Inspection on 26/08/09 for Rookvale

This inspection was carried out on 26th August 2009.

CQC found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rookvale 28/08/08

Rookvale 04/03/08

Rookvale 20/03/07

Rookvale 04/10/05

Rookvale 05/04/05

Rookvale 19/10/04

Rookvale 06/05/04

Similar services:

Snydale Care Home

Staveley Birk Leas Nursing Home

Fairmount Nursing Home

Currergate Nursing Home

Brookfield

Castlethorpe Care Home

Elmleigh Convent

Woodlands Respite Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOME ADULTS 18-65 Rookvale 3 Carlton Drive Heaton Bradford West Yorkshire BD9 4DL Lead Inspector Michael ONeil Key Unannounced Inspection 26th August 2009 09:50 Rookvale DS0000001286.V377301.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Rookvale DS0000001286.V377301.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Rookvale DS0000001286.V377301.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rookvale Address 3 Carlton Drive Heaton Bradford West Yorkshire BD9 4DL 01274 783771 01274 783700 rookvale@pcslimited.net 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) Mr Jarnail Singh Bassan Manager post vacant Care Home 19 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (4), Physical disability over 65 years of age (1) Rookvale DS0000001286.V377301.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th August 2008 Brief Description of the Service: Rookvale is situated in the Heaton district of Bradford approximately 3 miles from the city centre. The home provides personal care for people with mental health problems. The home does not provide nursing care. There are 9 single and 5 double bedrooms available on 3 floors. The home cannot accommodate people with physical disabilities. The home is close to a regular bus route and is well served with local amenities including, shops, post office, park, and public houses. The home stands in its own grounds and has outdoor sitting areas and parking. The home has a designated smoking area. Fees range from 315.84 to 678.79 pounds per week. Hairdressing, toiletries, transport and newspapers are not included in the weekly fee and are charged separately. This information was provided by the manager Eileen Shackleton on 26 August 2009. Copies of inspection reports are available from the home on request. Rookvale DS0000001286.V377301.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection carried out in one day over a period of six and a half hours by one inspector. The purpose of this inspection was to look at how the needs of people living in the home are being met and to follow up on the requirements made at the last inspection. During the visit we spoke to people living in the home, staff and management. We looked at various records including care records and looked at some parts of the home. Before the visit we sent surveys to the home to distribute to people using the service, visiting health care professionals and staff. Sixteen surveys were returned to us. We asked the home to complete an Annual Quality Assurance Assessment (AQAA); this is a self-assessment which focuses on how the home is meeting the needs of the people using the service. This was completed and gave us the information we asked for. We also carried out a random inspection at the service on 17th March 2009. The reason for the random inspection was to follow up the requirements from the last key inspection carried out on 28 August 2008 and to look at how the home was meeting the needs of the people who live there. This report is based on information from our site visit, the random inspection, the feedback from surveys, the home’s self assessment and information we have received about the home since our last visit. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. We have extended some timescales to meet requirements for this service. We can see that the service has made progress in meeting previous requirements and this must continue. We will be following up these requirements to make sure they are met otherwise we will consider future enforcement action. Rookvale DS0000001286.V377301.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The home has made some progress in meeting the requirements made since our last visit. Two previous requirements relating to staff recruitment and seeking the views of people who live at Rookvale have been met by the service. There is evidence that the ethos of the home is more open and transparent. The views of both people who use the service and staff are being listened to, and valued. People are now more involved in the drawing up and reviewing of their care plans which will help to ensure that people get the right support to meet their personal goals and changing needs. Rookvale DS0000001286.V377301.R01.S.doc Version 5.2 Page 7 People said that there are now more social activities arranged for them to join in. Good progress and improvements have been made to make sure that everyone living in the home gets the support they need to make the most of their abilities. People are supported and protected by the homes recruitment policy because all the required checks are now carried out before new staff start work. Health care professionals said: There has been a definite improvement in the standard of care delivered at Rookvale.Staff engage well with people and there is a warm welcoming atmosphere whenever I visit the home. Work is continuing to improve the environment and make it a pleasant and suitably equipped place for people to live. A new manager has been appointed since our last visit. People said things are much better since she came, she is great. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Rookvale DS0000001286.V377301.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 Rookvale DS0000001286.V377301.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, & 5 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are assessed before they move in. However there is not enough information available to help people decide if the home is the right one for them. EVIDENCE: Nine people living in the home completed surveys for us. They said they had been given enough information before moving in to help them decide if it was the right place for them. People told us they had visited the home before making a decision about moving in. We saw records of pre-admission assessments in the care plans we looked at. Rookvale DS0000001286.V377301.R01.S.doc Version 5.2 Page 10 People said they had not been provided with a copy of the homes statement of purpose or service user guide. This means that here is not enough information available to help people decide if the home is the right one for them. The manager and general manager said they are in the process of updating the documentation so that it incorporates recent changes to the staffing that have taken place at Rookvale. People living in the home said they have been provided with copies of the terms and conditions of their stay. A copy of this contract was also found in a persons care notes. This will make sure people have clear information about their rights and responsibilities. For example what services are included in the fees. Rookvale DS0000001286.V377301.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 8 & 9 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples changing needs are not reflected in sufficient detail in their personal support/care plan which means that people may not get the right support to meet their personal goals and changing needs. EVIDENCE: We looked at the two peoples care plans. Improvement in the care records has continued. We saw that peoples needs are assessed and the assessments include information on people’s personal, health and social care needs. We saw evidence of people now being consulted about how care and/or support is given. People also said that they were involved in the review of their care plans. Rookvale DS0000001286.V377301.R01.S.doc Version 5.2 Page 12 In one persons care records we saw that they can sometimes be verbally aggressive, however no plan was in place to guide staff on how to deal with this. Staff were able to verbally say how they diffuse volatile situations but these strategies were not recorded. Other inadequacies were found in peoples care plans one of which was highlighted as an inadequacy, and so, a requirement to address, at our last two visits to home in August 2008 and March 2009.The following inadequacies were found with the documentation: The care plans did not contain enough information as to the care or support the person needed from staff. The plans read more as a general assessment of the person rather than an actual plan of care or support. The persons care plans had not been signed or reviewed for over 2 months. Staff were failing to record times they made entries in the plans. Staff must be reminded that peoples care plans are a legal document and must always be signed, dated and timed. Staff, when writing peoples daily notes, were not being reflective of the information actually recorded in the persons care plan. An overall statement of enjoyed a good day is not sufficient or specific enough information. People told us they are able to make decisions about what they do and how they spend their time. They told us they are supported in maintaining their independence and the records showed that where this involves taking risks there are assessments in place to show how these risks will be managed. People said they often went out into the community with or without support from staff, chose what they wanted to do during the day and whom they preferred to spend time with. Health care professionals told us that they felt the service helped people to maintain as much independence as they could. Whenever possible people are supported in managing their own money and this is recorded in the care records. We saw individual records kept of all transactions. People living in the home told us that they are involved in meetings with the staff and management of the home which are held approximately every three months. Topics discussed focus on day to day life in the home such as the refurbishment programme; activities and menus. We were able to see minutes of recent meetings that had taken place. Rookvale DS0000001286.V377301.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): This is what people staying in this care home experience: 12, 13, 14, 15, 16 & 17 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Good progress and improvements have been made but more needs to be done to make sure that everyone living in the home gets the support they need to make the most of their abilities. This will involve them taking part in activities that are appropriate to his or her race, culture, religion, age, disability, gender, and sexual orientation. EVIDENCE: People living in the home who completed our surveys and who we spoke with said they are able to make decisions about what they do and how they spend their time. Rookvale DS0000001286.V377301.R01.S.doc Version 5.2 Page 14 Daily routines are flexible. People said they can have their meals at any reasonable time and we saw people eating their breakfast and lunch and varying times during the morning and early afternoon. People said that there are now more social activities arranged for them to join in. People said they were always busy and discussed the various places and leisure activities they participated in over the course of a week. People said they attended day centres and local community centres. This will help people to maintain their links with the local community. Some people said they had just returned from a holiday at the coast with the staff and other friends. Everyone said they had had a good time. Some people are independent and go out without support from staff. For example several people we spoke to were planning to go out for the day either to shop or to attend appointments. However, for people that need more support there is very little by way of a structured programme of activities. A more individualised activity programme is needed which should encompass the likes and dislikes of people; the staff can discuss this information with people and formulate a plan in the persons support plan. This will enable all people, including those who need more support, the opportunity to exercise their choice in relation to social and leisure activities. People told us they enjoy the food and are offered a choice of meals. People are consulted about the menus and changes are made to try to accommodate peoples wishes. Staff are trying to accommodate peoples personal tastes in relation to the food served. The atmosphere at lunchtime is not particularly positive though. The tables are not set out with table cloths, condiments cutlery or crockery. People are still queuing up at the hatch for their meals and there is very little attempt to make mealtimes a social occasion. Records required to show safe practices such as the food temperature records are up to date. Rookvale DS0000001286.V377301.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Generally peoples personal and health care needs are met. However, people may not always get care and support in the way they want and prefer because the care records do not have enough detailed information. EVIDENCE: Most of the people living in the home are able to look after their own personal care needs. Some people need staff to encourage and prompt them and we saw some information about this in the care plans. Care plans showed that peoples health was monitored and people had access to health care facilities and any relevant specialists that were necessary. On the day we visited one person was going to the hospital for an out patient appointment, they had organised this themselves. Another person was going to see their G.P; staff accompanied the person on this visit. Rookvale DS0000001286.V377301.R01.S.doc Version 5.2 Page 16 People are very positive about the level of care and support they receive at Rookvale and made comments such as: The staff are excellent, they are very supportive Couldnt be better here Im really happy here. Health care professionals said: There has been a definite improvement in the standard of care delivered.Staff engage well with people and there is a warm welcoming atmosphere whenever I visit the home I found in all respects that the service was extremely good and professional and suited my clients needs so well that she could not speak highly enough of their sympathetic and calm management. Staff have a very good knowledge of peoples health, social and emotional needs. We were impressed with the empathic way in which staff communicated with people .This was particularly noticeable when people were upset or agitated. There are suitable systems in place to make sure that medicines are managed safely and people get their medicines as prescribed. Medication checked is securely stored. All medications administered were signed for on peoples medication charts. People who self medicate told us they keep there medicines locked in their rooms. However, risk assessments relating to self medication safety were not available at the time of our visit. This means that people may not be protected from harm. People who administer their own medicines told us they keep their medicines safe in their bedrooms and lock their bedrooms doors when they are out. Staff said they are undertaking comprehensive medication training via a college. Staff say the training is excellent and this will provide staff with the knowledge to administer medication safely. Rookvale DS0000001286.V377301.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are appropriate systems in place to make sure that peoples concerns/complaints are taken seriously and acted on and to make sure that people are protected from abuse. EVIDENCE: Information about the complaints procedure is available in the home. People told us they know how to make a complaint if they need to and know who to speak to if they are unhappy. Staff who completed surveys for us said they know what to do if anyone has a complaint about the service. The home told us they have had 3 complaints in the last year, no complaints have been referred to us. Records are kept of complaints made and action taken to resolve concerns. There are procedures in place to make sure that people are protected from abuse. There has been one referral to the adult protection (safeguarding) unit in the last 12 months. The referral was made by the service and was reported promptly and appropriately. Staff said they are aware of protection polices and procedures. Records were seen of recent adult safeguarding training staff had undertaken. This ensured people who use the service were safe and protected. Rookvale DS0000001286.V377301.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clean and work is continuing to improve the environment and make it a pleasant and suitably equipped place for people to live. EVIDENCE: People living in the home told us it is always clean and it was clean when we visited. Refurbishment of the home is required as an ongoing project. Some parts of the home look tired and in need of brightening up. However work is continuing to improve the environment. The general manger was able to provide us with a refurbishment plan for the home. The programme has started and the new patio area which has been recently built Rookvale DS0000001286.V377301.R01.S.doc Version 5.2 Page 19 has certainly improved the garden area for people. People said they enjoy sitting in that area of the garden when the weather is nice. Some bedrooms, bathrooms, and corridors have also been decorated and refurbished recently People are supported by the staff to take responsibility for cleaning their rooms as part of their care programme to develop and/or maintain their independent living skills. The laundry is suitably equipped. People are supported in doing their own laundry. Rookvale DS0000001286.V377301.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are enough staff to meet peoples needs and people are protected because all the required checks are done before new staff start work. Staff do not have the training to make sure that they can look after the health, safety and wellbeing of people who live at the home. EVIDENCE: People told us that staff treat them well and take notice of what they say. People said there are usually two care staff on duty during the day, the manager, a cook and a domestic member of staff. People said staff are usually available when they need them. In the surveys staff said that there were sufficient numbers of staff employed to meet all the needs of people at the home. Rookvale DS0000001286.V377301.R01.S.doc Version 5.2 Page 21 The staff we spoke to were happy with the staffing numbers employed. We saw that staff were available to attend to peoples needs when needed. The manager told us that all the required checks are done before new staff start work. This was confirmed by the two staff files we looked at. There has been a marked improvement in the standard of staff files since our last visit. Staff said that they really enjoyed working at the home and got a lot of job satisfaction. We found that the staff were very enthusiastic and keen to improve the service further. They said things are a lot better at the home and that the amount of training available has increased. However, there is still a shortfall in staff training including some statutory training such as moving and handling, basic food hygiene and training more specific to the needs of the people resident at Rookvale. Rookvale DS0000001286.V377301.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are benefiting from improvements that have been made to the management and running of the home and their views are now being listened too. However, the homes procedures still do not fully promote the health, safety and welfare of people who use the service. EVIDENCE: A new manager, Eileen Shackelton, has been appointed since our last visit. She was appointed in July 2009.She told us she has made enquiries to apply to Rookvale DS0000001286.V377301.R01.S.doc Version 5.2 Page 23 be registered with us and to enrol on a NVQ 4 management course at a local college. Staff and people spoke very highly of the manager and said she is always available and very approachable. People said things are much better since she came, she is great. The management team of Rookvale have ways in which to check out the quality of the service that they are providing. Regular staff meetings are arranged. People who use the service meet with the management of the home on a regular basis. Minutes of meetings held were seen. The registered provider and general manager visit the home very regularly, 2 to 3 times a week people said. People and staff said they are able to talk to the managers at any time There is evidence that the ethos of the home is more open and transparent. The views of both people who use the service and staff are being listened to, and valued. The self-assessment form completed by the home indicated that the required maintenance and servicing of equipment is up to date, a sample of records we looked at confirmed this. However, the manager said that she was not sure if a fire risk assessment had been developed for Rookvale.The service should have such an assessement.The manager is advised to seek guidance form the local fire authority. Staff said they had not received any recent fire safety training. Staff did say they had participated in a recent fire drill and that the fire alarm was tested weekly. However, staff need this training as a priority so that they know what to do in the event of a fire. We will be asking the home to provide us with an improvement plan setting out how they intend to improve the service. Rookvale DS0000001286.V377301.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 2 2 3 3 X 4 X 5 3 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 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 3 X 2 2 X Version 5.2 Page 25 Rookvale DS0000001286.V377301.R01.S.doc Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Everyone living at the home must have a detailed care plan setting out the person’s goals abilities and care needs. This will mean that people get the care/support they need. Previous timescales of 31/07/08, 31/12/08 and 31/07/09 not fully met. 2. YA14 16(2) Everyone living in the home must be given the support they need to take part in a range of activities appropriate to his or her race, culture, religion, age, disability, gender, and sexual orientation. Timescale of 31/12/08 and 31/07/09 not fully met. 3. YA20 13 People who retain and administer their own medication must be protected by the homes policies and procedures for dealing with medicines. DS0000001286.V377301.R01.S.doc Timescale for action 01/12/09 01/12/09 01/10/09 Rookvale Version 5.2 Page 26 4. YA35 18 Staff must be given the training they need to enable them to work safely and meet the needs of people living in the home. As a minimum this must include training on food hygiene and moving and handling. Previous timescale of 31/12/08 and 31/07/09 not met. 01/12/09 5. YA41 17 The records required by regulation must be kept up to date and available for inspection. This includes: People’s care records Staff training records Maintenance records Fire Records This is to make sure the home can demonstrate it is being managed effectively and safety and in the best interests of the people living there. Previous timescale of 31/12/08 and 31/07/09 not met. Fire prevention and awareness training must be provided to all staff at the home. This is to make sure safe working practices are applied at the home and so ultimately people are protected. 01/12/09 6. YA42 23 01/10/09 Rookvale DS0000001286.V377301.R01.S.doc Version 5.2 Page 27 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 YA1 Good Practice Recommendations The Statement of Purpose and Service User guide should include all the required information so that people using the service and/or thinking about using the service have clear, accurate, and up to date information about the services offered. The persons daily notes should reflect the information actually recorded in their care plan. Staff should ensure that all written entries they make in peoples care plans are dated, timed and signed. Peoples care plans should be reviewed monthly unless there is a recorded reason as to why they do not need to be reviewed at this frequency. Meals should be served in pleasant congenial surroundings. The programme of renewal of the fabric and decoration to improve the environment should continue. Training should be provided to staff that is linked to peoples needs. A fire risk assessment should developed and made available for all staff so that all staff are clear about their roles in relation to fire safety at the home. 2. 3. 4. 5. 6. 7. 8. YA6 YA6 YA6 YA17 YA24 YA35 YA42 Rookvale DS0000001286.V377301.R01.S.doc Version 5.2 Page 28 Care Quality Commission Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshirehumberside@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Rookvale DS0000001286.V377301.R01.S.doc Version 5.2 Page 29 Rookvale DS0000001286.V377301.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!