Inspection on 22/07/05 for Raynesway View

This inspection was carried out on 22nd 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Raynesway View 21/01/09

Raynesway View 30/11/06

Raynesway View 28/11/05

Raynesway View 21/09/04

Raynesway View 14/04/04

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 Raynesway View Foyle Avenue Chaddesden Derby DE21 6TZ Lead Inspector Andrew Bailey Unannounced 22 July 2005 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. Raynesway View C02 C52 Raynesway view S36027 V239738 220705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Raynesway View Address Foyle Avenue Chaddesden Derby DE21 6TZ 01332 718300 01332 718300 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) Derby City Council Christine Wilson Care Home 35 Category(ies) of 35 - OP - Older People registration, with number of places Raynesway View C02 C52 Raynesway view S36027 V239738 220705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None stated Date of last inspection 21 September 2004 Brief Description of the Service: Raynesway View Care Home provides personal care to 35 older people. The home is owed by Derby City Council (the registered provider) and is situated in Chaddesden near to the city of Derby. Raynesway View is a two-storey building, which has staircase, shaft lift and stair lift provision enabling access to the first floor. All bedrooms are single occupancy. Support services are in place including general practitioner, district nursing, chiropody, dental and optician services. Raynesway View C02 C52 Raynesway view S36027 V239738 220705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and the duration of the inspection was approximately 4.5 hours. A tour of the building took place. Discussions were held with four service users, two relatives and with the acting manager and deputy manager. A number of records were examined during the visit, including care plans (as part of the case tracking process, which is used to help determine how the home meets the needs of individual service users). An assessment was also made of progress by the registered persons to address requirements made at previous inspections of this service. What the service does well: What has improved since the last inspection? The required written information about the service is now readily available to service users and their representatives. Standards in respect of recording care details in the care plan files have improved, although there is further progress to be made. There are on-going efforts to improve the physical environment with refurbishment of several areas planned for the coming months. Raynesway View C02 C52 Raynesway view S36027 V239738 220705 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. Raynesway View C02 C52 Raynesway view S36027 V239738 220705 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 Raynesway View C02 C52 Raynesway view S36027 V239738 220705 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) 1, 2 & 3 (standard 6 is not applicable to this home) There is written information available to service users to assist them in making decisions about this home as a place for them to live. Pre-admission procedures are in place to facilitate the admission of new service users on the basis of a comprehensive assessment of their needs. EVIDENCE: There was a Statement of Purpose and Service User Guide available at the home to provide written information about the service for service users and prospective service users/representatives. The acting manager stated that all service users had been issued with terms and conditions (previous requirement, now addressed). Social workers undertake the initial assessment of service users. The acting manager also usually assesses prospective service users before admission to the home, where appropriate e.g. admissions from hospital. There was documentation in the care plan files examined at this inspection confirming the assessment arrangements. The system provides appropriate evidence that the home seeks to provide a suitable placement for service users. Raynesway View C02 C52 Raynesway view S36027 V239738 220705 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 & 10 Recording on care notes is not always consistent, which could lead to staff not having appropriate information when caring for service users. The medication systems, whilst satisfactory overall, need improvement to aspects of documenting to further promote the welfare of service users. Service users report staff to be respectful of privacy and dignity. EVIDENCE: As part of the case tracking process three care plans were examined. Overall, the care plans laid out the needs of the service users and how these needs were to be met. Daily logs are filed separately from the main care plan documents and these logs are intended to provide a regularly updated record about the service users. However, detailed examination of these logs established that there was not always a clear link between the information recorded in the logs and the individual care plans developed for a service user. An example was where measures to manage a continence issue were described at length in a log, although there was no individual care plan written in respect of the identified continence need. Also, not all records in the files had been dated and signed by the person making the entry. Such omissions may lessen the value of the care plan as an accurate and legal record of the identified needs of the service user (and of any action taken to address identified needs). Raynesway View C02 C52 Raynesway view S36027 V239738 220705 Stage 4.doc Version 1.40 Page 10 It was noted that there is not a specific risk assessment document in respect of falls, although this subject is partially covered within an overall health and safety risk assessment. In accordance with the relevant National Service Framework (Department of Health) it is recommended that a specific falls risk assessment be introduced for use with all service users. There was written evidence in the care plan files examined to support that service users had been involved in the formulation of the care plans. Service users also stated that they had been consulted about care issues. This demonstrates a partnership in care between care staff and service users. The medication systems were not examined in full at this inspection, but it was established that all staff with medication responsibilities receive training. It was noted that where variable doses of a medication had been prescribed the actual dose administered was not always recorded. This does not provide an accurate record of the administration, for audit purposes or to gauge the effectiveness of prescribed medication. Service user photographs accompanied the medication administration records (MAR sheets). This system provides increased assurance that the identity of the service user is established when medications are administered. The documentation used to record the risk assessment and agreement for selfadministration of medicines should be reviewed to ensure that a comprehensive record is completed, where this is utilised. For example, the current documentation can be interpreted as covering arrangements where the service user either accepts or declines responsibility for all prescribed medication. However, there are potential circumstances where only a portion of the prescribed medications may be appropriate for self-medication e.g. inhalers. Service users spoken with confirmed that staff are respectful of privacy and dignity in their interaction with the service users e.g. knocking on doors before entering bedrooms. Staff observed on the day of the inspection were polite and supportive in their approach to the service users. Raynesway View C02 C52 Raynesway view S36027 V239738 220705 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 & 15 A social & leisure programme is organised, providing a range of opportunities for the service users. Service users are encouraged to maintain links with the community. The meals are reported by service users to be of good quality. EVIDENCE: There is an activities rota operating on a two-weekly cycle. This comprises quizzes (including reminiscence quizzes), bingo, board games, crafts, and manicures. Weekly or fortnightly, entertainers visit the home and ‘movement to music’ is organised two-weekly. The programme is based in the main around activities and entertainment within the home. Whilst service users spoken with were favourable in their comments about the programme in its current form, there was some feedback to suggest that more trips out from the home would be appreciated. Some of the service users reported that they go out from the home with relatives/friends, and the acting manager stated that there are some service users who go out from the home independently. Other comments from service users supported that they are able to exercise choice over how they spend their time. The food at the home received substantial praise from service users spoken with. There was confirmation of a choice of food items for the service users. Raynesway View C02 C52 Raynesway view S36027 V239738 220705 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 There is a robust complaints procedure in place, with confirmation from service users that any concerns are investigated and acted upon. EVIDENCE: The complaints procedure was examined at this inspection and this was contained in the Statement of Purpose, Service User Guide and was also on display in the home. This means that service users and visitors are aware of how to raise any concerns with the registered provider. Service user feedback indicates that management are accessible and deal with any concerns promptly. The complaints log was examined at this inspection and it was established that there were no complaints currently being investigated. Raynesway View C02 C52 Raynesway view S36027 V239738 220705 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 &26 The environment had been maintained to a satisfactory standard for the service users. All service users spoken with reported that the home is consistently kept clean and tidy. EVIDENCE: The acting manager stated that quotes were being sought for redecoration of the entrance area and the lounges, to provide new seating for the lounges, and to create a kitchenette on the first floor. This will enhance the visual appearance of the home and provide additional facilities for the service users. The Fire Officer had arranged to visit the home to speak with management in the week following this inspection. This is because the Fire Officer considers that there are some recommendations outstanding from a previous fire safety inspection. The Fire Officer will inform the registration authority of the outcome. This subject will be re-evaluated at the next inspection (or earlier, if necessary, in the light of the Fire Officer’s feedback). Raynesway View C02 C52 Raynesway view S36027 V239738 220705 Stage 4.doc Version 1.40 Page 14 The courtyard garden/seating area has an access door that requires a ramp fitting in order to provide wheelchair access. Whilst there is another ramped access entrance to this area, there is at least one service user who would benefit from this additional provision and who could then independently access this part of the home. All service users spoken with identified that the home is maintained to a good standard of hygiene by the domestic staff and that the laundry service is efficient and meets their needs. The acting manager explained that a sluicing disinfector is to be purchased. This will further improve the waste handling services at the home. Raynesway View C02 C52 Raynesway view S36027 V239738 220705 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 & 28 Sufficient staff are employed to meet the needs of the service users. A skilled team of staff, many having undertaken recognised training, care for the service users. EVIDENCE: The service users spoken with at this inspection praised the staff for their efforts and were appreciative of the good standard of care that the care staff provide. Overall, service users felt that there were sufficient staff employed, but some felt that the levels were perhaps a little low in the afternoons. The acting manager utilises the staff flexibly and there are higher levels of staff on duty in the morning (including ancillary staff) to handle the higher workload at this period of the day. The staffing rotas demonstrated that the staffing levels were in accordance with the occupancy and dependency of the service users admitted to the care home. The home currently exceeds the minimum required percentage of care staff who have completed National Vocational Qualification (NVQ) Level 2, or equivalent training. There are currently approximately 77 of care staff with this level of training (50 minimum required by 31 December 2005). The local authority has made it mandatory for newly appointed care staff to undertake this training. The achievement gives further assurance of a good standard of care delivery for service users. Raynesway View C02 C52 Raynesway view S36027 V239738 220705 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, 33 & 38 There is effective management of this care home and management is accessible and responsive to service users. The safe working practices systems promote the protection of service users from health, safety and best interest perspectives. EVIDENCE: The registered manager is currently providing cover at another local authority home. However, there is an acting manager working at the home, supported by deputy managers. The acting manager has the recognised qualifications to manage a care home. However, if it is envisaged that the cover arrangements are to continue then the local authority will need to identify a manager to be registered with the Commission. At the time of the inspection it was envisaged that the registered manager would be returning to her substantive position at this care home. Raynesway View C02 C52 Raynesway view S36027 V239738 220705 Stage 4.doc Version 1.40 Page 17 There was evidence of quality assurance monitoring at this care home, to demonstrate that there is on-going assessment of the service by persons not directly involved in the day-to-day control of the home. The arrangements involve managers from other homes, and also service managers, in undertaking checks of the key areas associated with delivery of this care service e.g. complaints, catering, health & safety etc. The acting manager described that system in place to seek service user views on their satisfaction with the service provided at the home. However, there was no evidence of an organised system of feeding back the results of satisfaction surveys to the service users, or any other interested parties e.g. by publishing the results in a format suitable for inclusion in the Service User Guide. Service users reported that the management were responsive to any issues or concerns raised with them. Staff had received training in safe working practices, with updates arranged as required. There was confirmation in the annual pre-inspection questionnaire that services, including gas, electrical and water services had been appropriately monitored and serviced. The systems in place promote the safety and welfare of the service users. Raynesway View C02 C52 Raynesway view S36027 V239738 220705 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 3 3 3 x 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 2 x x x x x 3 STAFFING Standard No Score 27 3 28 4 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x 2 x x x x 3 Raynesway View C02 C52 Raynesway view S36027 V239738 220705 Stage 4.doc Version 1.40 Page 19 no 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. 2. 3. Standard 7 7 9 Regulation 14, 15 14, 15 13 (2) Requirement All care plan entries, including reviews and risk assessments must be dated and signed All identified care needs must be supported by a written care plan to address the identified needs A record must be kept of the dose of medication administered to a service user where a variable dose is possible (previous requirement timescale of 31 December 2004 not fully complied with at this inspection The garden/courtyard access arrangements must facilitate easy access by persons using wheelchairs A report of the results of surveys of service user views of the home must be made available to service users Timescale for action 31 August 2005 31 August 2005 31 August 2005 4. 20 23 (2) 31 October 2005 31 October 2005 5. 33 24 (2) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations C02 C52 Raynesway view S36027 V239738 220705 Stage 4.doc Version 1.40 Page 20 Raynesway View 1. 2. Standard 7 9 3. 12 A risk assessment for falls should be introduced for use with all service users The system of assessment and documenting the arrangements for self-administration of medicines should be reviewed to provide a detailed outcome from the assessments The activities provided should include trips out from the home Raynesway View C02 C52 Raynesway view S36027 V239738 220705 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Souht Point Cardinal Square Nottingham Road, Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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