CARE HOMES FOR OLDER PEOPLE
Rearsby Home 34-36 Station Road Rearsby Leicestershire LE7 4YY Lead Inspector
Keith Williamson Unannounced 20 April 2005 at 9.00am 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. Rearsby Home C52 S1820 Rearsby V221513 200405.doc Version 1.20 Page 3 SERVICE INFORMATION
Name of service Rearsby Home Address 34-36 Station Road Rearsby Leicestershire LE7 4YY 01664 424519 01664 424519 None Rearsby Homes Limited 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) Mrs Sairendri Jawahar Care Home 27 Category(ies) of DE(E) Dementia over 65 - 27 registration, with number MD Mential Disorder - 27 of places DE Dementia - 27 MD(E) Mental Disorder - 27 Rearsby Home C52 S1820 Rearsby V221513 200405.doc Version 1.20 Page 4 SERVICE INFORMATION
Conditions of registration: No person under 55 years of age may be admitted to the home. Date of last inspection 09/02/05 Brief Description of the Service: Rearsby Residential home is a purpose built property in a quiet residential area of Rearsby village. This moderately sized home has space for 27 frail elderly residents, and specialises in residents suffering with Mental Health issues and Dementia. The home has a range of accommodation over 2 floors, both being serviced by a passenger lift. The home has a secluded garden that offers a level access from the home. The home is not situated near shops, though is well placed to access a local bus route to both Melton Mowbray and Leicester. Rearsby Home C52 S1820 Rearsby V221513 200405.doc Version 1.20 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over 1 day and started at 9.00am. An opportunity was taken to look round the home, view records and policies and talk to the staff. Residents were spoken with, though could not accurately comment on conditions in the home or staff. No residents’ relatives wanted to be interviewed or pass comment to the Inspector. The manager assisted the Inspector on the day. What the service does well: What has improved since the last inspection? What they could do better:
Staff could spend more time giving residents social input. Care plans could reflect social care preferences and staff be encouraged to assist residents to fulfil their social care ambitions. The greenhouse in the enclosed garden to the rear of the property could be made safer with the inclusion of safety glass. The temperature of the hot water in the home could be adjusted in individual rooms to ensure safety of residents. The menu board in the dining room could be filled in on a daily basis. The manager could review and date all the policies and procedures in the home. Staff supervision could be more regular and be performed with all staff in the home. Regular checks by the manager to ensure that accidents are recorded in both the accident book and daily records. Fresh milk could be included in the diet of residents in the home. Rearsby Home C52 S1820 Rearsby V221513 200405.doc Version 1.20 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Rearsby Home C52 S1820 Rearsby V221513 200405.doc Version 1.20 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 Rearsby Home C52 S1820 Rearsby V221513 200405.doc Version 1.20 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) 2, 3 & 6. All residents admitted into the home, are issued with the appropriate information and paperwork to enable informed choices. EVIDENCE: Of the resident files seen by the Inspector all had the appropriate information to allow clear plans of care to be compiled. These assessments were produced by the home, and were in addition to any assessment produced by a Social Worker, when involved in the admission process. The home does not offer intermediate care under Standard 6 of the National Minimum Standards. Rearsby Home C52 S1820 Rearsby V221513 200405.doc Version 1.20 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 & 11. Residents are well looked after in respect of their health, personal care, medication and final wishes. EVIDENCE: The Inspector saw three residents care plans; all were specific to that person, though none of the residents involved had signed their plan, this should not be the expected norm and each resident or their relative be involved in the care planning process. A number of differing formats are used to accurately record this information. Social care needs are recognised in some of the plans, though staff do not see spending time with residents as a priority. In the plans of care health needs a re recognised individually, and of the medication records, and times that medication was administered by staff, the Inspector witnessed that this was performed with a degree of professionalism and accuracy. Individual care plans had detailed information with regard to the final wishes of the resident or their families’, this is seen as good practice to have accurate information at this emotive time. Rearsby Home C52 S1820 Rearsby V221513 200405.doc Version 1.20 Page 10 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) 15. Residents are offered a balanced diet in line with dietary requirements and plans of care. EVIDENCE: Menus are made up in advance and residents offered appropriate choices of meals and dietary supplements. There is currently no cook in post; the Manager is actively involved in appointing a replacement. There was evidence of fresh meat, vegetables and fruit on offer throughout the meal system, though the inclusion of fresh milk would be an advantage for residents. Rearsby Home C52 S1820 Rearsby V221513 200405.doc Version 1.20 Page 11 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 & 17. The appropriate complaints and protection information is in place, resulting in a satisfactory protection of residents rights. EVIDENCE: There have been three complaints in the past 12 months, these were recorded and dealt with appropriately by staff in the home. Staff have a general awareness of the complaints procedure. Information on advocacy is freely available in the home. Rearsby Home C52 S1820 Rearsby V221513 200405.doc Version 1.20 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25 & 26. The home is comfortable and safe; residents can personalise their bedrooms. The home does not meet the required standards regarding environment. EVIDENCE: There is a urine odour apparent in some areas of the home, the Manager is active in reducing this problem and has changed the carpeted surfaces in several areas, this has resulted in these areas being cleaned and disinfected on a more regular basis. The Manager has employed a “professional” handyperson; he has commenced a number of repairs within the home. Some of the lounge seating requires to be repainted or replaced, this forms part of the replacement and repair programme in the home. Rearsby Home C52 S1820 Rearsby V221513 200405.doc Version 1.20 Page 13 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 & 29. A thorough and robust recruitment process protects residents and the Manager now regularly undertakes staff monitoring. Staff are employed in sufficient numbers to meet residents needs. EVIDENCE: A number of staff files were viewed and staff were interviewed within the Inspection process. A staff rota was in place, and this was accurate with the staff on duty, at the time of the Inspectors visit. The manager recognises the benefits of employing staff in specific posts, and is actively seeking a replacement cook. Rearsby Home C52 S1820 Rearsby V221513 200405.doc Version 1.20 Page 14 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) 38. The welfare health and safety of the residents is not protected or maintained by a robust system and policies. EVIDENCE: The Manager delegates a number of health and safety tasks to her staff, however does not always follow these up with close monitoring of the situation resulting in some variances in the expected outcomes of policies and procedures. Rearsby Home C52 S1820 Rearsby V221513 200405.doc Version 1.20 Page 15 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3
COMPLAINTS AND PROTECTION 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x x x x x x x x 3 Rearsby Home C52 S1820 Rearsby V221513 200405.doc Version 1.20 Page 16 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. 2. 3. Standard 19 19 19 Regulation 23 23 23 Requirement A plan of routine maintainance withy proposed completion dates is required to be put in place The lounge chairs in the main lounge of the home require to be re-stained. The external paintwork of the home must be planned into the plan of routine maintainance , and work completed by September 2005. The extractor fan in toilet number 29 must be repiared. (Timescale of 28/02/05 not met) Timescale for action by 30/05/05 by 30/06/05 by 30/09/05 4. 21 23 30/05/05 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. Refer to Standard 15 15 Good Practice Recommendations It is strongly recommended that the menu board in the dining room be accurately completed on a daily basis. It is recommended fresh milk be offered to residents at all leal times. Rearsby Home C52 S1820 Rearsby V221513 200405.doc Version 1.20 Page 17 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX 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 Rearsby Home C52 S1820 Rearsby V221513 200405.doc Version 1.20 Page 18 - 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!
