Inspection on 18/08/05 for Rockley Dene Nursing Home

This inspection was carried out on 18th August 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

Rockley Dene Nursing Home 21/03/07

Rockley Dene Nursing Home 09/10/06

Rockley Dene Nursing Home 14/04/05

Rockley Dene Nursing Home 05/10/04

Rockley Dene Nursing Home 11/05/04

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 Rockley Dene Nursing Home Park Road Worsbrough Barnsley S70 5AD Lead Inspector Steve Vessey Unannounced 18 August 2005 10:00am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Rockley Dene Nursing Home J51 6489 Rockley Dene N V245517 18.08.05 UI Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Rockley Dene Nursing Home Address Park Road Worsbrough Barnsley S70 5AD 01226 207916 01226 280187 None Angel Care plc Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Jane Bennett N - Care home with nursing 34 Category(ies) of OP - Old age (34) registration, with number of places Rockley Dene Nursing Home J51 6489 Rockley Dene N V245517 18.08.05 UI Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons accommodated shall be aged 60 years and above. Of the 34 registered beds, 30 can be used as nursing care (N) or personal care and 4 can be used as personal care (PC) only. Date of last inspection 14 April 2005 Brief Description of the Service: Rockley Dene is a purpose built home providing nursing and personal care. Accomodation is provided for 34 residents over the age of 60. The home is owned by Angel Care Ltd and is situated at Worsborough Bridge. The home is on a main bus route into Barnsley town centre and there are local shops nearby. The accomodation is provided on two floors, a lift and stairs access the upper floor. Resident accomodation is provided in 9 double and 16 single bedrooms of which 10 have an en-suite facility. There is one large lounge area and another lounge area within the conservatory. One lounge area is nonsmoking. The dining room opens onto a patio area and there is a pleasant garden area. It should be noted on the same site, but not attached, is Rockley Dene Personal Care Home. This is registered seperately and not covered by this inspection report. Rockley Dene Nursing Home J51 6489 Rockley Dene N V245517 18.08.05 UI Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over six hours from 10:00 to 16:00 The inspection process included a partial inspection of the premises, inspection of a sample of records and policies, discussions with staff, residents and relatives and observation of staff carrying out their duties. The majority of residents and staff were seen during the inspection and the inspector had the opportunity to speak to eight staff, seven residents and relatives in some detail. What the service does well: What has improved since the last inspection? Staff had received abuse awareness training and the manager had applied for places on the adult protection training provided by the local authority. A training plan had been developed for the home and a system for formal staff supervision had been implemented, although this had not yet included all staff. The records on resident’s personal money accounts had improved and included two signatures. Staff training records were available. Residents stated that they were happy with the activities on offer. Rockley Dene Nursing Home J51 6489 Rockley Dene N V245517 18.08.05 UI Stage 4.doc Version 1.40 Page 6 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. Rockley Dene Nursing Home J51 6489 Rockley Dene N V245517 18.08.05 UI Stage 4.doc Version 1.40 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 Rockley Dene Nursing Home J51 6489 Rockley Dene N V245517 18.08.05 UI Stage 4.doc Version 1.40 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) 3, standard 6 is not applicable at the home. Residents had a detailed assessment of their needs prior to admission to the home. EVIDENCE: Four care plans contained a pre – admission assessment undertaken by the home, information from the placing authority, including assessments and care plans and a detailed assessment carried out by nursing staff on admission to the home. Relatives confirmed that assessments had been carried out before residents were admitted to the home. Rockley Dene Nursing Home J51 6489 Rockley Dene N V245517 18.08.05 UI Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 9 and 10. Residents had a detailed up to date plan of care reflecting their identified assessed needs. Medication was managed safely and securely stored. Residents were treated with respect and their privacy was upheld. EVIDENCE: Four care plans checked included detailed information as to the actions required by staff to meet the needs of individual residents and were reviewed regularly by staff. Risk assessments were in place for the administration of medication, the development of pressure areas and the use of bed rails. Residents or their relatives had signed these risk assessments. Records were kept of medication being received into and leaving the home. There were medication administration records for residents, which were in the main completed appropriately, maintaining resident’s health safety and welfare. The nurse administering medication was sensitive to the needs of the residents, maintaining their dignity. Residents and relatives stated that they were happy with the care received and that staff were good at their jobs comments included “we are well looked after and couldn’t wish for a better home”. Rockley Dene Nursing Home J51 6489 Rockley Dene N V245517 18.08.05 UI Stage 4.doc Version 1.40 Page 10 Care staff were able to describe how they promote privacy and dignity when providing care for residents and senior care and nursing staff described how they monitored care delivery to ensure the privacy and dignity of residents is maintained. Rockley Dene Nursing Home J51 6489 Rockley Dene N V245517 18.08.05 UI Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 Residents are given choice in many aspects of their lives, allowing them to maintain their independence and were happy with the activities on offer, however some residents and staff stated they more opportunities for outings would improve the quality of the service. Relatives and friends are encouraged to visit and participate in some aspects of resident care enhancing the quality of life of residents. Residents receive a choice of food, which is of good quality and can eat in a pleasant dining room or their room, however some residents may not be comfortable as they were seated in wheelchairs at mealtimes. EVIDENCE: Residents stated that activities offered included painting, bingo and dominoes. Other residents stated that they liked to spend the majority of time in their rooms. Some residents stated that they go out regularly with family or friends. Relatives were observed visiting throughout the day and were welcomed by staff. Relatives stated that the staff are friendly, welcoming and approachable. The dining room was pleasant, table were set appropriately with tablecloths, tablemats, cutlery cruet, sauces and plants. The menu for lunch was displayed on the notice board in the dining room and corresponded to the meal served, some residents were aware of the choice of food available at teatime. Rockley Dene Nursing Home J51 6489 Rockley Dene N V245517 18.08.05 UI Stage 4.doc Version 1.40 Page 12 Some residents were left sitting in their wheelchairs to eat their lunch, staff were not observed asking residents their preference regarding seating arrangements, however residents were assisted back to their choice of communal lounge and assisted to sit in appropriate chairs immediately after lunch. Rockley Dene Nursing Home J51 6489 Rockley Dene N V245517 18.08.05 UI Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The complaints procedure was available, people were aware how to complain and thought that their complaints would be listened to and dealt with. Procedures are in place to protect residents from abuse, adult protection training would increase the level of protection. An anonymous complaint was investigated appropriately by the provider. EVIDENCE: Residents and relatives stated that they would tell staff if they were not happy, but also stated that they had nothing to complain about. Relatives stated that they had received information about the home prior to admission and this included details of how to complain. Staff spoken to stated that they had received abuse awareness training recently but stated more in depth adult protection training was planned. All staff stated that they would report any suspicions of abuse to the nurse in charge or the manager, some staff stated that if they needed to contact someone outside the home they would contact social services. The manager stated that she was in the process of applying for adult protection training facilitated by the local authority. An anonymous complaint was received by the CSCI in April 2005, the complaint was also referred to the Barnsley local authority Adult Protection team, and the strategy meeting agreed that the provider should investigate the complaint. Following the investigation and an additional visit to the site on 29th June 2005 the complaint was not upheld. Rockley Dene Nursing Home J51 6489 Rockley Dene N V245517 18.08.05 UI Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 24 and 26 The home was in the main well maintained. In the main the indoor and outdoor communal facilities were comfortable, however it was hot in the conservatory area. Most areas of the home were accessible, however one bathroom was being used for inappropriate storage. Residents were happy and comfortable in their rooms. In the main the home was clean, however there was an unpleasant odour in two bedrooms. EVIDENCE: The home was in the main clean, odour free and decorated to a reasonable standard, resulting in a mainly safe and well-maintained environment. Some residents sat in the conservatory stated that it was too hot, the manager stated that the temperature had been monitored and when it was warm residents were encouraged to have doors and windows open and cold drinks were offered by staff. Rockley Dene Nursing Home J51 6489 Rockley Dene N V245517 18.08.05 UI Stage 4.doc Version 1.40 Page 15 There were sufficient and suitable toilets and bathrooms, however one bathroom was still being used for inappropriate storage of equipment. Residents and relatives stated that their bedrooms were comfortable and kept clean. Bedrooms had been personalised and residents stated that they had all the furniture that they needed. Two bedrooms had an unpleasant odour, the manager stated that the carpets had been cleaned regularly in these rooms but the odour remained. One ensuite wash hand basin was blocked. Rockley Dene Nursing Home J51 6489 Rockley Dene N V245517 18.08.05 UI Stage 4.doc Version 1.40 Page 16 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, 29 and 30. The number of staff on duty does not always meet requirements. More than 50 of care staff are NVQ trained. Recruitment policies and procedures need to be more robust. Induction training provided is comprehensive, staff receive further training to assist them in meeting the needs of the residents, but do not yet have individual training plans. EVIDENCE: On the morning of the inspection there was one nurse, five care staff and the manager on duty. The rota showed that on the afternoon of the inspection there was one nurse and three care staff and previously there had been one nurse, three care staff and the manager on a morning shift. Staff stated that the majority of the time there was sufficient staff to meet the needs of the residents, however they stated that occasionally this was not the case, usually due to sickness or holidays. Residents stated that there was enough staff to meet their needs and that staff were available promptly if they needed assistance. Relatives stated that occasionally they had noticed that there was not as many staff on duty. The manager stated that more than 50 of care staff are qualified at NVQ level 2. Rockley Dene Nursing Home J51 6489 Rockley Dene N V245517 18.08.05 UI Stage 4.doc Version 1.40 Page 17 One staff file did not have written references, although there was some evidence that the home had obtained one verbal reference. The staff member’s previous employer had obtained the CRB disclosure that was in the file. The manager stated that the policy is to use a CRB disclosure from a previous employer if it is recent and then apply for an up to date disclosure following the appointment of the staff member. Some staff stated that they could not recall completing a CRB disclosure. Staff spoken to stated that they had received induction training, which included fire safety awareness and moving and handling and stated that there were regular opportunities for them to attend additional training. Residents stated that staff looked after them well, comments included “staff are brilliant” and “we are well looked after”. Relatives stated that staff are kind and look after residents well. Rockley Dene Nursing Home J51 6489 Rockley Dene N V245517 18.08.05 UI Stage 4.doc Version 1.40 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, 35, 36 and 38 The manager is working towards her management qualification. The manager was open and honest and manages the home for the benefit of the residents. Financial systems and procedures are in place to safeguard residents. A supervision system had been implemented, however all staff had not yet received regular formal supervision. The excessive hot water temperature in the identified area and the movement of residents in wheelchairs without the use of footplates compromised the safety of residents. Rockley Dene Nursing Home J51 6489 Rockley Dene N V245517 18.08.05 UI Stage 4.doc Version 1.40 Page 19 EVIDENCE: The manager stated that she was continuing to work towards her management qualification. Staff stated that the Manager and Deputy Manager were fair and approachable, treating all staff the same. Staff also stated that they would sort out any issues raised as soon as possible. Staff confirmed that they were asked about the running of the home and that regular meetings take place at which they can discuss any issues they have. Residents and relatives stated that they would feel comfortable approaching the manager if they had anything to discuss. Written transactions were kept for each individual resident whose money was kept in the safe, these records included two signatures for each transaction safeguarding resident’s financial interests. Residents spoken to who had money in the safe were happy with arrangements in place, other residents were happy that their family looked after their money. Records were available to show that staff had received fire training, this was confirmed by the staff spoken to, recently employed staff stated that they had been made aware of fire procedures and been shown where call points and fire fighting equipment was as part of their induction. The temperature of the hot water on the hand washbasin in the en-suite of room 15 was measured in excess of 50 degrees centigrade, on investigation it was found that there was no thermostatic mixer valve fitted. An immediate requirement was made and this was discussed with the manager who immediately contacted a plumber and arranged for him to visit to ensure the risk of scalding was removed until a mixer valve can be fitted. Staff were observed moving residents around the home in wheelchairs without footplates attached. The manager stated that some residents had stated that they did not want to use footplates or that there was a risk to some residents if footplates were used. The manager stated that this would be recorded in the relevant residents care plans however it was not recorded in all cases. Rockley Dene Nursing Home J51 6489 Rockley Dene N V245517 18.08.05 UI Stage 4.doc Version 1.40 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. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 3 2 2 x x 2 x 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 3 x x 3 2 x 2 Rockley Dene Nursing Home J51 6489 Rockley Dene N V245517 18.08.05 UI Stage 4.doc Version 1.40 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 12 15 Regulation 16 24 Requirement Residents must be consulted about outings they wish to undertake. Residents must be seated on dining chairs during mealtimes unless it is identified in their care plan that this is their personal choice or not appropriate to their needs. All staff must receive adult protection training. The equipment stored in the bathroom must be removed and stored in a suitable place (Previous timescale of 31.05.05 not met). The identified hand washbasin must be unblocked. All areas of the home must be free from unpleasant odours Adequate numbers of staff must be working at the home at all times. Staff must not be employed without a CRB and POVA check and the receipt of two written references (Previous timescale of 30.04.05 not met). An individual training and assessment profile must be developed for all staff (Previous Timescale for action 30.11.05 30.11.05 3. 4. 18 21 13 23 30.11.05 30.11.05 5. 6. 7. 8. 24 26 27 29 23 16 18 19, Schedule 2 18 31.08.05 31.08.05 30.09.05 31.08.05 9. 30 30.11.05 Rockley Dene Nursing Home J51 6489 Rockley Dene N V245517 18.08.05 UI Stage 4.doc Version 1.40 Page 22 timescale of 31/07/05 not met). 10. 11. 36 38 18 23 All staff must receive regular supervision (Previous timescale of 31.07.05 not met). Hot water temperatures must be regulated to around 43 degrees centigrade. 30.11.05. Immediatel y as instucted on the day of the inspection 18.08.05 30.09.05 12. 38 23 Risk assessments must be in place for residents who are moved in wheelchairs without the use of footplates. 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 20 31 Good Practice Recommendations The air temperature, in the conservatory should be monitored and if found to be excessive action taken to provide adequate ventilation. The manager should achieve NVQ level 4 in management by 2005. Rockley Dene Nursing Home J51 6489 Rockley Dene N V245517 18.08.05 UI Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffield, S9 2LR 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. 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