Inspection on 07/11/06 for Roberttown Nursing Home

This inspection was carried out on 7th November 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Roberttown Nursing Home 11/11/09

Roberttown Nursing Home 19/12/08

Roberttown Nursing Home 30/11/05

Roberttown Nursing Home 25/07/05

Roberttown Nursing Home 02/02/05

Roberttown Nursing Home 03/09/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Roberttown Nursing Home Church Road Roberttown Liversedge West Yorkshire WF15 8BE Lead Inspector Bronwynn Bennett Unannounced Inspection 7th November 2006 08:15 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 Roberttown Nursing Home DS0000001095.V311653.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 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. Roberttown Nursing Home DS0000001095.V311653.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Roberttown Nursing Home Address Church Road Roberttown Liversedge West Yorkshire WF15 8BE 01924 411600 01924 408395 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) CSS Investments Limited Ms Julie Ward Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29), Terminally ill (4), Terminally ill over 65 of places years of age (4) Roberttown Nursing Home DS0000001095.V311653.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can accommodate one service user under the age of 65 years Date of last inspection 30th November 2005 Brief Description of the Service: Roberttown Nursing Home is purpose built and registered to provide nursing and personal care for up to twenty nine older people. The home is also registered to provide nursing and personal care for four adults under the compassionate care scheme. The home is located in its own grounds and there are adequate car parking facilities to the front of the home. The home is situated close to the facilities and shops in the village of Roberttown. The home is staffed twenty-four hours a day and there are wakeful night staff on duty. The provider informed the Commission for Social Care Inspection on 04/10/06 that the fees range from £342.99 to £502.47. There are additional charges for hairdressing, newspapers and private chiropody. Information about the home and the services provided are available from the home in the statement of purpose and the service user guide. Roberttown Nursing Home DS0000001095.V311653.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit carried out by the inspector. The visit began at 8.15am and finished at 3.45 pm. During this visit the inspector spoke to some service users, some of the staff and the home’s manager Ms Julie Ward. The inspector read care records, audited a sample of medications, reviewed staff recruitment and training records, and carried out a tour of the home. Prior to this visit the Commission for Social Care Inspection sent twelve questionnaires to service users living at Roberttown Nursing Home. Six completed questionnaires were returned. There were twenty-six service users living at the home on the day of this visit. Surveys were sent to twelve service users’ relatives and seven GPs. The inspector received responses from eight relatives and four GPs. Other information used as part of this inspection process includes notifications from the home to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, and a pre inspection questionnaire was completed by the manager. The inspector would like to thank everyone for their assistance during this inspection process. What the service does well: The home continues to provide a warm and welcoming atmosphere and is clean and well maintained. The service users spoken with and the respondents to the survey said they receive the care and support they need, and the staff listen and act on what they say. There were some positive comments made by relatives who responded to the survey. One commented that the home offers an excellent standard of care. And another said the home offers a high standard of care and the staff are caring and helpful. A relative visiting the home said, “The staff are wonderful”. Fifty per cent of the care staff have achieved NVQ (National Vocational Qualification) level 2 or above. Roberttown Nursing Home DS0000001095.V311653.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Roberttown Nursing Home DS0000001095.V311653.R01.S.doc Version 5.2 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 Roberttown Nursing Home DS0000001095.V311653.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ needs are assessed prior to admission into the care home. EVIDENCE: There was evidence of a pre admission assessment being carried out in the care records looked at. And the manager confirmed that the needs of all potential service users are assessed prior to admission to the care home. Two of the surveys returned to the Commission for Social Care Inspection said that service users received enough information before moving into the home. Roberttown Nursing Home DS0000001095.V311653.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Generally, service users health, personal and social care needs are set out in the individual plan of care. Greater care is required to ensure the service users are sufficiently protected by the home’s medication policy and procedure. Generally service users are treated with dignity and respect. EVIDENCE: The service users who responded to the survey said that they receive the care and support they need. There is a warm and friendly atmosphere in the home and good relationships were observed between the service users and the staff. The GPs who responded to the survey said that they are always able to see their patients in private. Roberttown Nursing Home DS0000001095.V311653.R01.S.doc Version 5.2 Page 10 The service users spoken to during this visit said that the staff are good. Staff was seen interacting well with the service users and treating them in a respectful and dignified way. However, the inspector did observe a member of staff approach a service users without due regard for their dignity and privacy. This was discussed with the manager of the home who said she would address the matter. The care records for three service users were audited. These records contained general care plans with specific needs recorded where required. Risk assessments were in place and service users have assessments for nutrition and tissue viability (to measure the risk of developing a pressure sore). The care records examined were reviewed and up to date. However, greater care should be taken when reviewing the care records. Any changes relating to the care of the individual should be recorded in the specified needs section of the care plan. This will ensure care staff has up to date information of the care that is to be provided. The information in the daily records is brief and does not sufficiently record the individual’s plan of care. This was discussed with the manager and is a recommendation of this report. The home’s medication system was audited and the medication for three service users was checked. One medication was accurate. Two medications could not be fully reconciled with the records kept by the home. This was due to some medication not being carried forward onto the current MAR (Medication Administration Record) sheet. This was discussed with the manager who agreed to take immediate action to rectify the matter. Roberttown Nursing Home DS0000001095.V311653.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ cultural, religious, social and recreational needs are being met, and they are supported to maintain contact with their family and friends. The service users are able to exercise choice and control over their lives. The home provides the service users with a varied and nutritious diet. EVIDENCE: The service user surveys said that there are activities arranged by home that they are able to take part in. The care records looked at showed the service users preferred activities recorded in their recreation plan of care. There is a range of activities arranged by the home. Activities such as, bingo, hairdressing, trips out and pub lunches are available. A pantomime and Christmas party has been planned for the service users. Religious observance is respected for service users, with religious services being carried out in the home on a regular basis. Roberttown Nursing Home DS0000001095.V311653.R01.S.doc Version 5.2 Page 12 Service users are supported to manage their own finances, if they wish, and lockable facilities are provided in service users rooms. Individual rooms were seen during a tour of the home and service users’ rooms were personalised. The service users spoken with said that their relatives and friends are always made to feel welcome at the home. Two relatives spoken to said they are always made welcome by the staff. Seven relatives who responded to the surveys said that the staff welcomed them into the home at any time. The home offers a four weekly menu. A choice of food is made available to service users and specialist diets are provided. The service users are supported to discuss menus and choice of food when they attend meetings held in the home. The service users spoken to said the food served in the home is good. Four service users who responded to the surveys said the food is usually good. Roberttown Nursing Home DS0000001095.V311653.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally service users and their relatives are confident their complaints will be listened to and acted upon. Service users are protected from abuse. EVIDENCE: There is a complaints policy and procedure displayed in the home. The service users spoken with said they knew who to speak to should they have any concerns or complaints. Two relatives said they would be confident raising any concerns or a complaint with the manager of the home. Three service users surveys said that they knew who to speak to should they have a complaint. One of the respondents said they were not sure of how to make a complaint. Seven relatives who responded to the survey said that they were aware of the homes complaints procedure. One relative survey was not aware of the complaints procedure. The staff spoken with during this visit had a good understanding of adult protection issues and the necessary action that must be taken should there be any allegations of abuse. Roberttown Nursing Home DS0000001095.V311653.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe and well-maintained environment that is clean and comfortable. EVIDENCE: All service user surveys received by the Commission for Social Care Inspection (CSCI) said that the home is always fresh and clean. During this visit the home was seen to be clean and well maintained. There is an ongoing programme of renewal carried out at the home. Since the last visit by the CSCI some bedrooms have been redecorated, some new chairs have been purchased and the home now employs a gardener. The laundry facilities at the home are suitably sited, clean and well organised. Roberttown Nursing Home DS0000001095.V311653.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are employed in sufficient numbers and receive induction and ongoing training. Service users are supported and protected by the home’s recruitment policy. EVIDENCE: There are sufficient numbers of care staff employed to meet the needs of the service users. The service users who responded to the survey said they always receive the care and support they need and staff are generally available when needed. Two visitors were very complimentary about the staff at the home and one commented, “The staff are wonderful.” A relative who responded to the survey said that the home offers a high standard of staff who are extremely helpful. Another said the staff are friendly and helpful. 50 of the care staff working in the home have achieved NVQ (National Vocational Qualification) level 2 or above. Roberttown Nursing Home DS0000001095.V311653.R01.S.doc Version 5.2 Page 16 Three staff files were audited. The records looked at contained the information required to ensure service users are protected by the home’s recruitment procedures. The staff records audited showed that the staff have undertaken induction training. Ongoing training is made available to staff to ensure they are suitably trained to meet the needs of the service users. The manager is developing infection control training for all staff that meets the Department of Health Guidance 2006. Roberttown Nursing Home DS0000001095.V311653.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users live in a home run by a manager who is fit to be in charge. The home is generally run in the best interests of the service users. The financial interests of the service users are safeguarded. Generally the health, safety and welfare of the service users is promoted and protected. EVIDENCE: The registered manager of the home is Ms Julie Ward. The service users, their relatives and staff spoken to during this visit said that the manager is approachable and supportive. Roberttown Nursing Home DS0000001095.V311653.R01.S.doc Version 5.2 Page 18 The finance and financial records for three service users were checked and were up to date and accurate. The home has a quality monitoring system that is carried out within the home. Service users are supported to take part in meetings carried out in the home. The home carries out quality monitoring that seeks the views of service users, family and friends and other relevant professionals. The results of the quality assurance survey are published and available to service users and other interested parties. This is good practice. The information received by the CSCI shows that the equipment in the home is serviced regularly. The fire records were looked at. There is weekly testing of the home’s fire alarm system and emergency lighting system. All staff undertake fire drill training. Roberttown Nursing Home DS0000001095.V311653.R01.S.doc Version 5.2 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Roberttown Nursing Home DS0000001095.V311653.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 13.2 Timescale for action The registered person shall make 07/11/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The medication records must be kept up to date. All medication carried forward from the previous month must be transferred onto the current MAR sheet. Requirement 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 OP10 Good Practice Recommendations Where a care plan has been reviewed and identifies changes. Those changes should be identified clearly in the specific needs section of the care records kept. Daily records should be more detailed and accurately reflect the care given each day. The registered person should ensure that the staff DS0000001095.V311653.R01.S.doc Version 5.2 Page 21 Roberttown Nursing Home maintains the privacy and the dignity of the service users at all times. Roberttown Nursing Home DS0000001095.V311653.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Brighouse Area Office 1st Floor St Pauls House 23 Park Square (South) Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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