Inspection on 10/10/07 for Yews, The

This inspection was carried out on 10th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Yews, The 28/11/06

Yews, The 01/02/06

Yews, The 20/07/05

Yews, The 06/01/05

Yews, The 27/07/04

Yews, The 25/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Yews, The 2 Church Street Alvaston Derby Derbyshire DE24 0PR Lead Inspector Angela Kennedy Unannounced Inspection 10th October 2007 10:30 X10015.doc Version 1.40 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, The DS0000002011.V347556.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Yews, The Address 2 Church Street Alvaston Derby Derbyshire DE24 0PR 01332 756688 01332 571002 brenda.towell@yewsresidential.com 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) Mr Rakesh Bhalla Mrs Pushpa Bhalla Mrs Brenda Towell Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th November 2006 Brief Description of the Service: The Yews is a residential home for twenty-seven older people situated in a suburb of Derby city. It is within its own grounds and on a corner location. There are twenty-five single rooms and one shared double room, as since the last inspection an extension has been built which incorporates an additional ground floor bathroom, one disabled toilet and one general toilet, six ensuite bedrooms, a new lounge, which has allowed the old lounge area to be used as an extended dining area and additional laundry facilities. Access to the first floor is via a passenger shaft lift. There are two steps at one end of the first floor. The front and side of the property is lawned and accessible. There are two lounges adjoining each other and a dining room, all of which are well decorated with good quality furnishings and fittings. Support services are in place with a choice of General Practitioners, district nurses, chiropodist, dentist and optician. Community psychiatric nurses, occupational therapists, physiotherapists and dietician are accessed as required. Staff training takes place to inform and enable staff to care for residents appropriately. Regular entertainment is organised and those residents who wish to go out do so. At the time of inspection the fees at The Yews were from £ 344.00 to £354.00 a week. This includes a third party contribution. Items not covered within the fees included: Hairdressing, Chiropody, newspapers, magazines and travel expenses. Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over approximately 7 hours. Key inspections take into account a wide range of information and commence before the site visit by examining previous reports and information such as any reported incidents. The site visit is used to see how the service is performing in practice and to meet with residents and their representatives. The inspection was focused on assessing compliance with defined key National Minimum Standards. The commission had requested the service to complete an annual quality assurance assessment and the information provided within this assessment has been used to inform this report. Five residents completed care home surveys and the information provided within these has been included within this report. Three members of the care staff team were spoken with to ascertain their views of the service, the training provided and the support and care provided to the resident group. The registered manager was on duty on the day of this inspection visit. The registered provider was also at the home on the day of inspection and was spoken to briefly. Two residents were case tracked. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at care plans and other documents relating to that persons care, talking to staff regarding the care they provide, talking to the resident if they are able to communicate or observing the care they receive. Several other residents were also spoken with at this inspection visit. One visitor was also spoken with to gain their views on the services and care provided at a The Yews. What the service does well: The Yews provided a comfortable, clean, well-maintained and homely environment for the people who lived there. Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 6 The staff delivered a person centred approach to care, which was tailored to meet resident’s individual needs Residents and one visitor spoken with were very positive regarding the care and support provided by the staff team. Comments made included “we are looked after very well” and “ I think it’s a lovely place, I’m confident that mum is well looked after, she’s very happy here”. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service The service user guide requires further development to ensure prospective residents are able to make an informed choice about were to live. Terms and conditions of residency were in place and the needs of residents were assessed prior to admission, to ensure their needs could be met by the service. EVIDENCE: The written information provided by the registered manager prior to this inspection visit stated: New residents are admitted following a full assessment of their needs, this is carried out by: Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 9 For service user who is partially funded by the local authority a community care manager will complete an assessment and produce a care plan for the home to carry out, the manager also visits the prospective resident to assess that The Yews will be an appropiate placement and to introduce the home and its facilities, to ensure that when the service user arrives at the home there is already a familiar face to greet them. For privately funded residents the manager will visit the prospective resident in their own home or hospital ward, all prospective residents are invited to visit the home if appropriate or to stay on a short term basis. All interested parties are welcome to look around the home and are encouraged to ask as many questions as they need to know, we are happy to pass on any relevant information regarding the placement as normally it may be the first time that they have needed to look for a provision of twenty four hour care for their loved one, we can dispel worries and concerns, each individual having separate queries specific to their particular situation. The Yews comprehensive assessment tool covering all aspects of care is used in both situations, this will include their present and historical details and if there has to be any changes to their doctor etc. This is related to the prospectiveresident to ensure they understand that due to organizational constraints, ours and the multidisciplinary teams with whom we work, that they cannot always continue with their current doctor due to a change of address, if a service user enters the home on temporary basis we always arrange for a temporary GP to cover their stay, this enables that all repeat medication can be arranged and any medical needs can be met, to ensure that when service user is returning home they have a current supply of medication to continue their therapy. On the day of the inspection visit: At the last inspection visit a requirement was left regarding the service user guide to ensure all of the information required as stated in Regulation 5 of the Care Homes Regulation 2001 was in place. The registered manager stated that the homes service user guide had not been amended to include this information. This requirement will remain with an extended timescale to allow this work to be completed. At the last inspection visit the Terms and Conditions of residency within one residents file did not state the specific fee payable but stated that the fee payable was as per agreement with the local authority. A requirement was left regarding this. The Terms and Conditions of residency were seen at this inspection visit and had been updated to include the total fee payable. Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 10 Prior to admissions being agreed a needs assessment was undertaken to determine that the service was able to meet the individuals needs. Within the two residents files looked at, needs assessments were in place and covered all areas of personal, health and social care needs. The information gathered from the needs assessments was then used to formulate the residents care plans. Residents spoken with and information from the residents surveys confirmed that residents and/ or their representatives visited the home and received sufficient information about the home in order for them to make a an informed choice about The Yews before they moved in. Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service A person centred approach was provided to support the needs of the residents and the medication practices in place in general ensured resident’s safety was maintained. EVIDENCE: The written information provided by the registered manager prior to this inspection visit stated: All residents have a care plan that is generated from a comprehensive assessment and is carried out with the involvement of the resident and interested parties and all clinical needs identified are addressed. Care plans are reviewed monthly by key workers and with resident involvement. Assessments are in place for weight, nutritional screening, tissue viability, falls Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 12 risk and prevention and relevant professional advice is sought if a risk is identified. Chiropody and optical care is available to residents, although residents who wish to retain their current providers will be supported to do so. Hospital and clinic appointments are kept, family or interested parties are informed of appointments to enable arrangements to be made for transport and escort. A Medication assessment is made on admission and residents who wish to be responsible for their own medication are supported and protected under the homes policies and procedures for dealing with medication. Staff adhere to the homes procedures for the management of residents medication under the Pharmaceutical guidelines, the Medicines Act 1968. A lockable cabinet is stored in a designated medical room, a controlled drugs cabinet supplied by the chemist is located in the medical room with limited access to trained staff, a register of any controlled drugs administered is kept in accordance with the Misuse of Drugs (Safe Custody) Regulations 1973. A local pharmacy provides advice on medication and a pharmacy inspection is undertaken ever three months and a copy of their visit is kept in the medication room. Care staff document with report writing on daily logs for each resident at the end of every shift any critical change during the shift is reported to the Senior Care to deal with making appropriate referrals to professionals. Wishes on death are identified on the initial assessment of need. On the day of the inspection visit: The resident’s care files seen had care plans in place that had been developed from their initial needs assessments. One of the residents case tracked had high dependency needs, and the information contained in their care plans, risk assessments and daily logs demonstrated that the staff delivered a person centred approach to their care, which was tailored to meet this residents individual care needs. Staff should be commended on the level of care and support provided to this resident. Residents care plans seen were detailed and person centred and covered all areas of health, personal and social care needs. All care plans seen were dated and signed and had been reviewed by the resident’s key workers on a monthly basis to ensure any changing needs could be identified and met. The manager reviewed all care plans on a three monthly basis, which ensured that the standards of care plans in place were regularly audited ensuring good standards of care plan documentation were in place and maintained. Residents and one visitor spoken with were very positive regarding the care and support provided by the staff team. Comments made included “we are Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 13 looked after very well” and “ I think it’s a lovely place, I’m confident that mum is well looked after, she’s very happy here”. Records of visits from health care professionals were recorded this included visits from chiropodists, district nurses, doctors and opticians. The weight of residents had been recorded on a regular basis to ensure any changes in weight were identified. Daily logs were maintained for each resident to ensure each member of staff was kept up to date on the residents well being, daily activities and events. Risk assessments were in place regarding tissue viability, manual handling, falls, mobility and nutrition. All of the risk assessments seen had been regularly reviewed to ensuring any changing needs could be identified and the necessary amendments made to the assessment to promote resident’s safety. Risk assessments had been formulated from risks identified through care planning information. Discussions took place with the manager regarding cross-referencing care plans to risk assessments as a good practice measure. The medication practices in place at The Yews in general were good. Staff administering medication had undertaken the required training to ensure they had the skills and competency required. The medication administration records were seen and had been signed at each administration. All medication was stored correctly and at the correct temperatures, however it was noted that some cold storage medications such as eye drops had not been dated upon opening. The manager was aware of the need to do this, as these types of medication do have a limited expiry date once opened. The manager stated that dates were usually written on these medications upon opening. Residents who chose to self-administer their medication had assessments in place to demonstrate that they had the capacity to retain and administer their medication safely. Observations of the staff with residents demonstrated a friendly and respectful approach, and residents spoken with and information provided within the residents’ surveys confirmed that the staff team were respectful towards residents and treated them with dignity. Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 14 . Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home strives to meet the social needs of residents and religious interests were met. Residents maintained contact with family and friends. Residents were encouraged to exercise choice and control over their lives and the meals provided were of a good quality EVIDENCE: The written information provided by the registered manager prior to this inspection visit stated: All aspects of Social Contact and Activities are identified on the initial assessment tool; this tool is invaluable in identifying the residents’ expectations, preferences and capacity to exercise their choices in relation to daily living, visitors and activities. Preferences with whom residents wish to see, where and when is documented on the assessment also any visitors they are not happy see. The atmosphere in the home is welcoming and visitors come into the home on a regular basis, our new lounge area is equipped to enable sufficient seating and refreshments are freely available, visitors have the choice during their Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 16 visit in privacy or to sit with their family or friend in the lounge area. Resident are supported with any assistance required to continue with their chosen hobbies or pastimes Visitors are respectfully asked to avoid meal times as this is an important time for staff to attend to residents to maintain their health and well being with a nutrious and balanced diet, and support where needed without hurrying. Meal times are flexible to account for appointments, early breakfast or early lunches, food is well presented to encourage appetite with a varied menu to choose from. Meal observation charts are recorded to identify any areas of concern and dietician input given as required. Links within the community are maintained. Special days are celebrated at the residents’ request, cook makes a birthday cake, and the key worker purchases a gift on behalf of the home. Seasonal celebrations are observed for residents who like to celebrate and residents are able to invite their visitors to participate in seasonal celebrations and meals. On the day of the inspection visit: A notice board within the reception area displayed events and activities that were planned at the home. On the day of this inspection visit an attractive raffle prize for Halloween was on display that had been created by the manager and raffle tickets were being sold. Activities and events within the home included regular songs of praise once a month, communion services every month and visits from nuns of the local convent. Two residents visited their local places of worship within the community. Bingo, crosswords, reading and crocheting were also undertaken and the manager stated that the home had purchased a karaoke machine, which had proved very popular with the residents. One resident went out on a regular basis to play bingo. A hairdresser visited the home twice a week and was at The Yews at the day of this inspection visit, this service appeared to be very popular with many of the residents. Several residents were seen going out with their visitors and two other residents went out for a walk. These two residents were spoken with and stated that they went out for a walk together every day. The manager stated that two new wheelchairs had been purchased to enable residents to access the community with their visitors. Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 17 A Christmas party was held every year for residents and their guests, and it was stated that everyone that attended always enjoyed this. Trips out were organised for residents and this included a pantomime trip every New Year. No structured activities were seen to be taking place on the day of this inspection visit, although as already stated the hairdresser was at the home. One member of staff spoken with said that it was difficult to plan activities when the hairdresser was there, as the majority of residents would decline from taking part as they were waiting to have their hair done. One of the residents spoken with was able to go out independently but felt that there could be more daily activities for those residents whose mobility was limited and who spent most or all of their time within the home. Residents that were spoken with or that completed the residents’ surveys indicated that there were usually activities available at The Yews that they were able to participate in if they chose to. Visiting was open and visitors were seen to be made welcome by the staff team. One visitor spoken with confirmed that the staff were friendly and supportive. Information regarding local Advocacy services was advertised within the reception area of the home. Alternative choices were available at each meal if required. The main meal was served at lunchtime and cooked options were available each day at the teatime meal. Records were in place for the cook as to resident’s preferences and any special dietary needs. Residents that were spoken with or that completed the residents’ surveys indicated that the meals in general were of a good quality although a couple of residents did state within the surveys, “could do with more variety” and “ slight lack of variety”. As this information was provided within the residents’ surveys it is unclear if these residents have made their opinions known to the manager. However comments from one resident demonstrated that their concerns regarding the meals was listened to and acted upon, “ At first some of the food was not hot, we informed them and since it has been much better”. Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were confident that any concerns they had would be listened to and acted upon. The practices in place enhanced residents’ protection. EVIDENCE: The written information provided by the registered manager prior to this inspection visit stated: The Yews complaints procedure is displayed on the notice board in the hallway. a complaints book is on the hall table next to the visitors signing in sheet, we experience day to day running concerns and these are addressed immediately, serious complaints are recorded and dealt with within 28 days. Complainants are advised of the C.S.C.I. our registration body, if they have any complaints or concerns that they feel has not been resolved or acted on. this information is in the Service User Guide and Statement of Purpose. Advocacy through Age Concern has been sought for clients who have had difficulty in finalising their financial affairs when entering the home on a permanent basis. Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 19 All service users have the right to vote, pre election letters are given to all service users, who fill them in for themselves, or family and staff are available to assist if needed, postal votes are arranged if required. Staff are trained in the Protection of Vulnerable Adults, the home adopts a whistle blowing policy policy to ensure the safety and protection of sevcie users and we have robust procedures in place for reporting all allegations of suspected abuse, in accordance with the Department of Health (No Secrets). Financial affairs of service users are discussed in private on admission, this includes the arrangements we provide for the safe keeping of valuables. The Yews facilty for safe keeping some personal allowances is used by some of the service users who lack the capacity to handle their own financial affairs. On the day of the inspection visit: The Yews had received four complaints since the last inspection and these had been dealt with appropriately and within the required timescale. However it was noted that although the actions taken had been recorded, the complaints recording sheet did not have a specific area to record the actions taken and the outcome of the complaint. As a matter of good practice it is therefore advised that this is included to ensure that actions and outcomes are always recorded of any complaints received. Resident’s comments and the completed the residents’ surveys indicated that they knew how to make a complaint, those residents that were spoken to said that if they had any concerns they would discuss this with their families or with the registered manager. The safeguarding adults policy was looked at and referred to the Local Authority procedure in Safeguarding Adults. However it is recommended that this policy be amended to state that as the Local Authority are the lead investigators in Safeguarding referrals and investigations they should be contacted initially regarding any safeguarding matters. It is also advised that the contact number for the lead safeguarding officer within the local authority is recorded within this policy. No safeguarding referrals or investigation had been made or undertaken regarding The Yews since the last inspection visit. Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Residents live in a clean, safe, well-maintained environment. EVIDENCE: The written information provided by the registered manager prior to this inspection visit stated: The Yews Residential Home is set in its own grounds, which are safe and well maintained with an attractive patio area with seats and planters. The large windows and patio doors allow in light, the views from the patio doors and windows are situated a comfortable distance from the main access roads to ensure peace and quiet from the noise of traffic. The interior is designed to meet service users individual and collective needs, having a well decorated and comfortably furnished large hexagonal lounge area to enable social interaction and stimulation. There is an adjoining smaller lounge for service users who enjoy the quieter side of life. Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 21 A loop system is provided in both parts of the lounge and in the extended dining room. Maintenance is ongoing and carried out as required, the home meets all fire and environmental health regulations. A lounge for smokers is situated away from the communal lounges at the rear of the home, this being the only inside designated area in which to smoke. The front and rear of the home has areas for service users who wish to venture outside with seating and shelter, accessible for wheel chair users. Toilet facilities are close to lounges and dining areas and a recent extension of six purpose built ensuite bedrooms with TV and telephone points. In the established part of the home there are ensuite facilities in some rooms, other rooms have washing facilities and a toilet close by, a commode is provided in the room where there is no toilet at the service users request. A passenger lift and integral ramps form access for service users to access the library area and individual bedrooms. All corridors have grab rails, toilets and bathrooms have additional aids and grab rails. Nurse Call systems with alarm facility are in every room All rooms are centrally heated with low surface temperature radiators. On the day of the inspection visit: The Yews provides spacious communal areas for residents with the main hexagonal lounge being a popular area. Residents spoken with stated that they thought this room was ‘lovely’ and the room was bright, with large windows and spacious with a large wall mounted wide screen plasma television. Three of the residents spoken with had private accommodation within the ‘new’ extension part of the building. These rooms incorporated en suite facilities. These residents confirmed they were happy with their private accommodation. A laundry facility and sluicing machine room were in place with the new extension area to ensure that unlaundered clothes were not carried through the dining areas. The large laundry area was seen and housed the required equipment to launder residents clothing to the appropriate temperatures and met the disinfection standard. Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 22 A laundry assistant was employed at the Yews from Monday to Friday and at weekends night staff undertook the resident’s ironing and senior staff washed and dried resident’s laundry. All communal areas seen provided pleasant and comfortable surroundings and attractive furnishings. The Yews had a clean fresh smell throughout and good standards of hygiene were noted and residents that were spoken with or that completed the residents’ surveys indicated that good standards of hygiene were maintained at The Yews. Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s needs were met by the numbers and skill mix of trained staff who were competent to do their jobs, but the recruitment practices at the home must remain vigilant to ensure residents safety and welfare is maintained. EVIDENCE: The written information provided by the registered manager prior to this inspection visit stated: Robust procedures are in place for the recruitment and selection of staff with a mixture of skills to provide care for residents assessed needs. The ratios of staff is determined according to the assessed needs of the resident group, all staff who provide personal care to a resident are over the age of 18 and no-one under the age of 21 is left in charge of the home. Domestic staff are employed in sufficient numbers to ensure that the standards relating to food, meals and nutrition are met and that the home is clean and free from dirt and unpleasant odours. Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 24 Staff training is a high priority to ensure that good standards of care and working practices are maintained, fifteen of the eighteen care staff have achieved NVQ2 or above and three are enrolled on NVQ2. Mandatory training in Moving and Handling is carried out yearly, Fire Training is carried out twice yearly, On the day of the inspection visit: One senior carer and three were on duty each morning and one senior carer and two care staff were on duty in the afternoon and evening. Two waking night staff were available throughout the night. From Monday to Friday 2 members of the management team were also on duty. Staff spoken with felt that the staffing levels in place were generally sufficient to meet the residents needs. However some staff indicated that an extra member of staff during the late shift would be beneficial to support with bathing residents and assist with clearing away the teapots. Resident’s comments and the completed the residents’ surveys indicated that residents felt the staffing levels in place were able to meet their needs. However several residents did comment that staff were always very busy and worked very hard. Of the eighteen care staff employed ten had achieved a National Vocational Qualification (NVQ) at level 2 in care, four had achieved an NVQ at level 3 and three staff were enrolled on NVQ 2 training. The recruitment documents for two members of staff were seen and in general all of the required information and evidence was in place. However one member of staff had initially worked at The Yews as a student on placement and the organisation that arranged this placement had undertaken the Criminal Records Bureau (CRB) check for this member of staff. On commencement of a full time post at The Yews a new CRB check should have been undertaken and this had not been done. This was discussed with the manager and it was confirmed that a CRB check would be applied for immediately and this member of staff would work under the supervision of a senior member of staff until this CRB check was cleared. The inspector returned to the service the next day and evidence was in place to demonstrate that these actions had been taken. All mandatory training was up to date and training such as infection control and safeguarding adults had also been undertaken. Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 25 Staff spoken with indicated that the training opportunities at The Yews was good and enabled them to understand and meet the needs of the resident group. Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 26 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Resident’s live in a home that is well managed and is run in their best interests, but a system of feedback needs to be implemented. Resident’s financial interests were safeguarded and the health, safety and welfare of residents and staff was promoted and protected. EVIDENCE: The written information provided by the registered manager prior to this inspection visit stated: The Manager is qualified with NVQ 4 and RMA with 5 years experience in running the home with the commitment to meet its stated purpose, aims and Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 27 objectives. The Manager and Proprietor undertake periodic training to update their knowledge, skills and competence, both nearly completing IT Skills Level 2. Seminars of interest are attended, literature from care and business brochures are used to keep up to date with new market products for replacement and refurbishment of the interior. The managers approach creates an open and inclusive atmosphere, communicating a clear sense of direction and leadership, encouraging creativity and development, committed to equal opportunities in the home. The proprietor is a working member of the administration team, ensuring his commitment to the home to provide excellent resources for everyone to achieve an excellent standard of care provision. All health and safety working practices undertaken at the home are carried out by qualified engineers, supplying certification for gas, fire panel and fire fighting equipment, lifts and hoists, electrical wiring and PAT testing. On the day of the inspection visit: The registered manager has been in post at the Yews for the last five years and has achieved an NVQ at level 4 in care and the Registered Managers Award. At the time of this inspection the registered manager was undertaking I.T training at level 2. Residents, staff and visitors were complimentary regarding the registered manager’s approach to running the service and her approachable manner. Staff were generally positive regarding the running of the home but some staff spoken with felt the communication between shifts could be improved upon for care staff. It was stated that Senior Care staff handed over to each other between shifts and it was said that there was not always time for the senior care staff to update the care staff regarding any specific issue until later in the day. It is therefore suggested that a communication book be used to alert care staff to read residents daily logs if any immediate concerns or information need to be passed to care staff at commencement of their shift. Questionnaires had been sent out to residents in April 07 and at the time of this inspection visit this information was in the process of being audited. The registered manager stated that questionnaires were going to be sent out to relatives and information regarding residents meetings would be included with these questionnaires. A system was still not in place to feed back to residents, relatives and other interested parties the results and actions taken from the results of surveys, a Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 28 requirement was made regarding this at the last inspection visit and this will remain in place with an extended timescale in order for this work to be completed. Financial transaction records for resident’s monies were seen and all transactions had been recorded with two signatures at each transaction. The monies held for two residents was counted and corresponded with recorded balance held. Some of the records relating to the safe working practices undertaken at the Yews were examined and all were satisfactory and kept up to date. This included; maintenance certificate for fire panels and emergency lighting, weekly records of fire alarm tests, maintenance certificates for lifts and hoists. Fire training had taken place for the staff team the evening prior to this inspection visit and night staff had attended this training, which included a practical session on evacuation procedures. Staff spoken with confirmed they had attended this training and said they had found this training to be very useful in assessing the support needs of the residents in the event of an evacuation being required. The manager confirmed that following this training, a plan of the support that residents would require in an evacuation was being reassessed. This demonstrates that a proactive approach to health and safety measures are undertaken at the home. The information provided by the home prior to this inspection visit stated that all equipment had been serviced and maintained as required. Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 4 Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 5 Requirement The service user guide must contain all the information as stated in Regulation 5 of the Care Homes Act 2001. (Previous timescale for action 01/06/07) Timescale for action 01/04/08 2. OP9 13 (2) 3. OP29 19 Schedule 2 (7) 4. OP33 24 Medications with a short expiry 08/11/07 date once opened must be dated upon opening to ensure they are not used once they reach their expiry date. Criminal Records Bureau Checks 08/11/07 are not portable. All staff employed must have a Criminal Records Bureau (CRB) Check in place that has been requested by the employing body The results of resident’s surveys 01/04/08 must be published and made available to current and prospective residents, their representatives and other interested parties. (Previous timescale for action 01/06/07) Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 31 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 OP1 Good Practice Recommendations The residents’ guide should include residents’ views of the home, number of places provided and any specialist interests catered for. The statement of purpose and residents’ guide should be available in a variety of formats such as on tape, with symbols and in large print. Complaints recording sheets should have specific areas for the actions and outcomes of complaints to be recorded. The safeguarding adults policy should be amended to state that the Local Authority are the Lead Investigators in Safeguarding referrals and investigations, and should be the initial contact for all Safeguarding matters. The contact number for the Lead Safeguarding Officer within the Local Authority should be recorded within this policy. 2. OP1 3 4 OP16 OP18 Yews, The DS0000002011.V347556.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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