Inspection on 20/07/05 for Yews, The

This inspection was carried out on 20th July 2005.

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 10/10/07

Yews, The 28/11/06

Yews, The 01/02/06

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 The Yews 2 Church Street Alvaston Derby DE24 0PR Lead Inspector Janet Morrow Unannounced Wednesday 20 July 2005 at 11.30am th 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 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. The Yews C02 C52 The Yews S2011 V236599 200705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Yews Address 2 Church Street Alvaston Derby DE24 0PR 01332 756688 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Rakesh Bhalla Brenda Towell Care Home 21 Category(ies) of 21 - Old Age registration, with number of places The Yews C02 C52 The Yews S2011 V236599 200705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 6th January 2005 Brief Description of the Service: The Yews is a residential home for twenty-one older people situated in a suburb of Derby city. It is within its own grounds and on a corner location.There are nineteen single rooms and one shared double room.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 service users appropriately. Regular entertainment is organised and those service users who wish to go out do so. The Yews C02 C52 The Yews S2011 V236599 200705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and took place over 6 hours. Care records and maintenance records were examined. Two members of staff, one relative and seven of twenty-one service users were spoken with. A partial tour of the building was undertaken. What the service does well: What has improved since the last inspection? A wider range of activities was being investigated, such as speakers from the local history society and service users were encouraged to maintain their own hobbies. Examples of this were doing crosswords, sketching and plant care. Water temperatures were being recorded to ensure safety and eliminate risks of scalding and Legionella. A lockable refrigerator for the storage of medicines had been purchased and a lock had been fitted on the door in the toilet next to the dining room. Improvements had been made to the décor of the smoking room. The Yews C02 C52 The Yews S2011 V236599 200705 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Yews C02 C52 The Yews S2011 V236599 200705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Yews C02 C52 The Yews S2011 V236599 200705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 4 The assessment information provided on admission ensured that the home was able to provide relevant care to met individual service users’ needs. EVIDENCE: Three service users’ files were examined and there was assessment documentation in place in each that provided sufficient information over a range of needs for staff to provide care following admission. Information from the assessment and care management process was available. Service users interviewed stated that their needs were met and one described the home as ‘first class’. The Yews C02 C52 The Yews S2011 V236599 200705 Stage 4.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 Health care needs were met but additional interventions would ensure better consistency of care. Some aspects of the medication administration procedures were inconsistent and had the potential to put service users’ at risk. Privacy and dignity was respected. EVIDENCE: Three service users’ care records were examined. A care plan was in place in each. However, there was insufficient information available to identify risks. For example, none of the files examined had a moving and handling assessment in place and the nutritional assessment information available was limited. All the files examined had a statement signed by the service user indicating agreement to the care. Medication administration record (MAR) charts for three service users were examined. These were completed accurately. However, there was one medicine dispensed into the nomad pack that differed from the dispensing label. This had the potential to cause confusion and possible error. There was also a medicine hand written as a homely remedy on the MAR chart that had not been signed and dated by two people. The Yews C02 C52 The Yews S2011 V236599 200705 Stage 4.doc Version 1.40 Page 10 There was no aid to identity to minimise the potential for errors, such as a photograph, on the MAR chart. A copy of the Royal Pharmaceutical Society guidelines were available. The medication refrigerator temperatures were recorded daily. Service users interviewed stated that their privacy was maintained and it was observed that warm and friendly relationships existed between staff and service users. A relative interviewed stated that their relative’s health had improved since being at the home and that they were happy with the standard of care provided. The Yews C02 C52 The Yews S2011 V236599 200705 Stage 4.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Social activities and meals are both well managed and enhance service users’ daily lives. EVIDENCE: Service users were spoken to during lunch-time. Everyone asked stated that the food was good and they enjoyed it. Specialist diets such as diabetic were catered for. Daily routines were varied and one service user stated that they were ‘able to do what you want’. Daily activities such as dominoes and cards took place and service users were observed to be pursuing their own interests such as reading and crosswords. The manager stated that she was trying to organise other events such as a talk on local history and a summer garden event. Visitors were able to visit when they liked and stated that they were made to feel welcome at the home. The manager was aware of advocacy services and stated that one service user had an advocate. The Yews C02 C52 The Yews S2011 V236599 200705 Stage 4.doc Version 1.40 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Complaints were handled objectively and the home had clear adult protection procedures that ensured an appropriate response to service user protection and suspicions of abuse. EVIDENCE: The written information provided by the home stated that there had been three complaints at the home during the previous twelve months, all of which had been dealt with in twenty-eight days. Those service users and relatives interviewed were confident of a courteous response from the management to any concerns raised. An adult protection policy was in place but it did not make reference to Derby and Derbyshire Local Authority Social Services procedures, although the procedures were available. The written information provided by the home stated that no incidents of abuse had occurred in the last twelve months. Staff had undertaken training in adult protection in 2004. The Yews C02 C52 The Yews S2011 V236599 200705 Stage 4.doc Version 1.40 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 The home was well maintained and provided safe, comfortable and homely accommodation for service users. EVIDENCE: The home was well maintained and suitable for the needs of service users. Grounds were neat and tidy and accessible. Routine maintenance and refurbishing were undertaken as required. All bathrooms and toilets had appropriate aids and adaptations to meet the needs of service users. One newly acquired bath hoist was awaiting batteries before it could be used. It was reported that service users’ found one of the bath hoists uncomfortable due to its plastic seating. Three bedrooms were viewed and were clean, well decorated and personalised with service users’ own possessions. Not all the required furniture was in place, for example the bedrooms did not have a table and second chair. However there was evidence in service users’ files that consultation had taken place regarding requiring additional furniture. The Yews C02 C52 The Yews S2011 V236599 200705 Stage 4.doc Version 1.40 Page 14 All bedrooms were lockable, with access in an emergency. Service users were offered their own key. Service users had a bedside cabinet with a lockable drawer. Water storage temperatures were recorded and staff interviewed stated that bath water temperatures were checked with the available thermometers to prevent risk of scalding. Service users interviewed praised the laundry service. The laundry equipment was in working order and there were sluice facilities available. The home was clean, tidy and odour free. Records examined showed that staff had undertaken training in infection control in April 2005. The Yews C02 C52 The Yews S2011 V236599 200705 Stage 4.doc Version 1.40 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30 There were sufficient well trained staff to meet service users’ needs and provide consistency of care. EVIDENCE: The staff rota for the week beginning 18th July was examined and showed that sufficient staff were deployed to meet service users’ needs. One senior carer and two care staff were available on each shift. Discussion with the manager confirmed that any staff vacancies were covered from within the existing staff group. Staff training records showed that mandatory training in health and safety took place as well as other relevant courses, such as adult protection. Staff interviewed confirmed that they had sufficient access to training. The Yews C02 C52 The Yews S2011 V236599 200705 Stage 4.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 34, 37 and 38 The home was well managed, which ensured that service users’ rights and safety were upheld. EVIDENCE: It was evident from discussion with the manager that she was competent to run the home and she had continued to update her skills and knowledge through further training. Staff, relatives and service users interviewed confirmed that the home was relaxed and informal with a happy atmosphere. Warm and friendly relationships between staff and service users were observed. One service user stated that they felt settled and content shortly after their arrival and a relative stated that the home was well thought of in the local community. The home is commended for creating and maintaining an open, relaxed and inclusive atmosphere. The Yews C02 C52 The Yews S2011 V236599 200705 Stage 4.doc Version 1.40 Page 17 The proprietor stated that the home was financially viable and had plans for further investment in the home by planning an extension to the accommodation. Records were generally clear and legible and were stored securely. However, some of the health information required by Schedule 3 of the Care Homes Regulations 2001 was missing from service users’ records. There was a valid registration certificate and insurance certificate on display. Health and safety was addressed in the home. Staff had undertaken training in fire safety, food hygiene, moving and handling and infection control. Those maintenance records examined were up to date such as hoists and fire extinguisher maintenance and water storage temperatures were checked regularly. The Yews C02 C52 The Yews S2011 V236599 200705 Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 4 x 3 x x 2 3 The Yews C02 C52 The Yews S2011 V236599 200705 Stage 4.doc Version 1.40 Page 19 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 OP 7 Regulation 5 (2) (b) Requirement Timescale for action 1.9.05 2. op9 13 (2) 3. op 7 5 (2) (b) 4. op9 13 (2) 5. 6. op37 ) 17 (1) (a) & Schedule 3 Risk assessments that form part of service users care plans must be regularly reviewed. Previous timescale of 30th September 2004 not met 1.9.05 Any handwritten medication information on MAR sheets must be signed and witnessed. Previous timescale of 30th August 2004 not met Moving and handling risk 1.9.05 assessments must be updated. Previous tiemscale of 1st May 2005 not met The registered person shall make 1.10.05 arrangements for recording, handling, safekeeping, safe administration and disposal of medicines into the care home. . A record which includes the information. documents, and other records speciified in Schedule 3 relating to the service user must be maintained 1.11.05 The Yews C02 C52 The Yews S2011 V236599 200705 Stage 4.doc Version 1.40 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard op9 op9 op18 op21 op9 Good Practice Recommendations The home should ensure that MAR charts and dispensing systems correspond. Any homely remedy administered for more than 48 hours should be referred to a General Practioitner The homes adult protection policy should make reference to Derby and Derbyshire adult protection procedures. Consideration should be given to providing more comfortable seating on the identified bath hoist. A photograph of the service users should be available on each service users MAR chart. 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