Inspection on 28/11/05 for Raynesway View

This inspection was carried out on 28th November 2005.

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

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

Other inspections for this house

Raynesway View 21/01/09

Raynesway View 30/11/06

Raynesway View 22/07/05

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 Raynesway View Foyle Avenue Chaddesden Derby Derbyshire DE21 6TZ Lead Inspector Anthony Barker Unannounced Inspection 28th November 2005 09:15 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 Raynesway View DS0000036027.V262346.R01.S.doc Version 5.0 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. Raynesway View DS0000036027.V262346.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Raynesway View Address Raynesway View Foyle Avenue Chaddesden Derby Derbyshire DE21 6TZ 01332 718300 01332 718300 chris.wilson@derby.gov.uk 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) Derby City Council Christine Elizabeth Wilson Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Raynesway View DS0000036027.V262346.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd July 2005 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 DS0000036027.V262346.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 4.5 hours and was a routine unannounced inspection. The last inspection took place in July 2005 and was unannounced. Six residents and the Acting Manager were spoken to, records were inspected and there was a tour of the premises. Two residents were ‘case tracked’ in order to assess the services provided from their perspective. The focus of this inspection was on progress made on the requirements and recommendations made, and those standards not assessed, at the last inspection. What the service does well: What has improved since the last inspection? What they could do better: All care plan entries must be dated and signed and records of the medication administered to residents improved. Handwritten entries on the Medication Administration Record sheets must be signed, countersigned and dated. Residents’ wishes concerning arrangements after death must be discussed and recorded. The Home’s complaints procedure must include reference to the CSCI. Certain maintenance issues, detailed in this report, must be addressed and one carpet replaced. A record of all persons employed at the Home must be kept within the Home at all times and all staff fire training must be improved. A report of the results of surveys of residents’ views of the Home must be made available to residents. Raynesway View DS0000036027.V262346.R01.S.doc Version 5.0 Page 6 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 DS0000036027.V262346.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Raynesway View DS0000036027.V262346.R01.S.doc Version 5.0 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 the following standard(s): This section was not assessed. EVIDENCE: Raynesway View DS0000036027.V262346.R01.S.doc Version 5.0 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 the following standard(s): 7 & 10 Residents’ health, personal and social care needs were set out in individual care plans, although these could be improved. The quality of these care plans was monitored. Residents were not being fully protected by the Home’s procedures for dealing with medicines. Residents’ right to privacy was not being consistently upheld. EVIDENCE: Two files were examined as part of the case tracking process. The Acting Manager said that link workers complete care plans. These were found to be generally of a good standard although recorded care plan objectives/action for staff to take was rather minimal. Ways of improving matters were discussed with the Acting Manager. ‘Link workers’ monthly care plan check’ forms were being completed but on one form no details had been recorded when there was a change in the resident’s circumstances and there was no signature in the September/October and November columns. There was evidence of managers monitoring care plans and of manager three-weekly log reviews/summaries in the daily logs. These logs were often worded very generally and were not particularly meaningful. These issues were also discussed with the Acting Manager. She referred to staff receiving care plan training and to care plans being currently updated. She also said that care plans were prioritised as part Raynesway View DS0000036027.V262346.R01.S.doc Version 5.0 Page 10 of staff training and supervision. There was evidence of residents’ needs being identified and met, from the ‘old time’ music being played in the ground floor dining room. Recorded risk assessments were examined. These were satisfactory except that one nutritional assessment was not signed or dated and one tissue viability risk assessment had no staff name/signature recorded. Recorded risk assessment for falls had been introduced with an anticipated completion by January 2006. Other aspects of standard 8 were not assessed. There were several instances, on one resident’s medication administration record (MAR) sheet, where the number of paracetamol tablets were not being recorded. Another MAR sheet had hand-written entries where dates had been recorded but no signatures. The system of assessment and documenting the arrangements for self-administration of medicines had not been reviewed to provide a detailed outcome from the assessments. This was discussed with the Acting Manager. Other aspects of standard 9 were not assessed. One resident confirmed she was treated with respect by staff and another said, “I can’t speak too highly of staff”. One member of care staff was seen to enter a resident’s room without knocking. This was drawn to the attention of the Acting Manager. A pay-phone was seen to be placed in a relatively private area at the base of one stair-case. On one file examined no preference as to arrangements following death had been recorded. Other aspects of standard 11 were not assessed. Raynesway View DS0000036027.V262346.R01.S.doc Version 5.0 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 the following standard(s): 12 & 15 Residents were provided with a range of activities both inside and outside the Home. They were pleased with the quality of food provided. EVIDENCE: The Acting Manager spoke of an improvement in the number of trips out of the Home for residents. She said that three were planned for December and the aim was for monthly trips out from then on. She said that the Home was currently searching for coach firms to provide transport. She added that several residents go out with relatives and one male resident is offered fortnightly one-to-one staff help to go in to town. One resident said that she was helped to attend local church services with lunch. The Acting Manager said that indoor entertainment was funded by the Amenity Fund. The Acting Manager said that residents choose, from alternatives, their lunch and tea-time meal each day, after breakfast. These choices are recorded. Several residents were spoken to while eating their lunch. They were all positive about the quality of food provided. The kitchen larders were neat, tidy and clean. Fresh fruit and vegetables were seen. Raynesway View DS0000036027.V262346.R01.S.doc Version 5.0 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 the following standard(s): 18 Residents were being protected from abuse. EVIDENCE: The Home’s complaints procedure was displayed in the entrance hall. It referred to the National Care Standards Commission. One resident spoken to said that she felt able to talk to care staff if she had a problem. Other aspects of standard 16 were not assessed on this occasion. A copy of the Local Authority Protection of Vulnerable Adults procedure, and a Whistle blowing policy, was in place. The majority of the staff team had received training in the Derbyshire procedures as part of induction and some had attended a one-day course, too. The Acting Manager said that all the managers had undertaken the three-day course on adult protection. There had been no matters relating to adult protection since the Acting Manager came into post in April 2005. Raynesway View DS0000036027.V262346.R01.S.doc Version 5.0 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 the following standard(s): 19 Residents were living in an attractive and generally well-maintained environment, apart from some areas requiring attention. EVIDENCE: The Home was generally attractive and nicely decorated. The ground floor link corridor was bright and cheerful. Bedrooms seen were nicely personalised. The Acting Manager said that a six-week building programme had resulted in new ramps for wheelchair access into the courtyard and other outside areas, with handrails beside ramps to the front of the premises. New fire doors had been fitted to all bedrooms and to store cupboards and new inner front doors had been provided. The entrance foyer had new flooring and new furniture and redecoration was planned for this area. Some new carpets and redecoration had also been provided. Items requiring attention were… • there was a hole in the ceiling around a smoke detector in the bedroom of one resident who was spoken to as part of the case tracking process, • the varnish on a number of doors was damaged, • toilets and bathrooms were rather clinical looking - although attempts had been made to make them look more homely through floral decoration, Raynesway View DS0000036027.V262346.R01.S.doc Version 5.0 Page 14 • corridor walls were rather bare and ways of addressing this were discussed with the Acting Manager, • the smoking lounge carpet was singed in many places. Raynesway View DS0000036027.V262346.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 & 30 Residents were not being protected by the Home’s recruitment practices. Residents were generally benefiting from a well-trained staff group. However, their safety was being compromised by insufficient fire training of staff. EVIDENCE: The Home was holding three staff vacancies at the time of this inspection. The Acting Manager said that sickness levels were low and that there was good staff morale. Staff were, she said, willing to cover for colleagues’ sickness and holidays and were willing to receive training. Other aspects of standard 27 were not assessed on this occasion. Staff files contained no documentation relating to their recruitment. It was therefore not possible to assess the quality of the Home’s staff recruitment practices. The Acting Manager said that Social Services Personnel Section would send staff files to the Home, for inspection, given 24 hours notice. The Acting Manager was not aware of revisions to the Regulations in July 2004 regarding the documents and information required prior to staff appointments. The Acting Manager reported that all new staff complete an induction programme, which is in accordance with TOPPS specifications. This comprises a five-day session plus three days Moving and Handling training. Mandatory training is provided, on a rolling programme and includes training on Dementia. One staff file and the Home’s Training List were examined regarding staff training practices. These were satisfactory except for fire training. It was noted that one member of staff had not been provided with Raynesway View DS0000036027.V262346.R01.S.doc Version 5.0 Page 16 fire training since September 2003. It was particularly concerning that three night staff had not had fire training at all and two night staff not since January 2004. Raynesway View DS0000036027.V262346.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 & 35 The Home was being run in the best interests of residents although the results of surveys and resident views was not being fed back to them. Residents’ financial interests were being safeguarded. EVIDENCE: Evidence of quality assurance measures taking place in the Home included… • managers monitoring care plans and daily logs, • suggestion boxes and forms, upstairs and downstairs – the Acting Manager said responses were currently being processed to feedback to residents, • plans to introduce a newsletter. A report of the results of surveys of residents’ views of the Home had not been made available to residents. All residents spoken to, at this inspection, were positive about services provided by the Home. The money held in safekeeping for those two residents whose care was case tracked was checked. Residents’ money was kept separate and the records Raynesway View DS0000036027.V262346.R01.S.doc Version 5.0 Page 18 and amounts were cross-referenced and was satisfactory. The Registered Manager and senior members of staff have access to the safe and two signatures were recorded on the financial documentation. Good food hygiene practices were in evidence. The Acting Manager said there were no outstanding recommendations from the Environmental Health Officer’s last visit. It was noted that all radiators had covers to prevent scalding. Other aspects of standard 38 were not assessed on this occasion. Raynesway View DS0000036027.V262346.R01.S.doc Version 5.0 Page 19 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 X X X X X X X STAFFING Standard No Score 27 X 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X X Raynesway View DS0000036027.V262346.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 14, 15 Requirement All care plan entries, including reviews and risk assessments must be dated and signed. (Previous timescale was 31/08/05) A record must be kept of the dose of medication administered to a service user where a variable dose is possible. (Previous timescale was 31/12/04) Handwritten entries on the Medication Administration Record sheets must be signed, countersigned and dated. The registered person must ensure that all staff conduct themselves in a manner which respects the privacy and dignity of residents. Residents’ wishes concerning arrangements after death must be discussed and recorded. The Home’s complaints procedure must include reference to the CSCI. Maintenance issues, identified in this report, must be addressed. The smoking lounge carpet must DS0000036027.V262346.R01.S.doc Timescale for action 01/02/06 2 OP9 13(2) 01/02/06 3 OP9 13(2) 01/02/06 4 OP10 12(4)(a) 01/02/06 5 6 7 8 OP11 OP16 OP19 OP19 12(2)(3) 22(7)(a) 23(2) (b)(d) 16(2)(c) 01/04/06 01/02/06 01/04/06 01/04/06 Page 21 Raynesway View Version 5.0 9 OP29 19 Sch 2 Revised 10 OP30 23(4)(d) 11 OP33 24(2) be replaced. A record of all persons employed at the Home, including all documents specified in Schedule 2, must be kept within the Home at all times. The registered person must ensure that all staff are provided with fire training at least annually, and night staff at least twice a year. A report of the results of surveys of service user views of the home must be made available to service users. 01/02/06 01/03/06 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP7 OP9 Good Practice Recommendations Care plan objectives/action for staff should be improved as discussed. Logs entries should be meaningful and link with care plan objectives or reflect new matters/changes. They do not have to be recorded daily. The system of assessment and documenting the arrangements for self-administration of medicines should be reviewed to provide a detailed outcome from the assessments. (This recommendation was from an inspection dated 22/07/05) It is recommended that toilets, bathrooms and corridors be made to look more homely. 4 OP19 Raynesway View DS0000036027.V262346.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Derbyshire Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Raynesway View DS0000036027.V262346.R01.S.doc Version 5.0 Page 23 - 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. 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