163.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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’ rights are respected. Service users are offered a healthy diet and say that they enjoy their meals. EVIDENCE: Service users are supported to attend a range of educational and community based activities. Evidence of this was seen in service users’ records. Service Yews Hill DS0000026331.V296163.R01.S.doc Version 5.2 Page 13 users confirmed that they had been to day services/college on the day of inspection. Two day-care officers are employed to support service users at home on days that they do not attend day services/college. Service users contribute to the cost of a vehicle that is regularly used for accessing the community. There was evidence in daily records that good support is offered to service users to maintain contact with family and friends. Some service users spoken to confirmed this. All surveys completed by relatives indicated that staff make visitors feel welcome at the home. Service users’ rights were observed to be respected. Staff were observed to knock on bedroom and bathroom doors and to ask permission before entering service users’ bedrooms. Staff reported that, since the recommendation made at the last inspection, the practice of all staff having their break together to eat their evening meal has changed. Staff now have their break at different times to ensure that service users are not left unsupervised. Staff interacted in a respectful manner with service users and included service users in their conversations. Evidence that service users were given the choice of whether to be alone or spend time in the company of others was seen. Menus inspected demonstrate that a varied and nutritionally balanced diet is offered to service users. There was evidence that a choice of meals is available and this was confirmed by some of the service users spoken to. Yews Hill employs two cooks so that there is a cook on duty seven days a week. Service users at Yews Hill therefore have limited opportunities to participate in food preparation although they are involved in the setting and clearing away of tables. Staff reported that there is a list of service users’ likes and dislikes and that consultation about the menu takes place. A selection of photographs of food is available to enable all service users to make choices. Service users at North Rise have more opportunities to participate in the preparation and cooking of food. A service user told the inspector that she had been supported to cook the evening meal. Service users spoken to said that they like the food that is provided. Yews Hill DS0000026331.V296163.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are offered sensitive support with personal care. In general, staff are good at supporting service users to have their healthcare needs met. Medicine management needs to improve. EVIDENCE: Staff were observed to offer personal support sensitively. In those service user records that were examined, comprehensive information about how they prefer to be supported with their personal care was detailed in the care plans. The home has a keyworker system and 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. Clear records are kept of any health related Yews Hill DS0000026331.V296163.R01.S.doc Version 5.2 Page 15 consultations and appointments. Healthcare professionals see service users in private. Evidence of this was seen during the site visit. There was no record of the purpose or how to use a recently prescribed medication in a service user’s health record. This was discussed with the deputy manager at the time who said that this had been an oversight. Medication was checked against the records held. A number of gaps were noted on the Medication Administration Record (MAR), therefore the amounts available did not correspond with the stock balances recorded on the MAR. An auditing procedure is in place whereby all medicines are checked weekly therefore it was possible to establish when the errors had been made. Instructions for a prescribed mouth spray were unclear and there was no record of this in the individual’s care plan. In order to ensure that staff are clear about how prescribed medications should be used, there must be clear instructions on the MAR and, if necessary, within the care plan. A requirement has been made in respect of this. Clear guidelines are in place for the administration of ‘as required’ (prn) medication including individual protocols detailing when a ‘prn’ medication should be administered. This is good practice. Yews Hill DS0000026331.V296163.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A clear complaints procedure is available in the home. Robust procedures are in place to protect service users from harm or abuse, however multi-agency guidelines are not always followed appropriately. EVIDENCE: A satisfactory complaints procedure is in place containing all the required information. This is also available in symbol format. One complaint has been received in the last twelve months that was dealt with internally through adult protection procedures. 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. This was confirmed in the completed service user survey received. Three surveys were completed by relatives and two stated that they were aware of the complaints procedure and two had never had cause to complain. One stated that they were not aware of the complaints procedure and one said that they had complained in the past. A visiting professional confirmed in a survey that they had never received any complaints about the home. Robust procedures for the protection of vulnerable adults are in place in addition to the Kirklees multi-agency guidelines. An adult protection matter has arisen since the last inspection. This was dealt with internally; there was no evidence that a referral under the Kirklees adult protection policies and Yews Hill DS0000026331.V296163.R01.S.doc Version 5.2 Page 17 procedures had been made and the CSCI were not notified. A requirement has been made in respect of this. Staff spoken to had a clear understanding of their responsibilities with regard to adult protection and some staff have received training in this area. This training must be provided to all staff. Yews Hill DS0000026331.V296163.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a clean and comfortable home. EVIDENCE: All communal areas of the homes were seen in addition to some of the service users’ bedrooms. Both homes were clean and comfortably furnished. Some of the seating in the lounge at Yews Hill needs replacing as it is worn and in poor condition; a requirement has been made regarding this matter. Bedrooms seen were personalised and reflected service users’ interests and hobbies. All service users have their own bedroom. Service users living at Yews Hill are provided with a wash hand basin in their rooms whilst those at North Rise all have en-suite facilities. One service user survey was returned as part of this key inspection. The service user indicated that the home is always Yews Hill DS0000026331.V296163.R01.S.doc Version 5.2 Page 19 clean and fresh. Service users spoken to all expressed satisfaction with their rooms. Yews Hill has a small laundry room with commercial washing and drying facilities; a sluice cycle is available on the washing machine. A domestic washing machine and tumble dryer is provided at North Rise and these are sited in the kitchen. Given the size of the home and the needs of the service users, this does not pose an infection control risk. The staff member that accompanied the inspector whilst touring the premises explained that vinyl floor covering had been ordered for one bedroom where there was an unpleasant odour. All other parts of the homes were free from unpleasant odour. Service users participate in domestic tasks around the home with appropriate support where necessary. Yews Hill DS0000026331.V296163.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 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. A comprehensive training programme is in place, although not all staff have attended necessary training. Recruitment practice at the home is generally good. EVIDENCE: Staff were observed to interact positively with service users and service users appeared to be comfortable in the company of staff. Staff spoken to demonstrated a good understanding of service users’ needs. This was confirmed in a completed survey received from a visiting professional. Service users said that they liked the staff and got on well with them. A completed service user survey indicated that staff listen to service users and treat them well. Yews Hill DS0000026331.V296163.R01.S.doc Version 5.2 Page 21 Of twelve care staff, 4 are qualified to NVQ level two or above in care. It is recommended that at least 50 of care staff hold an NVQ level two or above, therefore a recommendation has been made. It should be noted that a number of staff are currently working towards achieving NVQ level two or above or are completing the Learning Disabilities Award Framework (LDAF) induction and foundation training. All new staff receive structured induction training. A comprehensive training programme is available and staff training records show that some staff receive a range of relevant training. There were, however, some staff whose records indicated that they had not received refresher training in fire safety, movement and handling, health and safety or abuse awareness. A requirement has been made in respect of this. Through discussion with staff, and examination of records, it was noted that physical intervention had been used with a service user. The staff involved in this intervention had not received physical intervention training and it is a requirement that appropriate training be provided. Physical intervention training should be accredited by the British Institute of Learning Disabilities (BILD) as described in the National Minimum Standards. Recruitment records in respect of five staff were examined. Most of the required information was available. One did not contain current references as the member of staff had worked for the Bridgewood Trust previously and had since returned; one did not contain a reference from the previous employer and the source of the references was unclear. All other checks had been completed as required. Yews Hill DS0000026331.V296163.R01.S.doc Version 5.2 Page 22 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): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An experienced, qualified manager runs both homes. Good quality assurance systems are in place at this home. The health, safety and welfare of service users is protected in most areas. Refresher training is necessary for some staff in relation to health and safety matters. EVIDENCE: Since the last inspection, the manager has been successful in becoming registered with the CSCI and completing NVQ level four in care. The manager is working towards the registered managers award. In June 2006, Yews Hill Yews Hill DS0000026331.V296163.R01.S.doc Version 5.2 Page 23 combined its registration with North Rise and, therefore, the manager has taken on responsibility of both homes. North Rise is situated next door to Yews Hill and was previously operated by the Bridgewood Trust. Through examination of the rota and discussion with staff, it was noted that the agreed management hours have not been achieved. The manager is regularly covering shifts, therefore having limited hours to complete management tasks. The provider should address this matter. 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. Service users spoken to confirmed that they attend regular residents’ meetings and minutes of these were seen. The pre-inspection questionnaire indicates that maintenance of equipment and health and safety checks are conducted at the required intervals. During the tour of the premises at Yews Hill, it was noted that the cupboard used for storing cleaning materials was unlocked. The staff on duty reported that the key was stuck in the lock. It is a requirement that this be repaired to ensure all hazardous substances are stored securely. Individual training plans for staff, submitted to CSCI, suggest that a number of staff have not received training in fire safety, movement and handling or health and safety. It is a requirement of the inspection that all staff receive necessary training. Yews Hill DS0000026331.V296163.R01.S.doc Version 5.2 Page 24 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 3 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 3 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 X 3 X 3 X X 1 X Yews Hill DS0000026331.V296163.R01.S.doc Version 5.2 Page 25 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 YA34 Regulation 17(2) Requirement 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 of 28/02/06 not met. The registered person must ensure that all staff have access to and are familiar with individual behaviour management plans. The registered person must ensure that clear administration instructions are recorded on the MAR for all medicines. The registered person must ensure that adult protection procedures are adhered to and that the relevant authorities (including CSCI) are promptly notified of any adult protection issues. Damaged and worn seating at Yews Hill must be replaced. Staff must receive training in the following areas: movement and handling, fire safety, health and safety, abuse awareness, physical intervention. Physical intervention training should be in accordance DS0000026331.V296163.R01.S.doc Timescale for action 31/01/07 2. YA6 12, 15(1) Schedule 3 13(2) 20/12/06 3. YA20 20/12/06 4. YA23 13(6), 37 15/12/06 5. 6. YA24 YA35 23(2)c 18(1)c 15/02/07 31/03/07 Yews Hill Version 5.2 Page 26 7. YA42 13(4) with Department of Health guidance. The COSHH cupboard at Yews Hill must be repaired to ensure that all COSHH items are stored securely. 15/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA32 YA37 Good Practice Recommendations 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. Yews Hill DS0000026331.V296163.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Brighouse Area Office St Pauls House 23 Park Square (South) 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.V296163.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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