CARE HOME ADULTS 18-65
Rook View Rook View 46 Rook Lane Chaldon Surrey CR3 5AB Lead Inspector
Susan McBriarty Unannounced Inspection 13th February 2007 09:00 Rook View DS0000013769.V327702.R01.S.doc Version 5.2 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 Rook View DS0000013769.V327702.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 Adults 18-65. 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. Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Rook View Address Rook View 46 Rook Lane Chaldon Surrey CR3 5AB 01883 383817 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) Surrey and Borders Partnership NHS Trust Mrs Kim Susan Mott Care Home 8 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (3) of places Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 23rd November 2006 Brief Description of the Service: Rook View is registered to Surrey and Borders Partnership NHS Trust and is one of a number of residential homes owned and managed by the organisation. The home is registered to accommodate a maximum of eight service users with learning disabilities. The home is detached and shares a site with other residential care services managed by the Trust. The home has eight single bedrooms over two floors with one communal dining room leading into the living room. Stairs reach the first floor. Local facilities and amenities are close by. Fees for 2006/2007 are £60,632 per annum. Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and was the first key inspection carried out by the commission. The inspection took place over six and half hours (6.5) hours, commencing at 9.00am and ending at 3.30pm. Ms Susan McBriarty regulation inspector carried out the visit. The registered manager of the service was present throughout the inspection. The inspection took into account the pre-inspection questionnaire information and records held at the home including service user files, staff personnel files, supervision, training, medication administration and daily records. Feedback was also obtained from members of staff and observations were made by the inspector of the interactions between staff and service users during the visit. The commission had not received comment cards from service users or other sources (such as relatives) and further copies of comments cards were left at home at the time of the visit. Members of staff were encouraged to work with the service users to try and complete the cards and enable service users views to be part of the inspection report. These were received on the 21st February 2007. What the service does well:
Interactions between members of staff and service users reflected a good rapport. Members of staff were observed responding to service users in a way that showed that they knew and understood their needs. For example one service user always a needed a particular item in their hand and this was observed being passed to the service user. Person centred care plans using pictures had been carried out with each service user showing their assessed needs and their preferred way of having their needs met. Service users rights were respected. For example the inspector was not able to view one bedroom, as the service user had made clear that no one was to enter without permission. The manager made this clear to the inspector and the service user decision was accepted. Photographs of members of staff were used to show who would be on duty and when so that service users would know what to expect during the day. Pictures had also been used to identify the various activities that service users would be taking part in during the week. The complaints procedure was also in picture format and would enable the staff to assist service users to understand the complaints procedure and how they could let members of staff know if they were unhappy for any reason.
Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 6 Training for members of staff was kept up to date and records and documents were completed to ensure that dates for refresher courses were clear. Members of staff said that they felt well supported by the manager and would be able to talk to her if they had any concerns, issues or additional training needs that they had identified. Five comment cared were received from service users who said that members of staff listened to them and acted on what they said and treat them well. What has improved since the last inspection? What they could do better:
A number of requirements and recommendations have been made. In the main these are in recognition of the changes taking place within the service and opportunities to further improve the service being offered. Some improvement was required in relation to the assessment process to ensure that the process was supported by the relevant policy and procedures. This will ensure that the needs of prospective service users are appropriately assessed, identified and met. Person centred care plans and risk assessments had been completed but those sampled had not been reviewed since June 2006. The home is also seeking a variation in registration to increase the number of people over the age of sixty five (65). A requirement was made to ensure that care plans and risk assessments are reviewed regularly taking into account the planned changes in registration. This will ensure that the changing needs and personal goals of service users are reflected in their care plans and that individuals are supported to take risks as part of their lifestyle. Some improvement was needed regarding recording to ensure service users make decisions about their lives and the assistance needed. This would ensure that where service users had made decisions or decisions had been made on their behalf that these were clearly recorded including the reason why. For example one care plan noted a particular issue and the outcome may be viewed as a sanction rather than an agreement due to the wording used. A recommendation was made to improve the assessment of gender and age needs and how these issues might affect the needs of the service users. For example access to well women and well men clinics for specialist health assessments. This will further improve how the home meets the physical and emotional needs of the service users. Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 7 The administration of medication needed some review with particular regard to food supplements. It was recommended that a review take place of how the administration of food supplements is recorded to ensure that a record is made on each occasion it is given. This would ensure the health and well being of service users. The communal areas of the home need some attention, such as repair and redecoration. In addition some items of bedroom furniture needed repair or replacement as they were showing signs of wear and tear. This will ensure that service users live in a homely, comfortable and safe environment. Some improvement was needed to ensure the recruitment policies and procedures were being followed confirming that service users are supported and protected by the home’s recruitment policies and practices. A review of training about communication was recommended in order to ensure that all opportunities to communicate effectively with service users had been explored and training provided where needed. This will ensure that service users individual and joint needs are met by appropriately trained staff. Some improvement was needed to ensure that a quality assurance process was completed and outcomes and actions taken recorded and documented. This will ensure that service users can be confident their views underpin all self-monitoring, review and development by the home. A recommendation was made that the provision of communal soap and towels in some areas of the home be reviewed in order to reduce the potential hazard of cross infection to service users and members of staff. This will further promote and protect the health, safety and welfare of service users. 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. Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 was assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some improvement was needed to ensure that the home had a policy and procedure in place to ensure any new service users would be assessed consistently and their needs and aspirations recorded and documented. EVIDENCE: No new service users had been admitted to the home since 1995, the majority had been transferred from long stay hospitals without a written assessment. An assessment form is now in place to help staff carry out an assessment on any new prospective service user, the form was found to be detailed. The manager said that service users would be able to visit the home before making a decision to move in. Two (2) of the comment cards received from service users confirmed that they were able to visit the home before moving in. One said ‘ I liked Rookview when I saw it’. Five (5) said they had enough information about the home before they moved in. The home is part of a larger organisation that is being merged with another and this has meant changes to policies and procedures. A policy and procedure for admission could not be found although the statement of purpose noted that Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 10 one was in place. The manager contacted head office for confirmation that a policy was not available. As a large number of policies and procedures were being changed (see also Conduct and Management). A requirement was made that the organisation review how these changes are being implemented to ensure the home is clear about what policies and procedures are in place and in use including an admission policy. Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 and 9 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. While risk assessments were in place and service users needs and personal goals were reflected in their care plans, these were in need of regular review to ensure changing needs were identified and met and that they are able to make informed decisions regarding their rights and lifestyle. EVIDENCE: A number of care plans were sampled. The home uses person centred planning setting out the needs and preferences of each of the service users. Pictures and easy read statements were used to help make clear what service users needs were and how support was to be offered. None of the care plans sampled had been reviewed since June 2006. The service users are getting older and the manager has applied for a change in the registration to show that more service users are aged over sixty five years (65). This might also mean a change in the standards being assessed by the commission. Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 12 Separate risk assessments had been completed for each area of risk identified. The risk was made clear and members of staff would know what to do and why. The risk assessments sampled had not been reviewed since June 2006. A requirement is made to ensure that care plans and risk assessments are reviewed regularly taking into account the expected changes in registration. This will ensure that service users changing needs and personal goals continue to be reflected in their care plans and are supported to take risks as part of their lifestyle. Some improvement was needed to make clear where decisions had been made either by the service user or members of staff on their behalf. For example voting; the manager stated that one person chose not to vote and others were not able to make that decision. Another example was how a decision had been written down, as it might seem to be a sanction rather than a choice. A requirement is made to ensure that where decisions are made that limit service users rights for whatever reason, the decision and who made the decision and why must be recorded and documented. This will ensure that service users are making decisions about their lives and the assistance needed. Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,15,16 and 17 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to maintain links with the community, family and friends and their rights and responsibilities are recognised in their daily lives. Meals were varied and healthy and service users were encouraged to enjoy and take part in mealtimes. EVIDENCE: The care plans, risk assessments, discussion with the manager and observations made during the inspection confirmed that the service users in this home would not be able to take advantage of employment or further education opportunities. Care plans; records and documents confirm attendance at various activities and pictorial information kept in the dining room showed that a number of activities are made available and support provided where necessary. These include attendance at church, day trips, shopping with members of staff as well
Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 14 as personal choice options ensuring that service users are part of the local community. Five (5) service users told us that they can do what they want during the week. One said ‘staff book trips for me and my key worker takes me places I enjoy’. Care plans and discussion with the manager confirmed that where there are family links these are maintained and encouraged. Observations made during the inspection confirmed that personal relationships are supported and encouraged. Some service users spoke about their plans for Valentine’s Day and Birthdays. This ensures that service users have appropriate personal and family relationships. Service users rights are respected and members of staff were observed responding appropriately to service users requests for assistance and in making plans for the coming week. The manager told the inspector during the tour of the home that one bedroom could not be viewed. The service user had made clear that they did not want anyone entering their bedroom. The request confirmed service users rights were respected. The statement of purpose set out the rules of the home including where service user were able to smoke if they so wished. The inspection started just as service users were helping to clear away after breakfast and although limited space to move about from the hall to the kitchen was observed the service users carried out this task safely and were patient when waiting for others to move out of the way. In the dining room a picture had been provided of what was going to be served for lunch ensuring service users would know what to expect. Where required in the care plan food supplements were provided. The pictures seen, discussions with the manager and the pre-inspection questionnaire confirmed the meals were varied. Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some improvement is needed to make sure that gender and age needs are made clear and acted upon. Service users receive personal care in a way they prefer and need and their physical and emotional needs are met. Some improvement was needed to ensure prescribed food supplements were recorded as given ensuring that service users were further protected by the home’s policies and procedures. EVIDENCE: The care plans set out in detail how service users preferred to be supported and why as stated previously the care plan used pictures and an easy read format. This ensures that service users receive the personal support they need in a way they prefer and require. Health action plans had been completed for each of the service users and a number of these were sampled. Changes in the assessed needs of service users had been noted and were waiting to be typed up. The plans show how often appointments are needed to attend doctors, dentists and other health care specialists. The plans also identified other health care needs and how they
Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 16 must be met. Records had also been completed confirming that their doctor carried out a full health check each year. Service users physical and emotional needs are met. Some improvement was recommended to ensure that gender and age needs were taken into account more clearly. For example attendance at well women or well men clinic. The manager confirmed that some service users had attended but this need had not been documented, as a specific health need as yet. This would ensure that all aspects of the service users health needs are monitored and potential problems and complications identified early including referral to an appropriate specialist. Policies and procedures were viewed including the use of homely remedies such as painkillers and the administration of medication. The home also had a copy of the pharmaceutical guidelines ensuring that members of staff stayed up to date with good practice matters. Members of staff spoken with, training records and discussion with the manager confirmed that appropriate training took place on a regular basis for those members of staff carrying out the administration of medication. Observations were also made during the visit confirming that members of staff were aware of and used the procedures provided. The medication administration records were sampled and some gaps were found relating to the administration of a food supplement. A recommendation was made that members of staff confirm on the medication administration record that the supplement was given or seek an alternative method of recording administration. This would further ensure that service users are protected by the home procedures. Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users views are listened to and they are protected from abuse neglect and self harm. EVIDENCE: Discussions with the manager, the statement of purpose and an easy read complaints procedure confirm that service users views are listened to and acted upon. The pre-inspection questionnaire noted that two (2) complaints had been received by the home since the last inspection and that these were still being investigated. Two (2) service users told us that they knew how to make a complaint and two (2) sometimes. Two (2) said they would be able to make a complaint with the assistance on members of staff. Five (5) said that staff listen to them and act on what they say; one said they write it down in the notes. A policy and procedure was in place for safeguarding adults. Training records and discussions with members of staff confirmed that they were aware of the procedures and what to do if a referral needed to be made. A copy of the local authority’s multi-agency guidelines for the protection of adults was available in the office and was easily accessible. One (1) safeguarding referral had been appropriately made in the last twelve months. Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvement was required with regard to the communal areas of the home in order to ensure that service users live in a homely, comfortable and safe environment. The home was clean and hygienic promoting the health and safety of service users. EVIDENCE: A tour of the home took place. All of the communal areas and all but one of the bedrooms was viewed. The bedrooms were seen as fresh, clean and some had pictures of family members and reminders of days out. The bedroom not viewed was at the choice of the service user. The manager stated that one bedroom was being refurbished and the service user who was looking forward to having a new carpet and new furniture provided confirmed this. The manager said that the bedroom not viewed did have problems and these were reviewed on a regular basis with the service user and the fire safety officer. The manager added that the fire safety officer visited the home on a regular
Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 19 basis to carry out a risk assessment with the staff and service user. Some of the remaining bedrooms required attention to the furniture as drawers and doors showed signs of wear and tear and needed repair or replacement. The communal areas were clean and hygienic however they needed some attention. In one area screws had been left in the wall, in others holes had been left when items had been removed from the wall. In addition tiles were coming away in the bathrooms requiring repair or replacement. The paintwork also required attention in all the communal areas. Three (3) serviced users said that the home was always fresh and clean and two (2) sometimes. Three (3) service users told us the sort of things they would like added to their bedrooms. For example new pictures, space for craftwork and a new light after the bedroom is decorated. The home has eight (8) service users and only two communal spaces that did not provide a great deal of room to move around in. It was observed that access to the kitchen was restricted by the lay out of the hall and entrance to the kitchen. The home is part of the larger development changes taking place within the organisation and it is not known what plans are being considered for the future development of this home. Previous recommendations had been made by the commission for the consideration of the conservatory to provide additional communal space for the service users. The recommendations had not been acted on. It is required that that a review take place of the home to ensure that any repairs, replacements and redecoration needed are noted and acted upon. This will ensure that the service users live in a homely, comfortable and safe environment. The office space used by the manager and care staff provided very limited space including difficult access to the computer and attached keyboard. A further recommendation is made to ensure that should a vacancy arise appropriate consideration to the space available and the assessed needs of any prospective service user be given. Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 20 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,34,35 and 36 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall, service users benefit from a well supported and supervised staff team, who are competent and trained to do their job. While service users are generally protected by the home’s recruitment practice. EVIDENCE: A number of staff files were sampled. All the information required for the recruitment of care staff was found including application forms, job descriptions and references. One application had been completed electronically the remaining were paper applications dated prior to 2002. The manager was not able to confirm that application forms now include the requirement to give all previous employment and where there were gaps in employment a reason why. A recommendation is made to confirm that application forms including electronic applications have been updated to include all the information required. Copies and originals of criminal record bureau checks were found in the care staff files. The manager could not confirm that the organisation kept a central record of the details as required by the criminal record bureau. The Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 21 organisation should consult the criminal records bureau for further advice and guidance regarding the storage and destruction of criminal record checks. This will ensure that service users are supported and protected by the home’s recruitment policy and practices. Discussions with members of the care staff, the manager, records and documents sampled confirmed that training is provided in all mandatory areas. This includes food hygiene, manual handling, fire safety and health and safety matters. Those staff spoken with said that the manager monitored their training needs and ensured that they attended the training needed. Two of the current staff team, excluding the manager, have national vocational qualifications and one is nurse qualified. Other qualified staff had recently been transferred to another home. The service users in this home needed assistance to communicate. Although the staff team spoken with knew the service users well and were able to understand their needs additional communication options had not been considered. Training in the use of Makaton was available but was not used by all the service users. A recommendation was made that a review take place of the communication needs of the service users and training needs of the care staff to ensure that all options have been considered in order to increase opportunities for service users. Five (5) service users told us that the staff always treat them well, one (1) said they miss the staff when they are off. The manager said that they had recently received training about equal opportunities and diversity and that the training team were planning to extend this to the staff team. The care staff spoken with confirmed that they had either not had training or had received training some time ago. The planned training in equal opportunities and diversity training should assist the staff team to further take into account the needs of service users including gender, disability and religious needs. Discussions with the care staff, manager and sampling of records and documents confirmed that members of staff receive regular documented supervision. Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 22 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39, 40 and 42 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home although some improvement is required to ensure that their views underpin all self monitoring, review and that their rights and best interests are safeguarded by the home’s policies and procedures. The health, safety and welfare of service users was promoted and protected. EVIDENCE: The manager has the appropriate qualifications including the registered managers award. Members of the care staff team spoke well of the manager’s ability to run the home and provide the necessary support to the staff team. Additional training had been undertaken by the manager and was confirmed when sampling training records. Additional training included the assessors’ award enabling the manager to assess care staff undertaking national vocational qualifying training.
Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 23 As noted earlier the organisation is going through a period of change and this includes changes to policies and procedures. The manager said that new policies and procedures were being sent electronically to the home and that at times it was difficult to know whether they were replacements or additions to current policies and procedures. Whilst policies and procedures were in place for a number of areas including health and safety and discharge from the home the manager could not find the policy regarding admissions to the home. A recommendation is made that the organisation review the process for the review and replacement of policies and procedures to ensure that managers and other members of staff are certain as to which ones are in use and that each home has a copy of each of the policies and procedures provided. Some work on quality assurance had been completed by the manager that indicated that the service provided by the home was well considered by others. However this had not led to a document or record of the outcomes and action needed to develop the service. A recommendation was made that the manager complete any quality assurance audit being carried out and ensure that outcomes and any action agreed are recorded and documented for sharing with others including the service users. This would ensure that service users views underpin all self-monitoring, review and development by the home. It was observed by the inspector that some toilets and bathrooms had been provided with communal soap and towels providing a possible hazard of cross infection. A recommendation is made that this provision be reviewed and consideration be given to the use of liquid soap and paper towels to reduce the potential hazard of cross infection by and to service users and members of staff. The manager had completed an audit of health and safety matters within the home. The document was sampled and found to be detailed and covered all aspects of the day to day running of the home with regard to risk management and health and safety needs including any actions required to ensure the home remains safe. Records and documents relating to accidents and incidents were sampled and found to be well kept and clear. Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 24 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 2 X 3 X Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 13(4) 15 (1)(2) Requirement The registered persons must ensure that service users care plans and risk assessments are reviewed regularly taking into account any planned changes within the service. This will ensure service users changing needs and personal goals are reflected in their care plan and they are supported to take risks as part of their lifestyle. The registered persons must ensure that where service users have made a decision about their lifestyle that it is recorded and documented clearly to ensure that service users make decisions about their lives and the assistance needed. Timescale for action 30/03/07 2. YA9 15(1)(2) 30/03/07 3. YA24 23(2)(b)(d) The registered persons must review the individual and communal areas of the home and ensure that any repairs, replacements and redecoration take place as needed. This will ensure that service users live in a homely, comfortable and safe environment.
DS0000013769.V327702.R01.S.doc 11/05/07 Rook View Version 5.2 Page 26 4. YA34 19 Schedule 2 The registered persons must confirm and ensure that the employment history of individuals is included on application forms for staff recruitment in order to ensure that service users are supported and protected by the recruitment policies and procedures of the organisation. The registered persons must ensure that up to date policies and procedures are provided in the home to ensure that the service users rights and best interests are safeguarded by those policies and procedures. 30/03/07 5. YA40 12(1) 13(4) 30/03/07 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. Refer to Standard YA18 Good Practice Recommendations It is recommended that the registered persons improve the assessment of gender and age needs and how these might affect the needs of the service users to further improve how the physical and emotional needs of the service users are met. It is recommended that the registered persons review the recording of administration of food supplements in order to ensure confirmation of administration. This will ensure that service users health and well being is fully protected. It is recommended that the registered persons review the training for assisted communication in order to ensure that all opportunities to communicate effectively have been explored, thereby ensuring service users individual and joint needs are met by appropriately trained staff.
DS0000013769.V327702.R01.S.doc Version 5.2 Page 27 2. YA20 3. YA35 Rook View 4. YA34 It is recommended that the registered persons consult the criminal records bureau for further advice and guidance regarding the storage and destruction of criminal record checks. It is recommended that the registered persons ensure that quality assurance information is completed and outcomes and actions required are recorded and documented. This will ensure that service users can be confident their views underpin all self-monitoring, review and development by the home. It is recommended that the registered persons review the provision of communal soap and towels to reduce the potential hazard of cross infection and ensure that the health, safety and well being of service users and staff is protected. 5. YA39 6. YA42 Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX20 1RD 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 Rook View DS0000013769.V327702.R01.S.doc Version 5.2 Page 29 - 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!
