Care Home: Yews Hill

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What the care home does well The home is well managed, and there are appropriate quality assurance and monitoring systems in place that ensure that people`s health and welfare are promoted and protected. People best interests are promoted and protected by a competent staff team, that is well trained, and appropriate employment checks are made on the people wishing to work in the home. People live in a clean and tidy home. Appropriate systems are in place to ensure that complaints are dealt with properly, and that people are safeguarded against abuse and harm. The systems operated within the home ensure that people receive care and support in appropriate ways; their health care needs are well met; and people are well supported with their medication requirements by a competent staff team. The service provides good opportunities for people to get involved in a range of activities both inside and outside of the home within the wider community. People`s wellbeing is promoted by way of the assessment and minimising of risks and good care planning. People who come to live at the home have their needs assessed before they move in, so that the staff know how to support and care for the person, and meet their individual needs. What has improved since the last inspection? At the last inspection in October 2007, a requirement was made in relation to a need to improve the care plans at the home; evidence of improvement was found. At the last inspection in October 2007, a requirement was also made in relation to a need to improve the way risk assessments are carried out within the home; evidence of improvement was found. A range of fulfilling, valued activities appropriate to their needs and wishes both in and outside of the home are now offered by the service, and the staffing arrangements have been changed since the last inspection so that staff are now available during the day to support those people who do not attend day centres or college, or take part in activities within the community, or at the organisation`s own resource centre. Revised systems are in place regarding medicine management. Weekly audits of the medication take place to ensure people are getting the right medication at the right time. The numbers of staff who are trained in the administration of medication has been reduced, and that people`s competencies in this area have also been assessed. At the last inspection in October 2007, a requirement was made in relation to a need to improve the way that complaints were dealt with by the service; evidence of improvement was found. At the last inspection in October 2007, a requirement was made in relation to a need to improve the way that records were securely kept within the home: evidence of improvement was found. All the records held within the home were found to be kept secure. At the last inspection in October 2007, a requirement was made in relation to a need to ensure hazardous products were stored correctly and safely: evidence of improvement was found. The cupboard that contains cleaning and hazardous products at the home now has an appropriate locking device fitted to it, and the staff said that it is now kept locked to protect people living at the home from harm. What the care home could do better: A recommendation that the service explore the opportunities of using recognized person centered planning tools has been made at the end of this report. CARE HOME ADULTS 18-65 Yews Hill 75 & 77 Yews Hill Road Lockwood Huddersfield West Yorkshire HD1 3SG Lead Inspector Tony Brindle Key Unannounced Inspection 28th April 2008 10:00 Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Yews Hill Address 75 & 77 Yews Hill Road Lockwood Huddersfield West Yorkshire HD1 3SG 01484 430329 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) lmacdonald@bridgewoodtrust.co.uk Bridgewood Trust Limited Mrs Valerie Broadley Care Home 17 Category(ies) of Learning disability (17) registration, with number of places Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th October 2007 Brief Description of the Service: 75 and 77 Yews Hill are registered with CSCI and managed as one as one establishment. Yews Hill provides care and accommodation for seventeen adults with learning disabilities; one house (known within the service as North Rise) accommodates five individuals whilst the other (Yews Hill Road) accommodates twelve. Yews Hill is owned by the Bridgewood Trust, a voluntary organisation that provides a range of services to people with learning disabilities. The houses are located in Lockwood, a suburb of Huddersfield. They are close to a bus route and there are a small number of community facilities in the area. Both houses are purpose built over two floors. Both houses have single bedrooms and there are good communal facilities and a large garden that both homes share. People living at North Rise have the benefit of en-suite facilities. The current scale of charges at Yews Hill is £301.60 - £692.83. All those living at the homes contribute towards transport costs. The service provider ensures that information about the service is available by way of the home’s Statement of Purpose, the Service User Guide and through CSCI inspection reports. Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit started at 10:00 and ended at 16:00. This was a very positive and enjoyable visit. There was the opportunity to speak to people living at the home as well as the two of the operations manager and care staff. The registered manager was on annual leave at the time of the visit. Records were looked at such as assessments, care plans, daily and medical records and the record of activities. Staff records were also looked at such as application forms, references, police checks, training and supervision records. A sample of peoples’ medications and finances were checked and a look around the home was undertaken. Other information considered was the homes returned Annual Quality Assurance document and surveys that were returned Commission for Social Care Inspection. Surveys that were sent to people living at the home, and healthcare/social care professionals were also considered. The feedback received was positive. The inspector would like to take the opportunity to thank the staff for their hospitality and to thank the people using the service for their patience and cooperation throughout the visit. What the service does well: The home is well managed, and there are appropriate quality assurance and monitoring systems in place that ensure that people’s health and welfare are promoted and protected. People best interests are promoted and protected by a competent staff team, that is well trained, and appropriate employment checks are made on the people wishing to work in the home. People live in a clean and tidy home. Appropriate systems are in place to ensure that complaints are dealt with properly, and that people are safeguarded against abuse and harm. The systems operated within the home ensure that people receive care and support in appropriate ways; their health care needs are well met; and people are well supported with their medication requirements by a competent staff team. The service provides good opportunities for people to get involved in a range of activities both inside and outside of the home within the wider community. People’s wellbeing is promoted by way of the assessment and minimising of risks and good care planning. People who come to live at the home have their needs assessed before they move in, so that the staff know how to support and care for the person, and meet their individual needs. Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: A recommendation that the service explore the opportunities of using recognized person centered planning tools has been made at the end of this report. Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who come to live at the home have their needs assessed before they move in, so that the staff know how to support and care for the person, and meet their individual needs. EVIDENCE: The records relating to three people living at the home were looked at. Evidence was found to show that people’s needs had been appropriately assessed prior to them moving into the home. The operations manager explained that if a new person wanted to move into the home, then they would be given the chance to visit the home, stay for a meal and get to meet the people living and working there. Feedback from people who completed our survey indicated that they had received satisfactory levels of information about the home before moving in. Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s wellbeing is promoted by way of the assessment and minimising of risks and good care planning. EVIDENCE: At the last inspection in October 2007, a requirement was made in relation to a need to improve the care plans at the home; evidence of improvement was found. The operations manager explained that the care planning system and documentation has recently been reviewed by the organisation. The plans that were looked at were found to set out how people’s current needs and requirements will be met by staff at the home. Individualised procedures for people likely to challenge the service was found and evidence was seen that the plans had been reviewed by the staff with the person or any significant professionals and their family. Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 11 Detailed daily records were found and the operations manager explained that these help the manager to audit the care being provided to people and are a way of ensuring that staff are following the guidelines in the care plans. The information contained within the daily records helped to demonstrate how individual choices have been made with people, and record instances when others have made decisions, and why. For example, the types of activities people get involved in and a daily basis such as going to a local day centre, or going shopping, and the amount of contact people had with their parents or relatives. Staff were seen to provide people with the information about what was going on inside and outside the home, and were seen to do this in a person centred way, taking into account people’s communication abilities. Feedback from people who completed our survey indicated that they were satisfied with the way peoples needs are met by the staff team. At the last inspection in October 2007, a requirement was made in relation to a need to improve the way risk assessments are carried out within the home; evidence of improvement was found. The operations manager explained that risks to the person are assessed prior to admission, and continues once a person has moved in. Information contained within people’s files showed that risk assessments are undertaken and includes information about what action needs to be taken to minimize identified risks and hazards. It was noted that on the documentation used by the service the phrase “person centred planned” is used. A discussion took place with the operations manager as to what extent the service used recognised person centred planning tools. The operations manager said that at the present time, recognised person centred planning tools are not yet used, but she agreed that the addition of such tools could be of potential benefit to the people living at the home. She added that the use of recognised tools would help to broaden the opportunities of people living at the home as this would mean that people are at the centre of person centered planning, which includes them having the opportunity to lead their own plan. A recommendation that the service explore the opportunities of using recognized person centered planning tools has been made at the end of this report. Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service provides good opportunities for people to get involved in a range of activities both inside and outside of the home within the wider community. EVIDENCE: The operations manager explained that people are now supported to participate in a range of fulfilling, valued activities appropriate to their needs and wishes both in and outside of the home. He added that the staffing arrangements have been changed since the last inspection, and that staff are now available during the day to support those people who do not attend day centres or college, or take part in activities within the community, or at the organisation’s own resource centre. Feedback from people who completed our survey indicated that they were happy with the activities on offer. And one Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 13 person living at the home said that they enjoy going out on trips, and going to the resource centre. Information held within people’s care plans indicated that they do take part in a range of activities suited to their needs. One staff member said that family and friends are welcomed, and their involvement in daily routines and activities is encouraged, with the service user’s agreement. The operations manager said that in order to support people to keep in touch with their family or friends, the arrangements for this are recorded in people’s care plans. He added that if the agreement is not kept to, the reasons for this are recorded. Information held with the records confirmed this. People were seen to be offered a choice of suitable menus. One staff member said that meals are offered three times daily, and that a range of drinks and snacks to meet individual needs are available at all times. People living at the home said that they can choose where and when to eat, and whether to eat alone or with others including staff. Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The systems operated within the home ensure that people receive care and support in appropriate ways; their health care needs are well met; and people are well supported with their medication requirements by a competent staff team. EVIDENCE: The operations manager explained that people living at the home require varying degrees of support with their personal care. Good information about people’s preferred routines and what support they require was found within the newly updated personal support plans. Examples of staff providing discreet and sensitive support to people was observed when supporting people to go and use the bathroom. Good levels of information were found within people’s care plans to show that people are Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 15 supported to have their healthcare needs met. The records show that people attend regular healthcare appointments with support. There was evidence that the expertise and guidance of healthcare professionals is sought. A new information pack for an individual to take to the hospital was seen. This contained really useful information that would support the person’s needs to be met appropriately. Good levels of information were found within people’s care plans with regards to people’s epilepsy and action the staff need to take in the event of a seizure or a fall. Since the last inspection, revised systems are in place regarding medicine management. Excellent information is available regarding what medication individuals are taking, why they are taking it, possible side effects and when they started taking the medication. Clear information about when ‘as required’ (prn) medication should be administered is available, along with a photograph of each individual to ensure the correct medication is given to the right person. Medication administration records were examined along with medication stored. All medication tallied with the records. The operations manager explained that the numbers of staff who are trained in the administration of medication has been reduced, and that people’s competencies in this area have also been assessed. Information contained within the staff training records and personnel files confirmed. The operations manager explained that weekly audits of the medication take place to ensure people are getting the right medication at the right time, and information held within the records confirmed that the audits do take place. Feedback from people who completed our survey indicated that they were satisfied with the way the service supported people with their healthcare needs. Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Appropriate systems are in place to ensure that complaints are dealt with properly, and that people are safeguarded against abuse and harm. EVIDENCE: At the last inspection in October 2007, a requirement was made in relation to a need to improve the way that complaints were dealt with by the service; evidence of improvement was found. The operations manager explained that there is a complaints procedure, which includes the stages of, and timescales, for the process. Information contained within the procedure confirmed that there is a clear and effective procedure in place. People living at the home said that they know who is complain to if they had worries or concerns. Feedback from relatives who completed our survey indicated that they too knew who to complain to. The records relating to complaints received by the registered manager were found to be in good order, and showed that people who had complained, were satisfied with the way complaints had been dealt with and investigated. Information held at the home shows that staff have access to the organisation’s policies and procedures relating to safeguarding people from abuse. The operations manager gave a very good explanation of the procedure, which showed how the organisation link in with the Local Authority and Police as and when required. Information held with the staff training Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 17 records confirmed that staff have had training in the area of safeguarding people from abuse, and one staff member who was spoken with gave a good account of what abuse is, how to deal with allegations or suspicions, and what the reporting procedures were. The home continues to notify the Commission of events and incidents within the home that affect people the wellbeing of the people living there. The operations manager explained that where there is doubt that people living at the home are able to make an informed decision when being asked to sign agreements relating to the use of their benefits, the manager now ensures that a relevant professional undertakes an assessment of that person’s capacity. He added that where it is felt that people do not have the capacity to make such a decision, appropriate steps are taken to reach agreement about what is in the individuals best interests, through consultation with a multi-disciplinary team. Information held within people’s individual files confirmed that this now takes place. Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People live in a clean and tidy home. EVIDENCE: All areas of the home were seen to be clean, free from unpleasant odours and comfortably furnished. Feedback from people who completed our survey indicated that they were all indicated that the home is always clean and fresh and those spoken to said they were happy with the maintenance of the home. Laundry facilities at the home were seen to be satisfactory and infection control procedures were seen to be are in place. Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 35 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People best interests are promoted and protected by a competent staff team, that is well trained, and appropriate employment checks are made on the people wishing to work in the home. EVIDENCE: The operations manager explained that there are consistently enough staff available to meet the needs of the people using the service, with more staff being available at peak times of activity, and added that the staffing structure is based around delivering outcomes for people at the home. Information contained within the home’s rotas show that the staff are used in creative ways, making sure that the home is staffed efficiently, and the operations manager explained that particular attention is given to busy times of the day and changing needs of the people who use the service. Information within the rotas confirmed this. The staff records show that some staff members undertake external qualifications beyond the basic requirements. Feedback from people who Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 20 completed our survey indicated that people believe that staff team to be skilled in their role and are consistently able to meet people’s needs. The operations manager explained that the organisation puts a high level of importance on training and some of the staff that were spoken with said that they are well supported through training. Information contained within the staff training files indicated that the staff receive mandatory training such as health and safety, movement, safeguarding and handling and first aid, and that other specialised training is offered such as dealing with epilepsy, communication skills and person centred care. The training records show that the number of staff with an NVQII qualification or above is currently 80 . The operations manager explained that recruitment procedure. Information contained within the staff personnel files show that the procedure is followed satisfactorily. The records show that staff meetings take place regularly, and that supervision sessions are regular and staff who were spoken with said that they find them helpful. The records show that supervision has a focus on improving outcomes for people using the service. Feedback from people who completed our survey indicated that they believed the staff to be well trained, and very capable in their caring role. Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well managed, and there are appropriate quality assurance and monitoring systems in place that ensure that people’s health and welfare are promoted and protected. EVIDENCE: The information held by the Commission indicates that the registered manager has the required qualifications and experience to run the home. The rotas show that the registered manager has a number of hours allocated to her that allows her to concentrate purely on managerial tasks. Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 22 Information held by the service and the Commission shows that since the last inspection, the organisation has worked well with the Commission to improve outcomes for people living at the home, and there has been a strong ethos of being open and transparent in all areas of running of the home. The information supplied by the organisation on its Annual Quality Assurance Assessment (AQAA) was found to be clear, relevant and supported by a wide range of evidence. The AQAA gave the Commission information about changes that the organisation has made and where they still believe thay need to make improvements. At the last inspection in October 2007, a requirement was made in relation to a need to improve the way that records were securely kept within the home: evidence of improvement was found. All the records held within the home were found to be kept secure, and the operations manager explained that only those people with permission to access the records do so. Improved security arrangements are now in place. Information held within the records at the home shows that there are good policies and procedures in place that are regularly reviewed and updated. The operations manager explained that there are effective systems to monitor staff adherence to policies and procedures during their practice. Information held within the personnel files and other documents within the home confirmed this. Staff members who were spoken with were fully aware of the home’s health and safety policy and the records show that they are well trained in this area. The records show that regular random checks take place in relation to medication and other systems within the home to ensure that the systems are safe. As already mentioned, safeguarding training is given and the service provides a range of policies and guidance for staff to underpin good practice. Information within the records at the home showed that the service has a consistent record of meeting relevant health and safety requirements. The records were seen to be of a good standard and are routinely completed. The operations manager explained that when risk assessments are undertaken, the involvement of people living at the home is encouraged. The records confirmed this. Quality assurance and monitoring process were seen to be in place that ensure the efficient running of the home.. The records show that the service has necessary insurance cover to enable it to fulfil any loss or legal liabilities. The records show that people are supported to manage their own money where possible. Where this is not possible, clear reasons for this are recorded in people’s plans. At the last inspection in October 2007, a requirement was made in relation to a need to ensure hazardous products were stored correctly and safely: evidence of improvement was found. The cupboard that contains cleaning and Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 23 hazardous products at the home now has an appropriate locking device fitted to it, and the staff said that it is now kept locked to protect people living at the home from harm. Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 YA6 Good Practice Recommendations The service should explore the opportunities of using recognized person centered planning tools such as PATHs, MAPs and Essential Lifestyle Plans. Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Yews Hill DS0000026331.V363432.R01.S.doc Version 5.2 Page 27 - 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. 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