Inspection on 14/12/06 for Rockley Dene Residential

This inspection was carried out on 14th December 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 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 Residential 14/02/06

Rockley Dene Residential 07/09/05

Rockley Dene Residential 11/01/05

Rockley Dene Residential 03/08/04

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 Residential Park Road Worsbrough Barnsley South Yorkshire S70 5AD Lead Inspector Mrs Jayne White Key Unannounced Inspection 14th December 2006 9:15 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 Rockley Dene Residential DS0000018277.V306102.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. Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rockley Dene Residential Address Park Road Worsbrough Barnsley South Yorkshire S70 5AD 01226 245536 01226 280 187 none 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) Angel Care Plc Mrs Beryl Skidmore Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2006 Brief Description of the Service: Rockley Dene is a care home providing personal care and accommodation for up to 40 residents aged 65 years or over. The home is situated in a residential area of Barnsley close to amenities and on the local bus route. The home is a two storey building, comprising of 22 single rooms, 3 of which are en-suite and 9 double rooms, 2 of which are en-suite. A range of communal rooms are provided, including 3 lounge areas and a large dining room. The home has sufficient bathing facilities, aids and adaptations such as ramps, a lift and handrails available. A central kitchen and laundry room serve the home. The home has a garden area that is accessible to residents. A car park is available. Angel Care Plc own the home. Currently, the fee to reside at the home is £315 per week. There are additional charges for chiropody and hairdressing. Information of the services and facilities the home offer, including the service user guide that holds the most current inspection report and terms and conditions/fees to residents and prospective residents, plus the home’s statement of purpose is kept in each of the service users’ bedrooms. Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection carried out from 9:15 to 18:00. As part of the inspection process questionnaires were sent to ten residents, three general practitioners and three care managers to obtain their opinions of the home. Seven questionnaires were returned by residents (two completed by family members) and one from a care manager. On the day, opportunity was taken to make a partial inspection of the premises, inspect a sample of records, observe care practices and talk to residents, their advocates, staff and the manager. The inspector spoke with ten residents about their opinions on aspects of living at the home, three of the staff on duty about aspects of their knowledge, skills and experiences of working at the home, two visitors and one health care professional about their opinions of the care provided by the home and the manager. Throughout the inspection positive and professional relationships were observed between staff and residents. Also taken into account was additional information received by CSCI about the service since the last inspection. In addition, the CSCI have reviewed their guidance on requirements, therefore, some requirements have been removed if they had no direct evidence of service user outcome, or reworded. The inspector wishes to thank the manager, staff and residents for their time and co-operation throughout the inspection process. What the service does well: On the whole residents and staff benefited from the ethos, leadership and management approach. Staff morale was good and all residents, their advocates and staff spoke positively about the management team. Residents were not admitted to the home without their needs being assessed, to ensure the home was able to meet their health, social and care needs and all resident questionnaires returned confirmed residents and/or their family received enough information about the home before they moved in, to decide if the place was right for them and that they received a contract. Resident’s personal, health and social care needs were met and residents were comfortable to talk about the care that they received. Comments from residents and their families about the care they received included “Rockley Dene care is first class”, “I have lived at Rockley Dene for six months. The care and attention is excellent. The management and staff are very caring and very cheerful. I am very happy and content at Rockley Dene”, “we are very happy about the level of care, cleanliness, comfort and diet at Rockley Dene”, “I am Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 6 very happy with the help and care my mother receives. I have visited my father-in-law in a nursing home in Sheffield and I now know just what he has been missing for the past four and a half years” and “hospital visits are always arranged”. Residents received personal support, which promoted their privacy, dignity and independence. There was a relaxed and friendly atmosphere within the home. Residents spoke positively about the staff team and described them as “always helpful and cheerful” and “staff are always very friendly”. Discussions with residents’ and their advocates described how they were helped to exercise choice and control over their lives and how the lifestyle within the home met their preferences, interests and needs. Residents maintained contact with family and friends and were able to receive visitors at any reasonable time. Residents received a diet that satisfied their requirements in a pleasant dining area and their comments about meals in the home included “good food – varied menus” and “the meals are very nice but I have a poor appetite”. Residents were confident their complaints would be listened to and acted upon. The building and its environment was clean, comfortable and well-maintained so that residents were provided with an environment that was safe, accessible and homely. All residents spoke positively about their environment and the level of cleanliness commenting, “there are never any smells” and “Rockley Dene is immaculately clean, well decorated, homely and cosy”. Residents spoke positively about the attitude of the staff and the service that they received and the numbers and skill mix of staff was sufficient to meet the needs of residents. Effective quality assurance and quality monitoring systems were in place that sought the views of residents that lived at the home. What has improved since the last inspection? What they could do better: Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 7 Although care plans were in place, these should be reviewed at least monthly. The monthly review should also include reviews of risk assessments. When respite residents are readmitted, that the original assessment and care plan are reviewed to ensure the information contained within it is up to date. The medication administration record needs to clearly record the amount of stock that is received into the home and/or carried forward from one month to another. This was a requirement from the last inspection and therefore was it was disappointing to see the requirement had not been met, particularly as the home’s procedure advocated this to protect service users. Subsequent to the inspection, the provider informed the CSCI, every senior staff member received medication training in December 2006. Staff require up to date training in the administration of medication. A review of the type of training provided for the protection of vulnerable adults must be made to ensure the training is sufficient to reinforce staff knowledge in regard to the protection of vulnerable adults. Their protection was placed further at risk because the recruitment procedure operated by the home was also insufficient to protect service users as criminal record bureau checks, including a check of the protection of vulnerable adults register was not always made, prior to the employment of staff. This again was disappointing as this had been a requirement at the last inspection. Staff had received training to equip them with the knowledge and skills for their roles within the home, but some of that training required updating. In addition, the type of training provided needed reviewing to ensure it was sufficient to meet the training needs of staff. Increase the number of staff trained to NVQ Level 2 or equivalent to meet the minimum recommended ratio of 50 . The provider stated subsequent to the inspection 71.4 of care staff hold NVQ Level 2 or equivalent. Written records of all financial transactions were maintained, however, the record lacked detail, with no description of where the monies came ‘in’ and ‘out’ from or to, or what the monies spent was used for. As a result crossreferencing monies spent against receipts was unable to be achieved. Neither did the financial transaction contain two signatories. This lack of detail meant that records were insufficient to fully safeguard residents’ finances. Formal supervision needs to be implemented to provide an opportunity for both the manager and the staff member to discuss issues relating to their role, work performance and training and development needs. To ensure the home’s policies and procedures are sufficient to promote the health, safety and welfare of service users and staff improvements are Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 8 required in keeping up to date staff fire training and drills and reporting notifiable incidents to CSCI. 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. Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 9 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 Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 10 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): The outcome for standard 3 was inspected. The home did not provide an intermediate care service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were not admitted to the home without their needs being assessed, to ensure the home was able to meet their health, social and care needs. EVIDENCE: A full needs assessment was carried out for all residents prior to their admission. This confirmed that the service was appropriate for the resident and provided staff with the information to formulate an individual plan of care. All resident questionnaires returned confirmed residents and/or their family received enough information about the home before they moved in, to decide if the place was right for them and that they received a contract. Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 11 Mrs Skidmore confirmed the home did not provide an intermediate care service. Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 12 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): The outcomes for 7, 8, 9 & 10 were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans were in place for all residents and included nutritional risk assessments. Care must be taken that the plans are reviewed frequently, particularly those for respite residents and include reviews of risk assessments. Resident’s health care needs were met. A policy and procedure was in place to ensure that staff adhered to the safe administration of medication, however, improvements of medication administration and recording is required to ensure it is sufficient to ensure residents are not placed at risk of harm. Residents received personal support, which promoted their privacy, dignity and independence. Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 13 EVIDENCE: Care plans were in place for all residents. The files inspected were tidy, well organised and the information provided was easy to track. Three care plans were inspected and both set out the action that was required by staff to ensure that all aspects of the residents care needs were met. Nutritional risk assessments had been completed for all residents. The care plans were not dated and not consistently reviewed on a monthly basis, particularly for those readmitted on a respite basis and did not automatically include reviews of risk assessments that were in place. This is necessary as it is an integral part of the plan of care and ensures that the changing needs of residents are reflected in their plan of care. No times were recorded on the daily report and therefore it was unclear at what time residents had received the care that was recorded. Healthcare records were well maintained and demonstrated hospital appointments were attended with the outcome recorded in the plan of care. The record also demonstrated that residents were receiving regular visits from their general practitioner, chiropodist and dentist. A visit from the chiropodist was observed on the day of the inspection. All residents spoke positively about the care that they received and were able to describe in detail the health care visits that they had received or were attending. Residents questionnaires returned identified residents always or usually received the care and support they needed, with residents comments including “Rockley Dene care is first class”, “I have lived at Rockley Dene for six months. The care and attention is excellent. The management and staff are very caring and very cheerful. I am very happy and content at Rockley Dene” and “we are very happy about the level of care, cleanliness, comfort and diet at Rockley Dene”. A relative commented “I am very happy with the help and care my mother receives. I have visited my father-in-law in a nursing home in Sheffield and I now know just what he has been missing for the past four and a half years”. Questionnaires also confirmed residents always or usually received the medical support they needed, with one resident commenting, “hospital visits are always arranged”. There was a policy and procedure to ensure that staff adhered to safe practices regarding medication and the protection of residents, however, staff were not following the procedure for the receipt of medication into the home. The recording and storage of medication was checked on a sample basis for three residents. The medication administration record inspected did not consistently record the amount of medication that had been received, only the amount of medication that had been prescribed. In practice, this meant the record did not correlate with the amount of medication administered. It is important that the specific amount of medication received or brought forward from the previous month is recorded to ensure that clear records are maintained and that there is an audit trail for all medication received into the home to ensure the protection Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 14 of residents. Allergies were not recorded on the medication administration record. This meant staff responsible for administering medication were not always aware of these for residents, even though they were recorded in the plan of care. This would place the resident at risk of harm if they were administered medication they were allergic to. Controlled drugs received were recorded, but the record was on loose leafed sheets that weren’t numbered and therefore the record was insufficient to protect service users. The record was also insufficient as it was required the drugs that were administered to be recorded in the drugs received column. The record and the amount in stock correlated. Subsequent to the inspection the manager confirmed she had obtained a controlled drug register for the recording of controlled drugs. All staff responsible for administering medication had not received up to date training to ensure their competence, promoting the safe administration of medication to residents. Subsequent to the inspection, the provider, informed the CSCI, every senior staff member received medication training in December 2006. Staff throughout the day were observed approaching residents in a respectful manner and respecting individual preferences. Good relationships between staff and residents were evident. There were areas where the privacy and dignity of residents was respected, for example, knocking on residents’ doors before entering and closing toilet doors when in use. Discussions with staff identified they were aware of the action to be taken to maintain the personal care needs of residents in a timely manner to respect their dignity. All residents spoken with said that they were well cared for and that staff treated them with respect. Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 15 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): The outcomes for standards 12, 13, 14 & 15 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Discussions with residents’ and their advocates described how they were helped to exercise choice and control over their lives and how the lifestyle within the home met their preferences, interests and needs. Residents maintained contact with family and friends and were able to receive visitors at any reasonable time. Residents received a diet that satisfied their requirements in a pleasant dining area. EVIDENCE: There was a relaxing atmosphere within the home. Residents were observed to be following their preferred routines. The majority of residents were spending time in the lounge areas, socialising with other residents. Residents’ spoken with described how they could choose to spend their day and confirmed that they could choose what time to get up and go to bed within reason, Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 16 accepting the constraints as part of group living. Personal items and furniture were brought into the home by residents to personalise their rooms. A programme of activities was available. The pre-inspection questionnaire stated entertainers visited the home on a monthly basis and staff do daily activities with residents. Resident questionnaires identified there were usually or always activities arranged by the home that residents could take part in and comments made by one resident included “different activities organised each day”. Not all residents wanted to take part in activities and one relative confirmed this saying “…generally will not join in with activities”. Residents said that their relatives and friends were able to visit the home at any reasonable time. A good choice of menu was offered and special dietary needs were catered for. Residents were satisfied with the choice and quality of food with comments including “good food – varied menus” and “the meals are very nice but I have a poor appetite”. Resident questionnaires identified residents always or usually liked meals at the home. The lunchtime meal observed was relaxing, with plenty of attention being provided by staff. The dining area was pleasant. The tables were set with cloths, cutlery and teapots and menus were displayed on the tables. Residents were given sufficient time to eat their meal. Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 17 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): The outcomes for standards 16 & 18 were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents were confident their complaints would be listened to and acted upon. There was an adult protection procedure in place at the home, however, staffs understanding about what to do if they felt a service user was being placed at risk of harm, were not sufficient to fully safeguard the residents’ safety and welfare. EVIDENCE: The complaints procedure ensured that residents and their relatives were aware of how to make a complaint and who would deal with them. The manager kept a central record of all complaints, although no complaints had been received since the last inspection. All residents spoke positively about the attitude of the manager and the staff team. They stated that they had “no complaints” yet felt that the staff team were approachable and that they would always listen to any concerns that they may have. Resident questionnaires identified residents always or usually knew who to speak to if they weren’t happy or had any complaints and comments included “manager and senior staff very approachable and always resolve any problems”, “a complaint form is in bedroom” and “don’t really know how to make a complaint. If I am unhappy I let my daughter know”. Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 18 There was an adult protection policy and procedure in place that promoted the protection of service users from harm or abuse. All staff had attended Adult Protection and Protection of Vulnerable Adult (POVA) training, however, this had not ensured they would follow the procedures should they suspect any abuse at the home, in order to protect residents. It was noted that the training consisted of watching a video and answering questions. Although videos are a useful resource to supplement training undertaken by staff, they should not be considered sufficient to meet staff training needs, as demonstrated when staff said that there may be some cases when they would keep abuse reported to them by a resident “a secret”. Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 19 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): The outcomes for standards 19 & 26 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The building and its environment was clean, comfortable and well-maintained so that residents were provided with an environment that was safe, accessible and homely. EVIDENCE: The home was clean, tidy and odour free. All areas seen were well maintained and pleasantly decorated. There were homely touches of pictures and flowers and it was evident that the manager and staff took pride in providing a homely environment for residents. The manager said that she was provided with a good budget, enabling her to maintain the home to a good standard and since the last inspection a lounge and the dining room have been re-carpeted and had new curtains, bedrooms have had new curtains and bedspreads and four Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 20 bedrooms have had new carpets. The hairdresser’s had been fully tiled and provided with a new floor and an en-suite bathroom has been provided with new flooring. Several bedrooms were inspected and all were clean and pleasantly decorated. All the rooms had been personalised by the resident. All areas seen were observed to have a good standard of cleanliness. All residents spoke positively about their environment and the level of cleanliness and all resident questionnaires stated the home was always fresh and clean and comments included “never any smells” and “Rockley Dene is immaculately clean, well decorated, homely and cosy”. Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 21 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): The outcomes for standards 27, 28, 29 & 30 were inspected. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents spoke positively about the attitude of the staff and the service that they received and the numbers and skill mix of staff was sufficient to meet the needs of residents. Staff had received training to equip them with the knowledge and skills for their roles within the home, but further training was required to reinforce this knowledge in regard to the protection of vulnerable adults. Some training required updating and to ensure the type of training provided was sufficient to meet the needs of staff, this needed reviewing. Residents were not fully protected by the recruitment policies and procedures operated by the home. EVIDENCE: All residents spoke highly of the manager and the staff. All resident questionnaires returned identified staff listened and acted on what residents said, with residents commenting, “staff are always helpful and cheerful” and “staff are always very friendly”. All questionnaires identified staff were always or usually available when residents needed them. Good relationships between Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 22 staff and residents were evident. Residents stated that they were satisfied with the level of care they received and that staff knew how to care for them. Observation of staff responding to assistance as required was good. The staff rota confirmed the required number of staff were on duty. There was sufficient ancillary staff employed. The pre-inspection questionnaire identified eighteen per cent of care staff were qualified to at least NVQ Level 2 or equivalent and all staff held a basic first aid certificate. A training and induction programme for staff was in place enabling them to meet the assessed and changing needs of residents. Staff confirmed that they had attended various training courses that included protection of vulnerable adults, food hygiene, safe handling of medication, health and safety, moving and handling, emergency aid, dementia, essential skills for health and care, death and dying and infection control. Staff commented that a good range of training was available appropriate to their job role. It was noted, however, that much of the training was some time ago and the majority of the training was done via a video and answer method. Whilst videos are a useful resource to supplement training undertaken by staff they should not be considered sufficient to meet staff training needs, particularly where practical exercises are needed to demonstrate staff competence. Three staff recruitment files were checked. Residents were not fully protected, as one file did not contain evidence that the staff member had undertaken a CRB disclosure prior to their employment. The manager confirmed this information was correct. The documentation on the other two files did not demonstrate the level of CRB obtained. An application form and two references were received for all employees, but a full employment history, together with a satisfactory written explanation of any gaps in employment had not been maintained. Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 23 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): The outcomes for standards 31, 33, 35, 36 & 38 were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. On the whole residents and staff benefited from the ethos, leadership and management approach. Staff morale was good and all residents, their advocates and staff spoke positively about the management team. Effective quality assurance and quality monitoring systems were in place that sought the views of residents that lived at the home. Residents’ financial interests were not sufficiently safeguarded by the recording procedures in place for dealing with resident’ finances. Formal supervision was not currently offered. Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 24 On the whole the home’s policies and procedures promoted the health, safety and welfare of service users and staff, but improvements are required in keeping up to date staff fire training and drills and reporting notifiable incidents to CSCI. EVIDENCE: The manager had many years experience within the caring profession that enabled her to contribute to the care of service users and communicate a clear sense of leadership to staff. Residents and their advocates spoke positively about the manager and it was evident that they were confident in her abilities to manage the home. Staff felt that there was good teamwork within the home and that they enjoyed working there. Several staff spoken with had worked at the home for many years, enabling them to provide a consistent service to residents. The manager must ensure, however, that she does fulfil all duties within her role to safeguard residents, including operating a thorough recruitment procedure. Quality assurance systems were in place, a sample of which included, weekly checks of hot water temperatures, fire alarm systems, nurse call systems, emergency lighting, fire escape routes and fire extinguishers. A resident survey analysis was provided for November 2006. As described throughout the report feedback about the home was positive, complimentary and all those surveyed expressed satisfaction with the service. Visits to the home as required by the provider to demonstrate their opinions of the quality of the service provided were being completed. Residents’ were able to maintain control over their finances if they wished and had the capacity to do so. Arrangements were in place for residents who were unable to manage their monies due to their mental health. Monies were securely stored. The financial transactions for one resident was inspected. Written records of all transactions were maintained, however, the record lacked detail, with no description of where the monies came ‘in’ and ‘out’ from or to, or what the monies spent was used for. As a result cross-referencing monies spent against receipts was unable to be achieved. The financial transaction did not contain two signatories. This lack of detail meant that records were insufficient to fully safeguard residents’ finances. Although there was a supervision record in place, the record was the action to be taken in regard to training, for example, watch video and answer questions on adult abuse. This type of supervision is not formal supervision, where there is the opportunity for both the manager and the staff member to discuss issues relating to their role, work performance and training and development needs. Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 25 Hazardous substances were securely stored. On the whole, inspection of the building identified fire exits were free from obstructions. One obstruction was identified to the manager who said the hoist had been placed there as a temporary measure to accommodate myself in the hairdressing room, however, the hoist was there on my arrival, which was unannounced. Three staff records were inspected for fire training and participation in fire drills. The fire training did not demonstrate fire training had taken place in the past six months and only two of the staff members had been present on fire drills in the past six months. This may place residents at risk of harm in the event of a fire as knowledge and skills decrease over time, if not practised/used. Inspection of a risk assessment within a plan of care identified an accident had taken place and an accident report could not be found for the incident. Neither had the accident been reported to the CSCI as a notifiable incident. The manager said she had reported them as notifiable incidents. A copy was not maintained on the premise to confirm this. Good moving and handling techniques were observed. There was sufficient equipment and aids and adaptations provided to meet the needs of the residents. Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 26 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 2 10 3 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 1 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 1 X 2 Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 27 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. 3. 4. Standard OP7 OP7 OP7 OP9 Regulation 15 15 15 13 Requirement The plan of care must be dated. The plan of care for residents admitted on a respite basis must be reviewed on each admission. The daily report must include the time the report was completed. Records of medication in stock at the home must be maintained. Previous timescale of 01/04/06 not met. Staff must be familiar with the allergies of residents. The medication administration record must contain any allergies of the resident. Staff administering medication must receive regular administration medication training. The record for controlled drugs must be in a bound book with numbered pages. The training provided for the protection of vulnerable adults must be reviewed and all staff provided with the training. Staff files must evidence that a satisfactory CRB, POVA check has been carried out prior to DS0000018277.V306102.R01.S.doc Timescale for action 28/02/07 28/02/07 28/02/07 28/02/07 5. 6. 7. OP9 OP9 OP9 13 & 18 13 13 28/02/07 28/02/07 30/04/07 8. 9. OP9 OP18 13 13 28/02/07 30/04/07 10. OP29 OP31 19, Schedule 2 28/02/07 Rockley Dene Residential Version 5.2 Page 28 11. OP29 OP31 19, Schedule 2 18 17 12. 13. OP30 OP35 14. 15. 16. OP35 OP38 OP38 12 23 37 employment. Previous timescale of 21/02/06 not met. Staff files must demonstrate a full employment history, together with a satisfactory written explanation of any gaps in employment. All staff training must be audited and where the training is not up to date, this must be arranged. The record of financial transactions must identify the purpose for which the monies were used. The financial transaction must demonstrate where the monies received has derived from. Fire prevention training, fire drills and practices must take place at six monthly intervals. All notifiable incidents must be reported to the CSCI. 28/02/07 28/02/07 28/02/07 28/02/07 28/02/07 28/02/07 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. 4. 5. 6. Refer to Standard OP7 OP28 OP30 OP31 OP35 OP36 Good Practice Recommendations The plan of care, including risk assessments should be reviewed on a monthly basis. A minimum ratio of 50 of staff should be trained to NVQ level 2 or equivalent. The type of training provided should be reviewed to ensure it is sufficient to meet staff training needs. The registered manager should have a level 4 NVQ qualification in management or equivalent. All financial transactions should have two signatories. Staff supervision should include discussions relating to their role, work performance and training and development needs. Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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. Extracts may not be used or reproduced without the express permission of CSCI Rockley Dene Residential DS0000018277.V306102.R01.S.doc Version 5.2 Page 30 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!