Inspection on 31/07/06 for Rookstone

This inspection was carried out on 31st July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Rookstone 21/09/07

Rookstone 29/11/05

Rookstone 25/10/04

Rookstone 25/10/04

Rookstone 19/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Rookstone 1 Lawrie Park Crescent Sydenham London SE26 6HH Lead Inspector Cheryl Carter Unannounced Inspection 09:30 31st July 2006 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 Rookstone DS0000038682.V294025.R01.S.doc Version 5.1 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. Rookstone DS0000038682.V294025.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Rookstone Address 1 Lawrie Park Crescent Sydenham London SE26 6HH 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) 020 7778 0317 Salvation Army Mrs Christine Fell Care Home 31 Category(ies) of Learning disability (1), Old age, not falling registration, with number within any other category (30) of places Rookstone DS0000038682.V294025.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 2005 Brief Description of the Service: The home is part of the Salvation Army Social Care Division and is a registered care home for 31 service users. The home provides 24-hour care, trained and experienced staff, ancillary staff and an activity worker. The home accesses all health care services in the local community. Opticians, Dentist and Chiropodist services are supplied through a domiciliary service. Rokstone is a large detached property that has been adapted as a residential home. There are 29 single rooms, adequate bathroom and washing facilities. The home has a lift to the upper floor. The home is located in a very quiet road, close to shops and public transport and has a very large garden. Rookstone DS0000038682.V294025.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over six and an half hours in the presence of the Assistant Manager. The manager and deputy manager were on leave. The staff are going through a time of uncertainty as the Provider has plans to change the staffing structure within all their homes including Rookstone. The time was spent speaking with the assistant manager and three members of staff. There were no visitors to the unit at the time of the inspection. Comment cards also provided written information from relatives, residents and visiting professionals about the care and service provided by the home. The assistant manager provided documentation of staff rotas that confirmed the numbers of staff on duty on each shift. Menu samples were also provided and information on regulated checks carried out since the last inspection. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Rookstone DS0000038682.V294025.R01.S.doc Version 5.1 Page 6 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 Rookstone DS0000038682.V294025.R01.S.doc Version 5.1 Page 7 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 the following standard(s): 1, 2, 3, 4, 4, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager provides written information about the home prior to admission and assessments are carried out prior to the service user being offered a place. EVIDENCE: The manager of the home has updated the statement of purpose and the service users guide to include changes in the home. The manager or a representative from the home visits the prospective service user to introduce him or herself and ascertain the needs of residents before they are admitted. The assessment record of the latest resident to be admitted was viewed these included the daily living activities and personal care needs that would be required before the service user is admitted. The registered manager must confirm in writing to all prospective residents its ability to meet their needs. (Req.1) Residents and or their relatives are given a copy of the terms and conditions of residency, including details of the fees to be paid, the room they will occupy. The home is not registered to provide intermediate care. Rookstone DS0000038682.V294025.R01.S.doc Version 5.1 Page 8 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 the following standard(s): 7, 8, 9, 10, 11 Quality in this outcome area is adequate. The judgement was made using available evidence including a visit to this service. Care plans and risk assessments could be improved to fully reflect the needs of the service users. EVIDENCE: The senior carer carries out pre-admission assessments and this also include reports from other health professionals and details for the care staff on how to care for the service user. These assessments should be more comprehensive that takes on board mental health assessments, nutritional screening, behaviour assessments, pressure sore assessments, personal resident risk assessments, and social and leisure history. This will give staff a more comprehensive picture of the service user. The registered manager must ensure that care plans, risk assessment and all supporting documentation is completed on all service users with comprehensive interventions on how to address the problems identified. (Req. 2) Rookstone DS0000038682.V294025.R01.S.doc Version 5.1 Page 9 Medication storage and files were inspected and found to be satisfactory. Staff who administer medication have received training in the administration and storage of medication Residents spoken to at the time of the inspection said that they are happy at the home and staff are very helpful. The home has a policy on death and dying that includes supporting relatives. Rookstone DS0000038682.V294025.R01.S.doc Version 5.1 Page 10 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 the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. The judgement was made using available evidence including a visit to this service. Social activities are well managed with group and individual interests for residents living in the home. Menus provide evidence that meals are varied and well balanced. EVIDENCE: Activities in the home have improved since the last inspection. During the visit to the home several service users were engaging in activities with the activity co-ordinator. There were only a few comment cards returned. These indicated that relatives were satisfied with the service and the other professionals had nothing negative to report about the home. Staff asks service users each day for their choice off the menu and the menu for the day is written up boldly for the service users. There is always an alternative to the main meals. Residents said that the food is very good. Dietary needs are catered for. Rookstone DS0000038682.V294025.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 16, 17, 18 Quality in this outcome area is good. The judgement was made using available evidence including a visit to this service. The home has a satisfactory complaints system with evidence that service users views are listened to and acted upon. EVIDENCE: The complaints procedure for service users and visitors is included with the service users guide. The complaints log was examined and recent complaints were discussed with the assistant manager. Residents are aware that they can complain and are confident their complaints or concerns are taken seriously and acted upon. The home has a procedure for responding to allegations of abuse. There is evidence that all staff have received some training in Adult Protection and whistle blowing. There is a written policy and procedure for dealing with allegations of abuse. Rookstone DS0000038682.V294025.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is adequate. The judgement was made using available evidence including a visit to this service. There have been some effort to create a more pleasing environment to the home and some refurbishment and decoration have been undertaken since the last inspection. EVIDENCE: A tour of the premises showed that the home was suitable for its stated purpose. Since the last inspection there has been some refurbishment and redecoration to the home, and this has created a more pleasing environment for the service users. This work is piece meal and there are still a number of areas to be refurbished and redecorated including the kitchen. The Assistant Manager advised the inspector that this is in hand. The registered persons need to provide written evidence of a planned programme of redecoration and refurbishment for the home. (Req. 3) There are hand-washing facilities in appropriate areas. Bedrooms are personalised in line with the service users wishes and needs. Maintenance work to the garden had begun but this is incomplete. Throughout the Rookstone DS0000038682.V294025.R01.S.doc Version 5.1 Page 13 inspection the home was found to be clean, tidy and free from unpleasant odours. Rookstone DS0000038682.V294025.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This is based on all information including the site visit. The staff in this home are subject to robust recruitment procedures and are fully inducted and trained to undertake the work. EVIDENCE: At the time of the inspection the management team was undergoing some changes and this has been a very worrying time for some of the management staff. The home has a relatively stable team of carers and ancillary staff that provides good continuity of care for service users. The inspector looked at copies of rotas for the previous four weeks and this indicated that there were sufficient trained staff to meet the needs of service users. Four staff files were assessed and all complied with Care Home Regulations. New staff to the home undergo induction training and this is recorded. Files contained training that staff has undertaken. Rookstone DS0000038682.V294025.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37, 38 The quality rating in this section is good. This is based on all information including the site visit. Service users benefit from a home that is well managed. There are good health and safety procedures in place. EVIDENCE: The manager of the home was on holiday on the day of the inspection and the Assistant Manager who holds a Level 4 NVQ and the Registered Managers Award carried out the inspection. The Assistant Manager also has substantial residential experience and has a good understanding of the needs of the service users and the areas in which the home needs to improve and develop. The Assistant Manager was observed interacting with her staff and talking to service users appropriately. Residents commented that she is very kind and caring. Rookstone DS0000038682.V294025.R01.S.doc Version 5.1 Page 16 Regulation 26 reports are received by the Commission however there is no structured quality assurance in place that takes on board the views of service users and their families and other professionals that use the service. The registered provider must carry out a yearly audit of the service and copies of that report should be sent to the Commission. (Req.4) There was evidence to show that staff receive regular supervision. Staff are responsible for safekeeping some personal money for residents. The home maintains appropriate records for residents monies. A selection of safety records was inspected. All records seen were satisfactory. Fire safety equipment has been serviced and tested as required. Staff are being provided with regular fire safety training. Staff said that they receive regular supervision. Servicing records relating to lifts and hoists, portable appliance testing have been appropriately maintained. Hazardous substances had been stored securely and accidents had been recorded and reported as required. Rookstone DS0000038682.V294025.R01.S.doc Version 5.1 Page 17 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 3 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 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 3 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 3 3 3 Rookstone DS0000038682.V294025.R01.S.doc Version 5.1 Page 18 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 OP3 Regulation 14 Requirement Timescale for action 31/10/06 2 OP7 15 3 OP19 23 4 OP33 24 The Registered Manager must ensure that all residents are appropriately assessed prior to admission and must confirm in writing that the home’s ability to meet the service user’s needs. The registered manager must 31/10/06 ensure that care plans, risk assessment and all supporting documentation is completed on all residents with comprehensive interventions on how to address the problems identified. The registered person must 31/10/06 ensure that the home and grounds are adequately maintained and decorated. In response to this report the Registered Person must notify the commission with a development plan of work for the home. The Registered person must 31/10/06 introduce and effective quality assurance system that includes consultation with service users and their representatives. Rookstone DS0000038682.V294025.R01.S.doc Version 5.1 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Rookstone DS0000038682.V294025.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Rookstone DS0000038682.V294025.R01.S.doc Version 5.1 Page 21 - 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!