Inspection on 21/06/05 for Rockhaven

This inspection was carried out on 21st June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Rockhaven 19/10/05

Rockhaven 08/03/05

Rockhaven 10/11/04

Rockhaven 04/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Rockhaven 57 Bachelor Lane Horsforth Leeds LS18 5NA Lead Inspector Stevie Allerton Unannounced 21st June 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Rockhaven 2005621 J52 S1368 Rockhaven V205636 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Rockhaven Address 57 Bachelor Lane Horsforth Leeds LS18 5NA 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) 0113 2584984 0113 2584984 St Annes Community Services Mrs Gloria Lesley Fryer Care Home with Nursing 7 Category(ies) of Learning Disability (7) Learning Disability Over registration, with number 65 (7) of places Rockhaven 2005621 J52 S1368 Rockhaven V205636 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 8th March 2005 Brief Description of the Service: Rockhaven provides nursing care for up to seven highly dependent men and women with learning disabilities, mainly the over-50 age group. The home is operated by St Anne’s Community Services, a major voluntary provider of services to people with learning disabilities in Leeds, and is managed by Ms. Gloria Fryer. The home comprises a large well maintained bungalow, a pleasant enclosed garden at the rear and good parking space at the front. All the bedrooms are well personalised and for single occupancy. There are good bathroom and toilet facilities and a comfortable lounge/dining area with a conservatory at the back. The bungalow is domestic in size and is situated in a quiet residential area near to the main shopping area in Horsforth on the outskirts of Leeds. Rockhaven 2005621 J52 S1368 Rockhaven V205636 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out without prior announcement and was the first of two inspections planned to take place during the year commencing 1st April 2005. It took place over a three and a half hour period in the middle of the day and was carried out by one inspector. The main focus of this visit was to monitor progress on improving the shortfalls in standards identified at previous inspections and to spend time with the service users. Five of the service users, one relative and four staff members were spoken with during this visit. What the service does well: What has improved since the last inspection? What they could do better: Care plans need to be expanded, to reflect not only the nursing interventions required by an individual, but also their day to day activities. These must also include risk assessments and action plans, where such risks are identified, along with a method to regularly review and update these plans. Staff have a great deal of knowledge about the individual likes and dislikes of the service users in their care, and which methods work well when having to carry out caring tasks. These should be incorporated into the care plans so that staff are able to work consistently. Rockhaven 2005621 J52 S1368 Rockhaven V205636 Stage 4.doc Version 1.30 Page 6 The Manager must ensure that relatives, or service users’ representatives, are given all of the information they need when a service user is admitted. This includes a copy of the contract and information regarding the facilities and services provided by the home. 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. Rockhaven 2005621 J52 S1368 Rockhaven V205636 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Rockhaven 2005621 J52 S1368 Rockhaven V205636 Stage 4.doc Version 1.30 Page 8 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 standard(s) 2, 3 & 5 Potential service users are carefully assessed to ensure that their care needs can be properly met by the home. Relatives acting on behalf of service users are provided with good information about the home and encouraged to remain involved in the decisions about future care. The home could be more proactive in providing written contracts, so that families know exactly what to expect from the service at an earlier stage. EVIDENCE: A new service user was admitted a few weeks previously, so the assessment information for this person was examined. His sister was also visiting at the time of inspection, so the inspection findings could be verified in respect of this group of standards. Documentation included a comprehensive assessment and service plan, carried out at the service user’s previous home, which identifies the need for nursing care. The relative expressed her satisfaction with the assessment and admission process and said that the staff kept her informed throughout. However, she was concerned that she had not yet received a copy of the contract for her brother’s care, detailing exactly what services were included and how much they would cost. The Manager undertook to chase this up at the organisation’s head office. Rockhaven 2005621 J52 S1368 Rockhaven V205636 Stage 4.doc Version 1.30 Page 9 There had been 5 referrals for a place at the home when the last vacancy had arisen, all of them people who had been identified as having a nursing need along with their learning disability. Each person referred was seen either by the Manager of Rockhaven or the Manager of the other nursing home within the organisation, and a written assessment carried out before a place was offered. Rockhaven 2005621 J52 S1368 Rockhaven V205636 Stage 4.doc Version 1.30 Page 10 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 standard(s) 6 Care plans in place were found to be very detailed for some aspects of care, but lacking in others. Assessment information that identified areas of care need was not always matched with a written plan to meet that need. Although individual staff members may hold a good deal of knowledge about a service user’s needs and preferences, it is difficult to achieve consistency in the delivery of care, or to monitor how effective those care interventions are, if written plans are not available to work to. EVIDENCE: Care planning was looked at in depth for the most recently admitted service user. The placing agency’s comprehensive assessment and service plan was detailed and established the individual’s needs in each area of their daily life. The home had developed their own wound care plans (the service user was admitted with extensive and numerous pressure sores), but no written plans had been developed in response to other areas of personal or social care need, such as continence management/catheter care, eating and drinking, or meeting leisure and recreational needs. Rockhaven 2005621 J52 S1368 Rockhaven V205636 Stage 4.doc Version 1.30 Page 11 In discussion with the staff it was evident that there was some common knowledge about how best to meet the service user’s needs, based on the admission documents and information from the family, but this was not written down. A review meeting was arranged to take place in the near future, at which the placing agency, the service user and his family could discuss the future of the placement and decide whether it would become permanent or not. Rockhaven 2005621 J52 S1368 Rockhaven V205636 Stage 4.doc Version 1.30 Page 12 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 standard(s) None of these standards were looked at on this visit. EVIDENCE: Rockhaven 2005621 J52 S1368 Rockhaven V205636 Stage 4.doc Version 1.30 Page 13 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 standard(s) 18, 19 & 20 Service users receive good attention to their physical care needs, particularly with regard to nursing interventions. The staff have good levels of knowledge about individuals’ preferences for the way they are cared for, but not always written down. EVIDENCE: The care plan that was examined in detail contained information about specific nursing interventions, some of which had required specialist training in order to deliver. There was also evidence that appropriate advice and expertise had been sought from specialists in the community, such as the Tissue Viability Nurse. Progress could be seen with regard to the healing of long-standing pressure damage, which the service user was admitted with. In discussion with the staff it was apparent that they had gained skills in using diversionary tactics, to take the service user’s attention away from the discomfort arising from changing wound dressings, etc. Medication storage, administration and recording were inspected. The procedures in place, along with the associated records were in order, in line with approved practice. None of the service users are able to look after their own medication. Rockhaven 2005621 J52 S1368 Rockhaven V205636 Stage 4.doc Version 1.30 Page 14 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 standard(s) None of these standards were looked at on this visit. EVIDENCE: Rockhaven 2005621 J52 S1368 Rockhaven V205636 Stage 4.doc Version 1.30 Page 15 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 standard(s) 24, 25, 27, 29 & 30 Service users live in comfortable, well-decorated surroundings, which are kept in a good state of repair. Service users’ safety and well-being are promoted by the level of specialist equipment provided. EVIDENCE: The bungalow is domestic in size and character, yet has provision to care for people with a high degree of physical dependency. Ceiling tracking has been provided to almost every area now, which assists in using hoists in confined spaces. Since the last inspection a new bath has been fitted, suitable for people with physical disabilities. Apart from some teething problems with how the bath has been fitted, this now provides a good facility for staff assisting with bathing very dependent service users. Staff have decorated many areas themselves and spoke of plans for decorating some of the service users’ bedrooms. The rooms seen were all well-furnished and were decorated to reflect the preferences and interests of each occupant. Where pressure-relieving equipment has been recommended, this was seen to Rockhaven 2005621 J52 S1368 Rockhaven V205636 Stage 4.doc Version 1.30 Page 16 be in position in the appropriate place. Some bedroom carpets have been replaced with good quality non-slip vinyl to enable better odour control. The home has recently increased their clinical waste collections, as more continence products are in use. Some refresher training in Infection Control was being arranged for the staff team. Domestic support is currently provided through an agency; however, it is the same worker who comes each time, which helps with consistency. Rockhaven 2005621 J52 S1368 Rockhaven V205636 Stage 4.doc Version 1.30 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 & 35 Service users are cared for by a team of staff who have the training and skills to meet their needs. Training for new staff follows a structured programme, designed to equip the worker with the skills and knowledge they need to carry out their role. EVIDENCE: The staffing rota shows an appropriate mix of qualified nurses and supporting care staff on each shift, with a minimum of two staff on duty at all times during the day or night. Recruiting to vacant posts has improved in comparison with recent years as, despite one of the qualified nurses having recently left for promotion, there have been some good quality applicants for the post. It has been agreed to recruit a nurse with RGN qualification so that their clinical nursing skills will enhance those of the Learning Disability nurses. As the most recent service user has been assessed as needing extra staffing to meet his care needs, a 35 hours per week support worker is also being recruited. Training records were examined for the newest staff member, who started work three months previously. Basic training has been carried out, Rockhaven 2005621 J52 S1368 Rockhaven V205636 Stage 4.doc Version 1.30 Page 18 complemented by an Induction workbook. This is to be followed by Foundation training after 6 months, followed by LDAF (Learning Disability Award Framework) training. The nursing staff are accessing training courses via the Primary Care Trusts. Rockhaven 2005621 J52 S1368 Rockhaven V205636 Stage 4.doc Version 1.30 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 41, 42 & 43 The organisation’s policies, procedures and records and administrative systems ensure the smooth running of the home and that service users’ best interests are safeguarded. Whilst staff do appear to represent service users’ rights and best interests, this was not reflected in some of the records seen. EVIDENCE: A selection of statutory and operational records were inspected, including service user care plans, risk assessments, fire safety records, medication records, staff training records, staff rotas and monthly reports on the conduct of the home, completed by the home’s Line Manager. Risk assessments are in place for all of the service users, apart from the person most recently admitted; however, most of these needed updating, at least one of those seen last reviewed 2 years ago. The fire records showed that there had been appropriate responses to a series of false alarms, some of which had happened during the night, and that the Rockhaven 2005621 J52 S1368 Rockhaven V205636 Stage 4.doc Version 1.30 Page 20 staff had received training. A recent report from the Fire Officer confirms that all fire precautions are satisfactorily maintained. The Manager reported that she just has two more units to complete in order to gain her NVQ (National Vocational Qualification) level 4 award, for Registered Managers, although she felt that, at the moment, she was not getting sufficient administration time within her working week. A letter has recently gone out to all relatives, inviting them to an Open House forum, encouraging service users’ representatives to have a say in the running of the home. The home is subject to regular monitoring by a Line Manager, who makes monthly reports in accordance with Regulation 26. Rockhaven 2005621 J52 S1368 Rockhaven V205636 Stage 4.doc Version 1.30 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 x 2 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 x 3 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x 3 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Rockhaven Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x 2 2 3 2005621 J52 S1368 Rockhaven V205636 Stage 4.doc Version 1.30 Page 22 NO 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 6 Regulation 15 Requirement Timescale for action By 31.8.05 2. 3. 41 42 17(3) 13(4) Care plans which cover all aspects of a service users physical, emotional and social needs, must be put in place. These must be generated from the Assessment Service Plan, include an assessment of risk and be reviewed at regular intervals. Records must be kept up to By 31.8.05 date. Risk assessments in place for By 31.8.05 service users must be reviewed and updated where necessary, at the appropriate intervals. 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. Refer to Standard 5 Good Practice Recommendations Service users representatives should be provided with a contract, stating what facilities and services the home will be providing, at the earliest opportunity. Rockhaven 2005621 J52 S1368 Rockhaven V205636 Stage 4.doc Version 1.30 Page 23 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 © 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 Rockhaven 2005621 J52 S1368 Rockhaven V205636 Stage 4.doc Version 1.30 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. 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