Inspection on 28/08/08 for Rookvale

This inspection was carried out on 28th August 2008.

CSCI 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 26/08/09

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 13/11/2008.

CARE HOME ADULTS 18-65 Rookvale 3 Carlton Drive Heaton Bradford West Yorkshire BD9 4DL Lead Inspector Mary Bentley Key Unannounced Inspection 28th August 2008 09:40 Rookvale DS0000001286.V371255.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 Rookvale DS0000001286.V371255.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. Rookvale DS0000001286.V371255.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 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.V371255.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th March 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. The weekly fees in August 2008 ranged from £320.00 to £350.00. People are sometimes asked to make a contribution to the cost of organised outings. If necessary the home can arrange services such as hairdressing at an additional cost but generally people prefer to make their own arrangements outside of the home. The inspection report available in the home was 2 years old, more recent inspection reports were not displayed. Rookvale DS0000001286.V371255.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 1 star. This means the people who use this service experience adequate quality outcomes. The inspection process included looking at the information we have received about the home since the last key inspection in March 2008. This unannounced inspection was done by one inspector between the hours of 9:40am and 5:55pm. 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 parts of the building. Before the visit we sent surveys to the home to be given to people living in the home, staff and health care professionals. In total 11 were returned. Before the visit we sent a self-assessment form to the home. This was not returned to us before the visit. The manager said he was still working on it and would send it to us. However, at the time of writing we had not received it. What the service does well: What has improved since the last inspection? There were 21 requirements following the last inspection. The home appointed a new manager in May this year and he has started to address these requirements. People living in the home told us they have started to see improvements since he started. However, he has not been in post long enough to deal with all the outstanding issues and therefore some of them have been carried forward following this inspection. Rookvale DS0000001286.V371255.R01.S.doc Version 5.2 Page 6 People living in the home told us the food has improved and there is more choice. Some improvements have been made to the care records. More work is needed to make sure that care and support is given in a way that takes account of people’s abilities and wishes. The manager is aware of this. The home has started to make improvements to the environment. Some redecoration has taken place and a cleaner has been employed to help make sure the home is kept clean. 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. The summary of this inspection report can be made available in other formats on request. Rookvale DS0000001286.V371255.R01.S.doc Version 5.2 Page 7 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.V371255.R01.S.doc Version 5.2 Page 8 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): 1, 2, & 5 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s needs are usually 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: Of the 8 people living in the home that completed our surveys 5 said they had been asked if they wanted to move into this home. The same 5 people said they had been given enough information, before moving in, to help them decide if the home was the right one for them. The home has a new brochure that provides very basic information about the service. The manager said work is being done to update the Statement of Purpose. We looked at the records of one person who has recently moved into the home. The manager told us the person had been to look around before moving in and that a pre-admission assessment had been done. However, the record of the pre-admission assessment could not be found. Rookvale DS0000001286.V371255.R01.S.doc Version 5.2 Page 9 People living in the home do not have copies of the terms and conditions of their stay. This information should be provided so that people have clear information about their rights and responsibilities. For example what services are not included in the fees, what are the periods of notice and what are the arrangements for reviewing care needs and progress. Rookvale DS0000001286.V371255.R01.S.doc Version 5.2 Page 10 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): 6, 7 8 & 9 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Some improvements have been made but more needs to be done to involve people in drawing up and reviewing their care plans. This will help to make sure that people get the right support to meet their personal goals and changing needs. EVIDENCE: We looked at the three people’s care plans. Work is in progress on improving the care records. We saw that people’s needs are assessed and the assessments include information on people’s personal, health and social care needs. We saw some evidence of people being consulted about how care and/or support are given. For example in one person’s records we saw that they had been involved in coming to an agreement about some restrictions such as a daily limit for Rookvale DS0000001286.V371255.R01.S.doc Version 5.2 Page 11 cigarettes and money and an agreement about how medicines would be managed. In two people’s care records we saw that they can sometimes be aggressive, however no plans were in place to guide staff on how to deal with this. The manager told us about other strategies that are used when dealing with potentially challenging behaviour such as negotiating agreements. There were no care plans to guide staff on using these strategies in the manager’s absence. Some risk assessments were in place, for example in one person’s records we saw risk assessments relating to smoking and drinking. The accident records showed that one person had fallen outside on a number of occasions recently. There was a risk assessment in place, however this should have been reviewed in response to the recent falls. People are supported in managing their own money as much as possible. In some cases this means money is held by the home and people have an agreed daily or weekly spending allowance. The home has meetings approximately every 3 months where people are encouraged to share their views and make suggestions for improving the service. The most recent was in July and the subjects discussed included breakfast times, food in general, activities, cleaning, and laundry. Prior to the appointment of this manager the home has been without a manager for some time. Some of the working practices that developed during that time did not support people in having a say in the running of the home. The new manager said he wants to change this and make sure people are involved in making decisions about how the home operates. Rookvale DS0000001286.V371255.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14, 15, 16 & 17 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. 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 and take part in activities that are appropriate to his or her race, culture, religion, age, disability, gender, and sexual orientation. EVIDENCE: Seven of the eight people living in the home who completed our surveys said they are able to make decisions about what they do and how they spend their time. Daily routines are fairly flexible and breakfast times have been extended to help make sure that people can have breakfast at whatever time they choose to get up. Rookvale DS0000001286.V371255.R01.S.doc Version 5.2 Page 13 There is information in the care records about people’s interests and past lives. However, there is not a lot of information about how people will be supported in following these interests or how they will be supported in maintaining or improving life skills. The manager is aware this is an area that needs to be addressed. One way in which he is hoping to improve this is by introducing people to drama therapy. The home has been provided with a computer and the manager is planning to provide support for people interested in learning to use it. Some people are independent and go out without support from staff. For example one person we spoke to had been out shopping in the morning. We saw in the records that one person goes to a day centre twice a week and another person goes to a club for Asian men every week. However, for people that need more support there is very little by way of a structured programme of activities. Plans were being made for one person who was going on holiday to Spain a few days after our visit. Staff were also talking to people about going on a holiday, which the owner was organising. We saw some evidence that people’s cultural needs are addressed. However, one person living in the home said this could be improved. We saw that people are supported in developing and maintaining intimate personal relationships and people who choose to are supported in maintaining family links. The home has a designated smoking area and people are given clear information about where they can and cannot smoke. The home’s policies in relation to alcohol and drugs are less clear and this needs to be addressed so that people know what is and what is not acceptable. New dining room tables have been provided and they give a slightly more domestic feel to the dining room. However, people still queue up at the hatch for their meals and there is very little attempt to make mealtimes a social occasion. Tablecloths have been provided but were not in use on the day we visited. People said the food has improved and there is usually a choice. They said it depends on who is cooking because the home does not have a cook at the moment. The records of food provided are not completed consistently and this means it is difficult to get a clear picture of what food is actually being served. Other records required to show safe practices such as the food temperature records were not up to date. Rookvale DS0000001286.V371255.R01.S.doc Version 5.2 Page 14 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): 18, 19 & 20 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Generally people’s 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: These are some of the comments made by people living in the home. • “The care I have received from Rookvale is without doubt excellent” • “I am very well looked after” 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. The manager told us he wants to support people in taking more pride in their appearance, as he believes this will help to improve their self-esteem. He wants to do this by encouraging people to buy more age appropriate clothes and by providing a full-length mirror so that people can see how they look. Rookvale DS0000001286.V371255.R01.S.doc Version 5.2 Page 15 On the day we visited one person was going to the dentist, they had organised this themselves. Other people told us they go to a local health centre, for example to see their GP or for chiropody. The manager told us that since starting one of his priorities has been to arrange a full review for everyone to make sure that all their health care needs are being addressed. This has included reviewing people’s medication to make sure they are receiving the correct medicines. We saw some evidence of this in the records and some reviews were taking place on the day we visited. More work is needed to make sure that the care records give a clear picture of how people’s health care needs are monitored and dealt with. For example people’s weights are not recorded, the manager is aware of this. We looked at how medicines are managed and at the records of two people that take their own medicines. Risk assessments were not available at the time of our visit, however the home has since informed us that they have been done. The medicines are ordered by the home and people are then given a weeks supply in a monitored dose box. The two people concerned told us they keep their medicines safe in their bedrooms and lock their bedrooms doors when they are out. However, it was not clear if there was a lockable storage space in their rooms for them to use. This was discussed during the visit. The medicine charts were up to date and accurate showing that people get their prescribed medicines. Rookvale DS0000001286.V371255.R01.S.doc Version 5.2 Page 16 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): 22 & 23 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are given information about the complaints procedure and action is taken to deal with any concerns raised. There are procedures in place to safeguard people. More training is needed to make sure staff understand their responsibilities in protecting people and promoting their rights. EVIDENCE: Five of the 8 people living in the home who completed our surveys said they know how to make a complaint or know who to speak to if they are not happy with some aspect of the service. The home told us they have had 2 complaints since the last inspection and they have been dealt with. We have not received any complaints since our last visit in March 2008. The manager told us a user-friendly version of the complaints procedure has been given to people living in the home. The home has a copy of the local adult protection procedures. Not all staff have had training on the protection of vulnerable adults and this needs to be addressed to help make sure people are protected. The local authority Rookvale DS0000001286.V371255.R01.S.doc Version 5.2 Page 17 provides training for managers on safeguarding and we recommended that the manager attend this. Rookvale DS0000001286.V371255.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): 24, 26 & 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Some improvements have been made and work is continuing to make sure the home provides a safe, pleasant and comfortable home for people. EVIDENCE: Of the 8 people living in the home that completed our surveys 5 said the home is kept clean and fresh. The remaining 3 felt this could be improved. One person said, “ A good cleaner would be appropriate” The home has employed a cleaner since our last visit but she was not working on the day we visited. Overall the home was clean. Some of the people we spoke to obviously take great pride in keeping their rooms clean and tidy. People are encouraged to see their bedrooms as their own personal space and most have keys to their rooms. In most rooms we saw that people have personal belongings, which reflect their interests. Nine of the 16 people living Rookvale DS0000001286.V371255.R01.S.doc Version 5.2 Page 19 in the home have kettles in their rooms so that they can make hot drinks whenever they want. The manager told us they are doing more to encourage people to take pride in their rooms. Some bedrooms, bathrooms, and corridors have been decorated recently. The home plans to continue the programme of refurbishment. The home told us they are planning to add en-suite facilities to 3 bedrooms but this work had not started when we visited. Most people are now provided with personal toiletries. However, we saw some large containers of shampoo in bathrooms, which suggests that some communal toiletries are still being used. The laundry is suitably equipped. People are supported in doing their own laundry. Rookvale DS0000001286.V371255.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): 32, 34, 35 & 36 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People may be at risk because all the required checks are not carried out 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: Most of the people living in the home who completed our survey said staff treat them well, listen to them, and take notice of what they say. One person said staff don’t listen and another said, “Some staff are not willing to negotiate, compromise and like to have their own way”. There are usually 2 or 3 staff on duty during the day. The home does not have a cook at the moment and therefore care staff have to do the cooking. The activities organiser and cleaner were off work when we visited meaning that care staff also have to take on these roles. This means they may not always have enough time to provide people with the care and support they need. Rookvale DS0000001286.V371255.R01.S.doc Version 5.2 Page 21 We looked at the files of 4 staff, two of which were new. The files for the new staff showed that both started work before the PoVA (Protection of Vulnerable Adults) First check had been obtained. The purpose of the PoVA First check is to make sure that staff are suitable to work with vulnerable people. Allowing staff to start work before this check has been completed could put people at risk. One the new staff only had one reference in the file, the manager told us he had seen a second reference but could not find it. The third file belonged to a member of staff who has been at the home for some time. There was very little information in the file, no application form, no references and no evidence that PoVA or CRB (Criminal Records Bureau) checks had been completed. The manager said that before he started there had been a problem with paperwork going missing from some staff files and he is in the process of dealing with this. The fourth file had all the required information. We saw that new staff complete an induction checklist but there was no evidence that a more detailed induction training programme is provided. The home has employed a training manager and we saw a training matrix of planned training. However, there was no evidence that any of this training has been done. The home told us that 60 of care staff have achieved an NVQ (National Vocational Qualification) at level 2 or above. The manager has started to provide supervision and is planning to do appraisals for all staff. Rookvale DS0000001286.V371255.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): 37, 39, 41 & 42 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. More needs to be done to show that the home is being managed effectively and that the opinions of the people living there are central to how the home is run. EVIDENCE: A new manager has been appointed since the last inspection. He told us he is in the process of applying for registration. People living in the home said they have seen some improvements since he started, people said he listens to them. The manager said one of the senior management team visits the home regularly to provide support and audit various aspects of the service. He said Rookvale DS0000001286.V371255.R01.S.doc Version 5.2 Page 23 he is given copies of the reports from these visits but was unable to show them to us because of problems with the computer. The manager told us he is developing questionnaires to send to people to get their views of the service. In the meantime there are meetings for people living in the home where they are encouraged to share their views of the service. We saw evidence that checks on portable electrical appliances have been done. We were unable to find the electrical wiring certificate or the gas safety certificate. The manager has since confirmed that the gas certificate was issued and work is planned to provide an electrical wiring certificate. Copies of these certificates must be sent to us as soon as they are available. The home has a fire safety assessment done by a private contractor earlier this year. The manager confirmed that the recommendations have been dealt with. The records showed that checks on the fire alarm system were being done every month, since our visit the manager has confirmed that they are now done weekly. The manager has also informed us that action has been taken to control the hot water temperatures to reduce the risk of scalding. Throughout the visit we found that some documents could not be found for example the maintenance records referred to above, a pre-admission assessment and some staff records. Other records such as the food records were not kept up to date. The home must make sure that all the records required by regulation are kept up to date and available for inspection so that they can demonstrate the home is being managed effectively and is a safe place for people to live and work. We will be asking the home to provide us with an improvement plan setting out how they intend to improve the service. Rookvale DS0000001286.V371255.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 2 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 2 X 2 2 X Rookvale DS0000001286.V371255.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001, and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 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. The plan must be drawn up with the involvement of the person together with family, friends, and/or advocate as appropriate, and relevant agencies/specialists. This will mean that people get the care/support they need. Previous timescale of 31/07/08 not 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. New staff must not start work in the home until all the required checks have been completed and all the required documents have been obtained. As a minimum DS0000001286.V371255.R01.S.doc Timescale for action 31/12/08 31/12/08 3. YA34 19 28/11/08 Rookvale Version 5.2 Page 26 there must be two written references and a satisfactory PoVA First. When staff start work with a PoVA First but pending the return of a full CRB disclosure there must be proper supervision arrangements in place. This is to protect people from possible abuse by staff that are not suitable to work with vulnerable adults. 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 moving and handling, food hygiene, safeguarding and equality and diversity. 5. YA41 17 The records required by regulation must be kept up to date and available for inspection. This includes: • People’s care records • Records relating to the safe management of food • Records of food provided to people • Staff records • Maintenance records • Reports from management visits 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. 6. YA39 24 A quality assurance system must be established and maintained which includes seeking the views DS0000001286.V371255.R01.S.doc 4. YA35 18 31/12/08 31/12/08 31/12/08 Rookvale Version 5.2 Page 27 of people using the service. This will make it possible for people to contribute to the improvement and development of the service. Previous timescale of 31/10/08 not met. 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. People living in the home should be provided with copies of the terms and conditions of their stay. This will mean people have clear information about their rights and responsibilities and will know what services are included in the fees and what they have to pay for. 2. YA5 Rookvale DS0000001286.V371255.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Rookvale DS0000001286.V371255.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. 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