CARE HOME ADULTS 18-65
Reevy Road Resource Centre 60 Reevy Road West Buttershaw Bradford BD6 3LH Lead Inspector
Michael Smithson Key Unannounced Inspection 12 and 14th July 2006 11:00
th Reevy Road Resource Centre DS0000046750.V298722.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 Reevy Road Resource Centre DS0000046750.V298722.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. Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Reevy Road Resource Centre Address 60 Reevy Road West Buttershaw Bradford BD6 3LH 01274 691035 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) Bradford District NHS Care Trust Mr Gary Hoyland Care Home 24 Category(ies) of Learning disability (24) registration, with number of places Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 14th February 2006 Brief Description of the Service: Reevy Road is a Bradford Care Trust unit for service users with learning difficulties. There are 24 places available and all of the bedrooms are singles. Bedrooms are located on the ground and first floor. The unit can accommodate service users with a variety of differing needs including complex health needs and semi-independence. The home is not a nursing home, however they are very well supported by the nursing services. A good range of facilities are provided within the premises including a Jacuzzi and sensory area. The current scale of charges for Reevy Road is approximately £62.30 per week. Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) will be inspecting homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. All regulated services will have at least one key inspection between April 2006 and June 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people using it. The entire core National Minimum Standards are assessed and this forms the evidence of the outcomes experienced by Service users. On occasions it may be necessary to carry out additional site visits, some visits may focus on a specific area and are known as random inspections. This was the first inspection of this home during for the 2006 to 2007 period. The visit was unannounced and completed by 1 inspector. The inspection was undertaken over 1 full day and concluded at a follow up half day. Feedback was provided for the registered manager at the end of the inspection. Copies of reports for this and previous inspections are available either from the home or can be found on the CSCI website. The views of a number of service users and staff were sought during the inspection and time was spent with the management team. A series of feedback comment cards were left at the inspection. A total of four residents were case tracked. Case tracking is the method used to assess whether residents receive good quality care that meets their individual needs. The 21 key standards from the Care Homes for Younger Adults National Minimum Standards were assessed as well as other relevant standards. Due to concerns found during the inspection an Immediate Requirement Notice was left at the end of the inspection highlighting work requiring immediate attention. This was given to the registered manager. A follow up letter was also sent to the registered provider on the 18 July 2006 to make them aware of the concerns found. Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection?
There were only two requirements made at the last inspection. One related to consultations regarding the removal of the respite services from the home. This has improved the ability of the staff to know what levels of care are required for service users over a longer placement. The second requirement relates to the environment. No significant improvements have been made to the building and the information required regarding budgets and timescales for improvements to the enviroment were not received. Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 7 What they could do better:
The statement of purpose and service user guide needs to be up dated to include the recent changes. A separate complaints procedure is available in pictorial form and this now needs to be included in the service user guide. All new admissions to the home must be fully assessed prior to admission and documented evidence of the assessment available at the home. This will demonstrate that service users had a degree of choice in the placement and that Reevy Road could best meet their needs. Service users who do not have a carer or family to assist the admission should be offered support from an Advocate. The transfer of the 6 service users from Farmill Court should have been organised much better. Adequate time was available to facilitate a more positive transfer for service users. The care planning should have been in place at or prior to the admission and the bedrooms offered to service users must have been properly prepared prior to admission. Service users were placed in some of the bedrooms, which were maintained to a poor standard, and care plans are still not available for all the service users. Care plans play a major role in the care of individual service users. They must be kept up to date and reflect the care provided at Reevy Road. It was evident that one care plan seen referred to a previous placement and many of the identified risk were not being addressed. A general review of how the staff team is organised must take place. Better cover must be provided for cooking, cleaning and laundry duties, with less reliance on care staff to undertake these tasks. The night staffing arrangements need to be reviewed to look at providing extra cover to ensure the safety of service users. The current organisation of the medication system must be reviewed. The storage needs to be better organised and the 2 monitored dosage systems reorganised into one. All medication for individual service users must be included on the medication administration records and a better system of monitoring the medication system as a whole put in place. The service users transferred from Farmill Court have changed to a local GP. It is advisable that a review of all their medication is organised. Adult protection training must be provided for all staff. It is evident some staff have not had any training. It was also noted some staff, who had completed the training approximately 3 years ago, had a limited understanding of adult protection issues and all staff would benefit from an up date.
Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 8 The environment at Reevy Road is poor and has been for a number of years. This poor standard of the environment has been raised at previous inspections and requirements have been included in reports that the Health Care Trust must provide information as to their plans for improvement. These requirements have been ignored. Very little investment and up keep has been provided, subsequently standards have deteriorated. This also appears to have had an effect on the staff morale and the pride staff take in the environment. During interviews with management and staff it was evident they were all frustrated at the lack of improvement to the environment. All areas of the home need refurbishment, however the communal areas, bedrooms and bathrooms are a priority. Health and safety issues regarding the environment were noted during the inspection. Nails were protruding from walls and screw heads left protruding from the Jacuzzi bath panel. Fire doors were propped open and cupboards containing hazardous substances left open. Staff recruitment needs to be more robust. Evidence of suitability of staff with criminal records must be available and evidence that all new staff have had a proper induction. Comments made by management and staff that a small number of the staff team were undermining the good work staff try to do must be addressed. This must be achieved either through better supervision, re-training or disciplinary action. The management of the home must be more consistent and senior staff not removed from the home without adequate cover being in place. The management must be more proactive in addressing poor standards at the home and have better monitoring of care practice and safety issues in place. The registered manager must distinguish between the improvements that he and the staff can make at the home and those that require finance and authorisation from the Health Care Trust. He should formally make his views known to both the provider and CSCI about the lack of finance and support to make the required improvements. Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 9 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. Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 10 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 Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not provide evidence that all service users are properly assessed prior to admission and the admission its self is not always a positive experience. The availability and format of the information relating to the home could be improved. EVIDENCE: The Statement of Purpose and Service User Guide must be up dated to include the relevant changes at the home. These include the removal of the respite service and the increase in the beds available to Older People. The Service User Guide is produced in a simple pictorial form, which suits the needs of the service users. This is good practice. The complaints information is included in the service user guide, however it is in written form and must be in a more user-friendly format. The admission information for 3 service users recently transferred from a home that closed was checked. There was no evidence of a pre-admission assessment or information indicating service user choice. No details of a proper planned admission were available. The Health Care Trust had significant advance knowledge of the closure of the home. However the transfer was
Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 12 poorly organised. Service users were allocated bedrooms, which were of a poor standard, and the staff at Reevy Road have completed very little care planning information. Many of the service users have little or no family to act on their behalf. However no evidence was available of any Advocacy support provided to help facilitate the transfer. Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The care documentation does not always provide up to date information about service user needs. EVIDENCE: The care plans for 3 service users who were part of the recent transfer were checked together with a long stay service user with challenging behaviour. Only 1 service user recently transferred had a care plan completed since the move. The care plan was basic and did not fully reflect the views and wishes of the service user. The care plans must be more person centred and provide evidence of service user involvement. The long stay service user had a risk assessment completed by her previous placement and a care plan completed by the staff at Reevy Road. The risk assessment was not being fully followed by the staff and was not up to date with the situation at the home. Basic information like the room number was incorrect and instructions that all harmful fluids must be kept locked were not
Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 14 being followed. The risk assessment must be up dated to reflect the current situation. Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 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. Service users are offered a good range of activities and can influence their daily lives. The availability of a proper cook to cover the current shortfall would be an improvement. EVIDENCE: The inspector spoke with a number of service users present during the inspection. However the majority were out at day centres. The service users remaining behind tended to be the older people transferred from Farmill Court. The staff are looking at providing a range of activities for the service users and during discussion with staff it was evident that they were aware of the different needs of the older people. This included the range of activities they may prefer and a more traditional diet. Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 16 The staff felt they had the opportunity to arrange activities for service users. They were able to request changes to the rota to organise activities and outings in advance. However it does prove more difficult to arrange activities at short notice due to the recent reduction in staff numbers and the needs of the current service users. The menus were checked and were found to be organised on a week-to-week basis. There is currently only one cook who works 5 days a week. A member of care staff is covering the remaining 2 days. The cook is responsible for organising the menus and the weekly shopping. The menus are produced to include any individual preferences and any special diets. These currently include a Diabetic and Halal meals. The cook does like to use fresh produce were possible and home baking and not rely on prepared convenience food. However some convenience food is available as an alternative to the menu and for easy preparation when the care staff do the cooking. Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. While staff have a good understanding of the health care needs of service users. The current organisation of the medication system does put service users at risk. EVIDENCE: During conversations with staff it was evident that they had a good understanding of the individual needs of the service users. The completed care plans do reflect individual needs and these are reviewed to keep them up to date. There is a key worker system in place, which again allows staff to focus on individual service users and develop positive relationships with carers, family and other professionals. A spot check of the current medication storage and administration system was undertaken. The medication room was cluttered and poorly organised. A lack of proper secure storage for the safe keeping of medication was noted. The service users transferred from Farmill Court currently use a different pharmacist and monitored dosage system, which is confusing and is causing administrative and storage problems. This was apparent during the medication
Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 18 spot check. Two lots of medication were not recorded on the medication administration records. One being Rectal Diazepam which is a controlled drug. The Rectal Diazepam had only recently been entered into the Controlled Drug Register and staff present during the spot check had no previous knowledge of its existence. Medication not in the monitored dosage system is kept in a floor level cupboard with no clear system to recognise individual’s medication. This means staff have to spend time bending or sat on the floor trying to locate medication. A more suitable system of storage should be provided. The service users transferred from Farmill Court have now been allocated a new GP. Many of the service users do take large amounts of medication. It was unclear from the records when the last medication review was completed. In light of this the new GP should be asked to complete a review of all the medication at the earliest opportunity. Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Good information regarding the complaints procedure is provided, however its availability to service users could be improved. Staff would benefit from further adult protection training. EVIDENCE: The records showed there had been no complaints recorded since the last inspection in February 2006. The complaints information is included in the service users guide, however it is not detailed or available in a user-friendly format. The Health Care Trust does produce a service user-friendly pictorial version of the complaints procedure. This was pinned on the office wall which is not an area regularly used by service users and visitors. The complaints procedure should be more accessible and be incorporated into the service user guide. Not all staff have completed adult protection training this includes some of the Residential Social Workers who take charge of shifts at the home. During discussions it was evident that some staff had only a basic knowledge of the adult protection policy and procedure. This must be addressed. Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The building is maintained to a poor standard and the provider has ignored previous requirements to provide evidence of the finance available to make the required improvements. EVIDENCE: The environment has been an issue, which has been included in previous inspection reports. At the last inspection a requirement was made for the Health Care Trust to provide information regarding the budget for improvements and timescale for completion of priority work. This requirement has not been met. Many areas of the home are now in a very poor state of repair and decoration. The standard of many of the carpets fixtures and fitting are poor. Unit 1 Carpets in communal areas must be replaced. The corridor carpet is heavily stained and despite the best efforts of the staff does not improve with cleaning
Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 21 The shower is maintained in a very poor standard of hygiene and repair. This has been a longstanding problem, which has now got considerably worse. The linen cupboard, which is a fire door, was left open together with a general storage area, which contains toxic substances. This was brought to the attention of staff on the first day of the inspection. At the follow up visit on the 14th July 2006 the doors were still left open. Work is required to a number of bedrooms including replacing light bulbs, replacing carpets and redecoration. One bedroom wall has a plaster repair, which now requires redecoration. The panel on the side of the Jacuzzi bath had protruding screw heads, which could cause skin damage to both service users and staff. This was addressed during the inspection The walls leading to the Snoozelen area had previously contained a variety of pictures and objects. These have now been removed, however the nails used to hang them still remained making the area both unsightly and a possible risk to service users and staff. Again the inspector requested these be removed immediately. At the follow up inspection on the 14 July 2006 this had still not been completed. Unit 2 Three of the bedrooms had water damage, the first on the corridor being the worst affected. The carpet in this room was due to be replaced. A service user entering the bedrooms at night and turning on the sink taps is causing the flooding. The taps have been removed from 1 of the bedrooms and requests have been made to fit stop taps. However this does not address the cause of the problem, which is a lack of nighttime supervision. This area has been highlighted in greater detail in the staffing section of this report. All the bedrooms and bathrooms on this unit need to be refurbished the corridor repainted and the carpet replaced. Unit 3 The corridor requires redecoration. A number of the bedrooms either had no light bulbs in the main lights or were broken. This must be rectified. Bedroom 1 needs a light shade, Bedrooms 3, 4 and 5 needs redecoration and bedroom 3 also needs a new carpet. Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 22 The toilet door is broken and must be repaired and soap, paper towels and a bin provided. The bathroom and kitchen were kept locked. Unit 3 is specifically for service users who are more independent. This practice must be reviewed and a proper risk assessment completed. The linking fire door was propped open using a chair. This practice must cease. The door is on the automatic release system and if it is in working order should remain open. If the door release system is not working it must be repaired. Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Evidence of greater protection of service users must be available within the recruitment records. The organisation of the staffing does not meet the needs of all service users and must be reviewed. EVIDENCE: The recruitment records for 2 staff were checked. One was for a permanent member of staff and one for a casual. The permanent member of staff had all the recruitment information required; however no evidence of an induction was available. The casual staff member had a discrepancy with a declaration of a criminal offence. The records did not provide evidence of a decision of the suitability of the staff member. During discussions with staff issues were raised regarding the reduction of the numbers of staff on shift during the day. The staffing has been reduced from 6 to 5 per shift. The decision was made following the removal of the respite
Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 24 service from Reevy Road. It was felt that the transfer of permanent service users would require less staffing than the organisation of respite service users. It appears this may not be the case and staff were concerned that more service users were now in the building during the day and the needs of service users had not been significantly reduced. Staff are also undertaking cleaning and laundry duties to cover shortfalls in the catering and ancillary staff. A review of the staffing arrangements must be undertaken and any vacant posts filled. The current night staff arrangements are 2 waking care assistants and a sleep in senior usually a Residential Social Worker. These arrangements appear inadequate. One service user is currently causing serious problems during the night leading to flooding of bedrooms. The current night staffing arrangements must be reviewed to prevent damage to service user bedrooms. It was noted that despite incidents occurring at night the sleep in member of staff is very rarely woken. It may be more appropriate to have 3 waking night staff, one on each unit and to replace the sleep in staff. Staff felt they had received adequate training to meet the needs of the service users. Mandatory training is provided including, manual handling, basic food hygiene and health and safety. A number of training up dates are being organised. There was a feeling among the people interviewed that the majority of the staff contributed positively to the running of the home and tried to maintain a good level of morale and good quality care. However they did feel that a small number of staff lack the same levels of commitment and can undermined improvements they try to make at the home. Although they feel the numbers of poor staff may be small they feel this is an area, which must be addressed by the providers and management of the home. The inspector shares this view. Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 25 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Both the providers and the manager must provide better support and monitoring of all aspects of the home. EVIDENCE: Service users have the opportunity to contribute to the day-to-day running of the home via the regular meetings and questionnaires. However it does appear that quality assurance questionnaires have not been used for some time. The available analysis of service user and carer views was not dated making it difficult to know how up to date it was. The management of the home has been insufficient. The deputy manger has only recently returned to the home following a period of time on secondment and supports the registered manager. Her responsibilities at the home were not adequately filled during this period. Also an experienced member of the
Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 26 care staff is now undertaking driving duties and his skills and enthusiasm has been lost from the day-to-day operation of the home. The registered manager must clearly distinguish the improvements he can make at the home from the responsibilities, which require resources from the Health Care Trust who are the registered providers. He must be more proactive in making the providers aware of their responsibilities and any work required at the home. This is particularly important with regard to the poor environment. He must however undertake his responsibilities for the day-today running of the home and driving forward the required improvements. Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 27 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 2 2 1 3 2 4 2 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 1 27 1 28 1 29 X 30 1 STAFFING Standard No Score 31 X 32 3 33 2 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 2 2 X X 1 1 Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 28 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 YA1 YA22 Regulation Reg 4 Reg 5 Reg 6 Requirement The statement of purpose and service user guide must be up dated and include a more user-friendly complaints procedure. Service users must only be admitted to the home following a proper assessment. The assessment must be available for inspection. Care plans must be available for all service users. The care plans must be person centred and provide evidence of service user involvement in their completion. Risk assessments must be kept up to date and be relevant to the care provided at Reevy Road. The storage, recording and monitoring of medication must be Timescale for action 01/09/06 2. YA2 Reg 14 01/09/06 3. YA6 Reg 15 01/09/06 4. YA9 Reg 13 01/09/06 5. YA20 Reg 13 14/07/06 Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 29 6. YA23 Reg 13 7. YA24YA26YA27YA28YA30 Reg 16 Reg 23 YA24 Reg 23 8. improved. (An Immediate Requirement Notice served regarding this issue on 14/07/06) Adult protection training and up dates must be provided for all staff. All the building work highlighted in this report must be completed. The budget for the refurbishment of the environment must be agreed. The list of work required, which the manager, has produced, must be used to prioritise the work required. This must include: Replacing carpets to communal areas, bedrooms and corridors. Replacing light bulbs and light shades. Redecoration of bedrooms, corridors and bathrooms. CSCI must be kept fully informed of the progress of the refurbishment. (Outstanding from last inspection) (An Immediate Requirement Notice served regarding this issue on 14/07/06) 01/11/06 01/11/06 14/07/06 9. YA33 Reg 18 A review of the 01/09/06 staffing numbers available on shift must
Version 5.2 Page 30 Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc 10. YA34 Reg 19 11. YA35 Reg 18 12. YA39 Reg 24 13. YA42 Reg 23 14. YA42 Reg 13 15. YA42 Reg 13 16. YA42 Reg 12 take place. Particular attention must be paid to the number of waking night staff available each shift. Evidence must be provided of the suitability of staff with criminal records. (An Immediate Requirement Notice served regarding this issue on 14/07/06) Evidence of completed induction training must be available for all staff. An up to date quality assurance and monitoring system must be put in place. The practice of propping open fire doors must cease. (An Immediate Requirement Notice served regarding this issue on 14/07/06) All designated cupboards with fire doors must be kept locked. (An Immediate Requirement Notice served regarding this issue on 14/07/06) All nails protruding from walls must be removed. The corridor leading to the Snoozlem area presents the greatest risk. (An Immediate Requirement Notice served regarding this issue on 14/07/06) All cupboards 14/07/06 01/09/06 01/11/06 14/07/06 14/07/06 14/07/06 14/07/06
Page 31 Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 17. YA43 Reg 10 containing hazardous substances must be kept locked. (An Immediate Requirement Notice served regarding this issue on 14/07/06) The manager should 01/09/06 be more pro-active in identifying improvements he can make at the home and those which require authorization or financial support from the provider. 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 YA3 YA4 YA20 Good Practice Recommendations Service users with no carer or family should be offered an Advocate to assist with admissions. The admission procedure should be improved and better preparations made for new service users. A review of the medication for the service users from Farmill Court should take place Reevy Road Resource Centre DS0000046750.V298722.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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