Care Home: Yew Trees

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What the care home does well There is a warm welcoming atmosphere, and visitors to the home said that staff were always helpful and available to answer any of their queries. Residents and their visitors were complimentary about the way in which the staff supported them. Comments included: "I can always go to staff with a problem, they are always there to help. They will do anything to help you, I have no complaints, I`m happy with everything". "The staff are so nice, they make a jolly atmosphere". Relatives said: "I visit every week and the staff are absolutely excellent. I couldn`t wish for better care. I can approach them with any concern". "They (the staff) give brilliant personal care. My mother is so happy and contented. Staff are so good with her and she sees the same familiar faces". "I feel the staff really know individual needs and I feel I can be confident and trust staff to meet needs". The staff team were very enthusiastic and demonstrated a high level of commitment to their care role. All staff said they had plenty of opportunities to go on training courses to help them to develop their knowledge and skills. The training programme showed that the organisation was committed to prioritising training and development opportunities. There was evidence to show that the manager used a variety of methods to promote good practice. Supervision with staff was used to highlight good practice ideas, and staff felt well supported by the manager. The internal and external space offer residents and their relatives pleasant comfortable surroundings. All residents who were spoken to spoke highly of their personal space and many bedrooms were personalised to reflect individual taste. The lunchtime was a relaxed and pleasant occasion. There was a choice of menu and individual tastes and preferences were catered for. One resident said, "The food here is lovely, there`s something for everyone". What has improved since the last inspection? There was evidence of ongoing maintenance and renewal. During this visit contractors were present to fit new flooring to the conservatory. Information in the AQAA identified that review of care plans was an area where there had been improvement. This was also seen during this visit. Care plans were regularly reviewed and included meaningful recordings of any changes that had been identified during this process. Since the last inspection, all staff have received training in safeguarding, and this means that residents and their relatives can be confident that staff are aware of issues surrounding abuse and know what to do in the event of any allegation of abuse. Staff training continues to improve and there was evidence to show that progress was being made with National Vocational Qualifications (NVQ). One senior care staff has completed level 3 training in NVQ and two seniors have completed senior development training. One care staff has attended training to help her improve activity programmes in the home. CARE HOMES FOR OLDER PEOPLE Yew Trees Yew Trees Lane Dukinfield Tameside SK16 5BJ Lead Inspector Ann Connolly Unannounced Inspection 09:03 22 September 2008 nd 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 Yew Trees DS0000005587.V364672.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. Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Yew Trees Address Yew Trees Lane Dukinfield Tameside SK16 5BJ 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) 0161 338 3053 0161 303 0072 yewtrees@meridiancare.co.uk Meridian Healthcare Ltd Susan Chadwick Care Home 40 Category(ies) of Dementia - over 65 years of age (40), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (3), Old age, not falling within any other category (40), Physical disability over 65 years of age (40), Sensory Impairment over 65 years of age (2) Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 40 service users to include: *up to 40 service users in the category of OP (old age not falling within any other category). *up to 40 service users in the category of PD (E) (Physical disability over 65 years of age). *up to 40 service users in the category of DE(E) (Dementia over 65 years of age). *up to 2 service users in the catergory SI(E) (Sensory impairment over 65 years of age). *Up to 3 service users in the category of MD(E) (Mental disorder excluding learning disability or dementia over 65 years of age). 22nd September 2006 Date of last inspection Brief Description of the Service: Yew Trees is a large, purpose built establishment owned and managed by Meridian Healthcare Limited. The home provides care for up to 40 older people, some of whom have a dementia or physical disability. The accommodation is provided in single rooms over two floors, 25 of which have en-suite facilities. There is a full passenger lift and aids to enable the residents mobility. Both floors have lounges and dining areas and there is a designated area on the ground floor for those people who smoke and a large conservatory. Small kitchens are situated on each floor where drinks and snacks can be prepared. In addition, there is a small room containing specialist equipment to help residents who have dementia. The home is located on the edge of a residential area with associated local facilities and transport links. There is an enclosed garden to the rear of the home, shared by an adjacent home. Car parking is the front of the building. Fees for accommodation and care at the home range from £415.79 to £444.29. Additional charges are also made for hairdressing and chiropody services, newspapers and personal toiletries. Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes This was a key inspection that included a site visit to the home. The manager was not told beforehand that we were coming to inspect, this is called an unannounced inspection. This inspection looked at all the key standards and included a review of all available information received by the Commission for Social Care (CSCI) about the service provided at the home since the last inspection. During the site visit a selection of records, care plans, policies and procedures were examined. Discussions took place with the manager, staff working in the home, and some relatives who were visiting. Some visiting professionals were asked for their comments about the home. Several residents living in the home were spoken to in private during the visit, and discussions took place with them to find out what they thought about the home and what they felt about how the staff supported them. A tour of the home was undertaken and residents were asked for their comments and views about the environment. Before the inspection, we also asked the manager of the service to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well, and what they needed to do better. This is one of the ways that we get information from the manager of the service, about how they are meeting outcomes for people using their service. Information provided in the (AQAA) for this service was detailed and comprehensive, and provided evidence of a service that was committed to focusing on positive outcomes for the people who use the service. Since the last inspection visit, which took place on 22nd September 2006, the Commission for Social Care Inspection has not received any concerns about this service. There was evidence during this visit that the manager was managing complaints well, and that procedures were followed appropriately. Over the last twelve months the home’s manager has received 6 complaints, and information in the AQAA states that these were investigated within 28 days. All 6 of these complaints were upheld. A number of these complaints were minor in nature, and the response made by the home shows that no matter how small the complaint, the home takes all concerns seriously. Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? There was evidence of ongoing maintenance and renewal. During this visit contractors were present to fit new flooring to the conservatory. Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 7 Information in the AQAA identified that review of care plans was an area where there had been improvement. This was also seen during this visit. Care plans were regularly reviewed and included meaningful recordings of any changes that had been identified during this process. Since the last inspection, all staff have received training in safeguarding, and this means that residents and their relatives can be confident that staff are aware of issues surrounding abuse and know what to do in the event of any allegation of abuse. Staff training continues to improve and there was evidence to show that progress was being made with National Vocational Qualifications (NVQ). One senior care staff has completed level 3 training in NVQ and two seniors have completed senior development training. One care staff has attended training to help her improve activity programmes in the home. 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. Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 8 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 Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 9 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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are assessed prior to admission to the home so they can be confident their care needs can be met by staff. (Standard 6 was not assessed as this home does not offer intermediate care). EVIDENCE: Three care plan files were looked at during this visit. They all contained preadmission assessments, and an assessment from the care manager from the placing authority. The manager or senior representative from the home visits all prospective residents to complete the assessment documentation. On all three files the assessments were brief, and provided limited information. It was recommended that more time was taken to gather information about individual Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 10 care needs when undertaking these assessments so that staff have enough information to generate a working care plan. Yew Trees DS0000005587.V364672.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care received by residents is based on their individual assessed needs. Resident’s privacy and dignity are respected. EVIDENCE: Three care plans were looked at during this visit. Two out of the three care plans were written in detail and gave staff the information they needed to meet care needs in a safe way. One care plan contained brief information, and would have benefited from input equal to the other two plans looked at. Care plans should be reviewed and audited to ensure consistency in the quality of recordings. Care needs were documented with instructions for staff on how residents wanted to be supported. When changes in care needs were identified there was documentary evidence to show that the care plan had been updated to reflect the changes. Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 12 Records were in place to monitor nutrition, weight, falls and general risk assessments including moving and handling. One file which was looked at showed that a resident was experiencing difficulty with maintaining mobility. This need was clearly documented and recorded, with strategies and interventions for staff to help them to support this person. The review in this case included a referral to appropriate healthcare support services and the physiotherapist. The care plans include daily recordings to show what support had been provided to each resident. Some of these recordings were inappropriate and contained information which was not relevant to the care plan. There was documentary evidence to show that the manager had identified this shortfall and was currently addressing this in supervision sessions. Care staff had been provided with written samples of good practice in recording information, and were being given appropriate guidance and training to support them in this part of their work. There was documentation to show that regular monthly reviews were taking place, and where changes had taken place in health care needs, these had been updated in the care plan. There was evidence to show that residents were supported to access healthcare services and records were kept of all these visits including visits from the General Practitioner and visiting consultants. One visiting medical professional confirmed that staff were always on hand to provide support and were receptive to any guidance that was offered to them. All the residents who were spoken to during this visit were highly complimentary about the staff team. Staff were observed carrying out their duties in a sensitive, polite and caring manner. Residents were supported to maintain their privacy and dignity at all times. One resident said, “The staff are nice and they make a jolly atmosphere”. A relative who was spoken to said, “The staff are absolutely excellent. We couldn’t ask for any better care, and I can approach the staff with any concern”. Medication was administered using a monitored dosage system and there were plans in place to change to a new supplier who is going to supply a ‘blister pack’ monitored dosage system. Medication administration records were appropriately maintained. The receipt and disposal of medication received in bottles and packs was recorded in a bound book, however, the receipt of the medications received in the dosette boxes had not been recorded. All medication received into the home must be recorded. There was an overstocking of some medication. The manager must arrange for an audit of all medication in the home so that stock levels balance with the record of medication held in the home. There were systems in place for the safe storage of controlled drugs. However the cabinet did not meet the current legislation for safe storage of controlled medication and the manager said that a new storage unit was on order. Staff who are responsible for the administration of Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 13 medication receive appropriate training so that residents can be sure that they will receive their medication safely. Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 14 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to engage in the social activities and daily life in the home. Staff support and encourage residents to maintain links with their family and friends and to exercise as much choice and control over their lives as they can. EVIDENCE: Two part time activities organisers are employed by the home. Every day, five hours of activities are organised by one of the activity organisers. The activities available were listed in the reception area. Residents who were spoken to confirmed that there were always a wide range of activities available including trips out, bingo, art and craft etc. One resident said, “ I really like it when we have our quiz”. During this visit quizzes were taking place in the two lounges. Other residents said they preferred their own company and enjoyed chatting to other people. One of the organisers spoke with us and told us that she had recently attended training that provided her with a greater understanding of Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 15 the needs of people with dementia. She described ways in which she was implementing some of the ideas she had learned. The home has a relaxation room. The equipment in this was not working and several resources were missing. Some staff said the room was never used because residents showed no real interest. However, many of the residents in the home would not be able to initiate this activity themselves, as they require support and guidance to motivate them to access the resources in the home. This issue is discussed further in the staffing section of this report. The manager was informed about the problems with the activity room and addressed this at the time of the visit by referring the faulty equipment to the handyman for repair. Residents were seen coming and going as they pleased and staff were seen supporting residents to get on with their daily lives and routines in a way that suited them. There were a large number of visitors during the course of the day. Staff provided a warm welcome and seemed to have time to answer any queries that people presented to them. The lunchtime was a relaxing and pleasant occasion. The dining room was bright and spacious and consisted of small group seating arrangements. The meal was well presented. There was a choice of meals available every day, and on the day of the visit the menu consisted of cottage pie with green beans, omelette or jacket potatoes. The desert menu was a choice of pear crumble and custard or yogurt and fruit. The evening meal consisted of soup and chip, potato cakes and home made scones. Residents seemed to enjoy the mealtime occasion. Staff engaged in meaningful and pleasant conversation and there was a warm ‘homely’ feel generated. All residents spoke highly of the meals in the home. Comments included: “Food is quite good”. “We can’t grumble about the food here”. Individual dietary needs were catered for and one resident was served a pureed meal which was presented well. One member of staff provided one to one support for this resident throughout the whole lunchtime period. The care and support provided was sensitive and caring, and the carer focused on this person throughout the whole period to ensure that her dignity was maintained. Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 16 Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 17 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents rights are protected by robust polices and procedures and there is an open transparent approach to managing complaints. EVIDENCE: Yew Trees has a comprehensive complaints procedure, which is made available to existing and prospective residents and their representatives. Information in the home’s annual quality assurance (AQAA) document states that 6 complaints had been received. All of these were addressed within 28 days and all of them were upheld. The Commission has not received any complaints about this service. We looked at some of the complaints and they showed that the home takes all complaints seriously no matter how small. During discussions with the manager there was evidence of an open and transparent approach to any complaint and concern. The manager said the staff were pro-active in supporting staff to respond quickly to concerns raised by residents and their families, so that issues of concern could be managed and addressed quickly and efficiently, and positive outcomes were experienced by any complainant. Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 18 A record is maintained of any complaints and there are systems in place to monitor all complaints made to the home. The home had made several safeguarding referrals and had followed correct procedures by notifying social services who take the lead in any investigations. The home had failed to notify the Commission of some of these referrals. The manager must ensure that the Commission is notified of any events affecting the health and well being of residents in the home. There was evidence in documentation and in the information provided by the manager in the AQAA document, that safeguarding and adult abuse issues were re-inforced to staff in supervision sessions and staff meetings. The training programme included training in the protection of vulnerable adults. Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 19 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides residents with a safe, pleasant and well maintained environment. EVIDENCE: A handyman is employed and he has responsibility for general maintenance and re-decoration throughout the home. Bedrooms were clean and tidy, and many were personalised, reflecting individual tastes. A number of residents had brought their own television and small items of furniture, pictures and ornaments. Many of the rooms appeared cosy and comfortable. Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 20 During this visit there was evidence of ongoing maintenance and renewal. The conservatory was being fitted with new flooring and one of the lounge areas had been re-decorated. Bedrooms had been fitted with new carpets or wooden flooring. Residents and relatives who were spoken to expressed satisfaction with the environment. The outside patio area provided residents with a safe pleasant area to enjoy the warmer weather. The area featured raised flower beds, and pleasant seating areas. Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 21 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs were being met by the skill mix of staff deployed in the home. Recruitment procedures ensure that all appropriate reference checks were carried out. EVIDENCE: Three staff files were examined. These contained documentation required by legislation. All files which were looked at provided confirmation that Criminal Record Bureau Checks (CRB) had been carried out. Staff who were spoken to were enthusiastic about their caring role, and all of them confirmed that they were in receipt of supervision. Supervision records confirmed that staff had regular access to support in their supervision sessions which were held on a regular basis. There was evidence on files that staff had accessed training relevant to their roles. Information in the AQAA states that 75 of staff have attained NVQ level 2 or above. The training matrix provided the manager with an overview of current training and identified where training was required. Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 22 Residents and their relatives were very complimentary about the standard of care and support provided by staff in the home. Many of the comments made reference to the warm, sensitive caring personalities of the carers. During this visit there was one senior staff and two carers upstairs, two carers downstairs. Also on duty were two domestics, the manager and a cook. In the afternoon a part time activities organiser was on duty to co-ordinate activities on the two floors. At the beginning of the inspection the care staff appeared very busy and there seemed to be a tendency for staff to be task focused. Some residents had to wait to get a response from staff who were busy with other residents. In the afternoon, the atmosphere appeared more relaxed and residents benefited from having an additional member of staff to carry out the leisure activities. Some staff said that residents did not always access facilities in the home, for example, the relaxation room. However, many of the residents would not be able to instigate activities on their own as they need support and guidance to motivate them and help to use facilities such as the relaxation room. Staff said they had noticed that the dependency levels of residents had increased over the past 12 months, however, staffing levels had remained the same, with no increase to reflect the greater demands. One staff said that this meant there was not always sufficient time to spend with individual residents on a one to basis. One visiting professional expressed concerns that the service did not have enough staff hours to give residents the one to one attention they needed. The information in the AQAA states that the service specialises in dementia care and promotes a person centred approach. The manager should review staffing levels in the home to ensure that they are sufficient to meet the assessed needs of residents in the home and of any prospective residents. Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 23 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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. This service is run in the best interests of the residents, and the management ensure that the safety and welfare of residents and staff is promoted. EVIDENCE: Residents and staff expressed confidence with the way in which the manager managed the home. All people spoken to said that the manager was always approachable. One of the relatives spoken to during this visit said that she had found the manager very responsive to any problems, and that the manager was approachable and quick to respond to any complaints. Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 24 The manager has completed the registered managers award and continues to attend courses and training as part of her ongoing professional development. There was documentary evidence of regular staff and residents meetings. The meetings were used as a forum to exchange views, and to seek the views of residents about how the service could be developed. Information in the AQAA stated that quality-monitoring systems were in place and the quality report was looked at during this visit. This demonstrated that residents and their relatives were consulted on all aspects of care services provided by the home. Information in the AQAA provided evidence that good standards were maintained for the maintenance of equipment for health and safety including fire prevention equipment. The findings during this visit provided evidence of a service that is committed to developing the service so that residents have positive outcomes. Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 25 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 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 13 Requirement Timescale for action 20/12/08 2. OP18 37 All medication received into the home must be recorded so that there is an accurate record and audit trail of medication receipt, administration and disposal. Stock levels must reflect the records of medication stored in the home. The manager must ensure that 10/10/08 the Commission is notified of any event in the care home which adversely affects the well being or safety of any residents in the home. 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 OP7 Good Practice Recommendations Care plans should be audited to ensure consistency in the quality of recording and so that staff have all the relevant information to help them to supports residents in a safe and appropriate way. DS0000005587.V364672.R01.S.doc Version 5.2 Page 27 Yew Trees 2. OP27 The manager should review staffing levels in the home to ensure that they are sufficient to meet the assessed needs of residents in the home and of any prospective residents. Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Yew Trees DS0000005587.V364672.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!