Inspection on 10/05/05 for Roann House

This inspection was carried out on 10th May 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

Roann House 28/07/08

Roann House 19/02/08

Roann House 27/06/07

Roann House 30/05/06

Roann House 11/10/05

Roann House 15/11/04

Roann House 05/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Roann House 91 Bouverie Road West Folkestone Kent CT20 2PP Lead Inspector Joseph Harris Unannounced 10th May 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. Roann House H56-H05 S57418 Roann House V223678 100505 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Roann House Address 91 Bouverie Road West, Folkestone, Kent CT20 2PP 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) 01303 253705 roannhouse@onetel.co.uk Roann House Limited Mrs Sursatie Pieries CRH 18 Category(ies) of OP 18 registration, with number of places Roann House H56-H05 S57418 Roann House V223678 100505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2004 Brief Description of the Service: Roann House is situated in a residential area of Folkestone approximately 1 mile from the town centre which has a good range of amenities. The home is also a short walk from The Leas and seafront of the town. There are good public transport links available nearby including a train station and bus routes. The service is owned and managed by two experienced Registered Mental Nurses who are involved in the running of the home on a day to day level. Mr and Mrs Pieries took over ownership of the home just over one year ago. The service provides care and support for up to 18 older people. There is a condition of registration allowing one specific service user who has dementia care needs. The home is set out over three floors with the majority of the residents rooms being on the ground and first floor. There is a good sized passenger lift and a stair lift to enable access throughout the house. The home benefits from a large open lounge with natural breaks, a relatively small dining area and a quiet room with a private telephone. To the rear of the home is a good sized conservatory, which needs a little attention. There is an accessible, enclosed courtyard garden at the back of the house, which is in the process of being cleared and improved. The owners have a planning application on-going to add an extra floor to a single storey extension, which could provide 2 further bedrooms. Roann House H56-H05 S57418 Roann House V223678 100505 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. What the service does well: What has improved since the last inspection? What they could do better: A number of issues are in the process of being addressed, but now require concentrated effort to ensure the relevant standards are met. These issues include the full introduction of improved care plans and risk assessments, as well as environmental risk assessments. A focus needs to be placed on the training needs of staff ensuring that all mandatory training is provided. There are also a variety of additional courses, such as dementia awareness, which would also be beneficial. Medication storage facilities should be reviewed. Environmental changes are planned including an extension, but some renewal is also required within the home such as the conservatory floor and garden area. The home needs to complete work on updating the statement of purpose and service users guide as well as introducing a statement of terms and Roann House H56-H05 S57418 Roann House V223678 100505 Stage 4.doc Version 1.20 Page 6 conditions of residence for all residents. Staff rotas must be kept up to date and evidence of service users involvement in the planning of menus would be beneficial. 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. Roann House H56-H05 S57418 Roann House V223678 100505 Stage 4.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 Roann House H56-H05 S57418 Roann House V223678 100505 Stage 4.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) 1, 2, 3 and 5. Prospective service users have access to some information in the form of a service user guide and statement of purpose, but both of these documents need to be updated. A statement of terms and conditions of residence also needs to be developed and implemented. There are adequate systems for assessing the needs of potential service users referred to the home. Prospective service users have the opportunity to visit the home for trial visits and overnight stays prior to admission. EVIDENCE: Both the statement of purpose and service user guide were developed by the previous owners of the service. These documents contain the majority of information required to enable prospective residents to make an informed choice about the home. However, some of the information is now out of date and needs to be reviewed and updated. In addition to this the documents were not readily available and it was suggested that copies should be kept in accessible places for service users, visitors and relatives. It was reported that there is work on going to develop a brochure. Refer to requirement 1. Roann House H56-H05 S57418 Roann House V223678 100505 Stage 4.doc Version 1.20 Page 9 The home is yet to finish developing a statement of terms and conditions of residence, which is in the process of being completed. Refer to requirement 2. Pre-admission assessments had been completed for relatively recent admissions to the home. These assessments included the modified Crichton assessment covering the holistic needs of the service users. Dependency ratings had also been completed. The registered manager stated that this format is used for all referrals to the home. Where an individual is subject to care management processes a joint assessment and any other relevant information is requested. Families and service users are also encouraged to contribute to developing ‘life stories’ providing additional background information. The registered manager encourages trial visits to the home prior to admission based on the needs of each individual. One relative spoken to stated that she had been able to visit the home with her mother a number of times prior to moving in and that the staff are “welcoming and friendly”. Roann House H56-H05 S57418 Roann House V223678 100505 Stage 4.doc Version 1.20 Page 10 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, 9 and 10. The registered manager is in the process of updating the care planning system, but at the current time this standard has not been met. Medication systems, policies and procedures are adequate for the needs of the home. Service users are treated in a respectful and dignified manner. EVIDENCE: The registered manager has begun to introduce updated and much improved individual plans of care. A number of these have been completed, but the system is yet to be fully implemented. The current documentation in use is inadequate and does not clearly set out the needs of service users and constructive action plans. A discussion was held about further developing risk assessments to ensure that they address potential risks adequately. Refer to requirement 3. The systems for medication administration and storage were assessed. Administration records were well kept and up to date and staff who administer medication have had appropriate training, although it was suggested that all staff are provided with medication training to ensure that suitably qualified staff are always on duty. Storage facilities would benefit from improvement, Roann House H56-H05 S57418 Roann House V223678 100505 Stage 4.doc Version 1.20 Page 11 although at the present time there are practical difficulties in being able to significantly improve this area. There are adequate policies and procedures covering medication issues in place. Refer to recommendation 1. Service users and relatives stated that they are treated with respect and dignity. One service user said that “the staff are wonderful” and a relative spoken to stated that Mr and Mrs Pieries (the owner/managers) are “special people and very caring”. There is a private telephone and quiet room for service users to talk in private. Staff knock before entering bedrooms and were observed spending time with service users and interacting positively. One staff member said that she “enjoys working in the home” and that “there is a good atmosphere”. Some service users choose to spend more time in their rooms, which is respected by the staff. Roann House H56-H05 S57418 Roann House V223678 100505 Stage 4.doc Version 1.20 Page 12 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) 13 and 15. There is a positve ethos in the home welcoming visitors and relatives. Service users are provided with an adequate and balanced diet. However greater evidence of choice and the involvement of service users in planning menus where possible should be addressed. EVIDENCE: Staff in the home encourage visitors and provide a welcoming and friendly environment to promote this. There are adequate facilities to ensure that people can meet in private should they wish to do so. One relative stated that she tries to visit her mother every day and that she “enjoys coming to the home”. One service user stated that her “friend visits every week” and that she attends her Salvation Army meetings and social events on a regular basis. One gentleman receives regular visits from his daughter, but can become upset when she is unable to visit. The home has sought to manage this situation positively and thoughtfully to minimise his distress. Menu records demonstrate that a wholesome and balanced diet is provided and mealtimes were seen to be relaxed, unhurried and social. Food was presented well and service users made comments such as “the food is very nice”. One resident, when asked, said that she did not know what she was about to have for lunch. Service users should be included in menu planning on a weekly basis to enable positive choices. Refer to recommendation 2. Roann House H56-H05 S57418 Roann House V223678 100505 Stage 4.doc Version 1.20 Page 13 Roann House H56-H05 S57418 Roann House V223678 100505 Stage 4.doc Version 1.20 Page 14 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. Service users, relatives and stakeholders are able to make complaints and that any concerns will be acted upon. EVIDENCE: The home has an adequate complaints procedure in place enabling service users, relatives and staff to make any concerns known. The registered manager stated that the aim is to deal with all complaints on an informal basis in the first instance, but if this proved unsatisfactory would use the formal procedures. A complaints procedure is accessible in the home and includes details of CSCI. One relative said that the “manager is approachable”, but that she has never had any complaints as she is “very happy with the care” her mother receives. Service users stated that if they were unhappy they could talk to the registered manager and owners about their concerns. Roann House H56-H05 S57418 Roann House V223678 100505 Stage 4.doc Version 1.20 Page 15 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 and 26. The home, in general, is suitable and adequate for the needs of the service users. Some minor work is required to update the environment with particular reference to the conservatory flooring and courtyard garden. Some additional work is planned to provide more en-suite rooms and planning application has been made to extend the home. EVIDENCE: A detailed tour of the building was undertaken. The premises were clean, hygienic and free from offensive odours. The present owners, having relatively recently taken over the home, are planning some upgrading of the environment. This includes the provision of more en-suite bedrooms and an extension, subject to planning permission. There are areas of the home that would benefit from renewal and redecoration, in particular the flooring in the conservatory and the garden area. The registered manager should also consider improved medication storage facilities. There are adequate toilet and bathroom facilities at the current time. The home has sufficient equipment and Roann House H56-H05 S57418 Roann House V223678 100505 Stage 4.doc Version 1.20 Page 16 adaptations to ensure the needs of the residents can be met, these include a passenger lift, hoists, ramps and a stair lift. A number of the bedrooms were viewed, which were adequately equipped and personalised to varying degrees. The room sizes are within the National Minimum Standards, but attention should paid to this in relation to the proposed en-suite facilities. Window restrictors were in place and the majority of radiators are guarded. Roann House H56-H05 S57418 Roann House V223678 100505 Stage 4.doc Version 1.20 Page 17 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 and 30. There are adequate numbers of staff on duty throughout the day and night. The home needs to ensure that all staff have the necessary mandatory training and National Vocational Qualifications. EVIDENCE: The home has three members of staff on duty throughout the day and two staff available at night time. The staffing levels are adequate for the needs of the home and exceed department of health guidance in this area based on the needs of the resident group. There was not an up to date staff rota available, which does need to be rectified however. Refer to requirement 4. It is acknowledged that some progress has been made with regard to staff training since the last inspection, but this does remain an issue that needs addressing. Mandatory training and training updates must be provided for all staff covering issues such as manual handling, food hygiene, fire safety and first aid. Additional training should also be explored addressing dementia awareness, medication and risk assessments. Refer to requirement 5. Two staff members have now commenced NVQ level 2 or above and these opportunities should also be made available for other team members to achieve the 50 target. Refer to requirement 6. Roann House H56-H05 S57418 Roann House V223678 100505 Stage 4.doc Version 1.20 Page 18 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, 32 and 38. The home is managed by a suitably qualified and experienced manager. There is a positive ethos and atmosphere in the home amongst staff and service users. Health and safety checks had been routinely carried out, although shortfalls remain in the mandatory staff training programme. EVIDENCE: The registered manager/owner is a qualified psychiatric nurse with many years of experience. He has achieved his NVQ level 4/Registered Managers Award in recent times. The current management have been involved in the home for just over a year and one service user, who has been resident for many years, stated that ‘things have improved’ in this time. It was evident through discussion with service users, relatives and staff that there is a positive ethos and an atmosphere of co-operation in the home. One relative said that she ‘always enjoys visiting the home’. A staff member spoken to said that she Roann House H56-H05 S57418 Roann House V223678 100505 Stage 4.doc Version 1.20 Page 19 ‘feels supported’ and that there is ‘a family atmosphere’. It was noted that all relevant health and safety checks have been completed, although greater clarity should be introduced to evidence that fire drills are completed. The accident book was up to date. The home does need to develop detailed environmental risk assessments demonstrating evidence of regular review. Refer to requirement 7. All staff must also complete induction programmes and the necessary mandatory training within the first 6 weeks and 6 months of employment respectively. Refer to requirement 6. Roann House H56-H05 S57418 Roann House V223678 100505 Stage 4.doc Version 1.20 Page 20 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 1 1 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 1 28 1 29 x 30 1 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 3 x x x x 1 Roann House H56-H05 S57418 Roann House V223678 100505 Stage 4.doc Version 1.20 Page 21 Yes 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. Standard OP1 Regulation 4, 5 Requirement To review and update the statement of purpose and service user guide. To ensure that these documents are readily accessible to all. To develop a full and comprehensive statement of terms and conditions covering the key aspects of the home. To fully implement adequate systems of individual care planning including risk assessment processes. To ensure an up to date and accurate staff rota is available at all times providing sufficient detail. To work towards achieving at least 50 of staff with NVQ level 2 or above. To ensure all staff receive all mandatory training and additional service specific training. To develop detailed environmental risk assessments subject to regular review. Timescale for action 01/07/05 2. OP2 4, 5 01/07/05 3. OP7 15 01/09/05 4. OP27 17(2) 01/07/05 5. 6. OP28 OP30 18(1) 12, 18 On going On going 7. OP38 12, 13 01/08/05 Roann House H56-H05 S57418 Roann House V223678 100505 Stage 4.doc Version 1.20 Page 22 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 OP9 OP15 Good Practice Recommendations To review medication storage facilities. To enable service users to make positive choices about meals and menu planning. Roann House H56-H05 S57418 Roann House V223678 100505 Stage 4.doc Version 1.20 Page 23 Commission for Social Care Inspection 11th Floor, International House, Dover Place Ashford Kent TN23 1HU 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 Roann House H56-H05 S57418 Roann House V223678 100505 Stage 4.doc Version 1.20 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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