Inspection on 04/10/05 for Rookvale

This inspection was carried out on 4th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rookvale 26/08/09

Rookvale 28/08/08

Rookvale 04/03/08

Rookvale 20/03/07

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 09/07/2008.

CARE HOME ADULTS 18-65 Rookvale 3 Carlton Drive Heaton Bradford BD9 4DI Lead Inspector Michael Smithson Announced 9.30am 4 October 2005 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 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 Stationary 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 20051004 Rookvale Ann Stage 4 S1286 V197844 J52.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Rookvale Address 3 Carlton Drive Heaton Bradford BD9 9DI 01274 543898 01274 783700 Telephone number Fax number Email 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 J BASSAN Mrs A Lowles Care Home 19 Category(ies) of Mental Disorder (14) Physical Disability - over registration, with number 65 (1) Mental Disorder- over 65 (4)_ of places Rookvale 20051004 Rookvale Ann Stage 4 S1286 V197844 J52.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7 April 2005 Brief Description of the Service: Rookvale is situated in the Heaton district of Bradford, which is approximately 3 miles from the city centre. The home provides personal care for service users with mental health problems who are under pension age. The home does not provide nursing care. There are 9 single bedrooms and 5 double bedrooms available on 3 floors. The home cannot accommodate service users 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. Rookvale 20051004 Rookvale Ann Stage 4 S1286 V197844 J52.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over the morning and early afternoon of the 4th October 2005. The inspection was announced and a poster and service user feedback questionnaires were provided. This was the second of 2 inspections for this year. The first inspection was unannounced. Copies of reports for previous inspections are available either from the home or on the CSCI website. This inspection focused on the issues outstanding from previous inspections, the care records, staff records and discussions with service users and staff. The feedback from service users was positive, many have lived at the home for a number of years. Two of the service users were recent admissions and felt they had settled well at the home. They both had the opportunity to visit the home prior to admission. The staff showed a good understanding of the daily routines and the needs of individual service users. The care staff undertake cleaning duties as well as providing support for service users, although service users are encouraged to keep their own bedroom tidy. What the service does well: The home provides a friendly environment for service users. Many of the service users have made friendships and have formed long term relationships. The records were well organised and were kept up to date. The care records reflect the needs of service users and include aims and objectives. The service users and other professional have input into the plan of care. Rookvale 20051004 Rookvale Ann Stage 4 S1286 V197844 J52.doc Version 1.40 Page 6 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. Rookvale 20051004 Rookvale Ann Stage 4 S1286 V197844 J52.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Rookvale 20051004 Rookvale Ann Stage 4 S1286 V197844 J52.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 5. The service users have a degree of choice of placement, however they are guided by the placing agent and health care professionals. The home provides information regarding the care provided. EVIDENCE: The statement of purpose and service user guide reflect the care provided and the facilities offered at the home. The last 2 service users admitted to the home were given the opportunity to visit the home prior to admission. All new service users have a pre-admission assessment completed by the placing social worker. The manager also has a pre-admission format, which she also completes. All the current service users are funded by the local authority and are provided with a local authority contract. The last admission is still awaiting a contract. Rookvale 20051004 Rookvale Ann Stage 4 S1286 V197844 J52.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 9. The records accurately reflect the needs of service users and highlight areas of risk. Staff and service users have input into the care records, which allows staff to provide the appropriate levels of care required to maintain independence. EVIDENCE: Case tracking was undertaken for 2 service users recently admitted to the home. Detailed pre-admission assessments had been completed and aims and objectives identified. The care plans included the needs of service users and any risk assessments. The daily reports reflect issues identified in the care plans. A staff key worker system is in place and the key workers are consulted on specific care issues relating to service users. The care plans are reviewed every 3 month. The service users are involved in reviews and are encouraged to sign the review reports. Rookvale 20051004 Rookvale Ann Stage 4 S1286 V197844 J52.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 17. The home is able to meet the cultural and dietary needs of the service users. EVIDENCE: The home has a new cook who works Monday to Friday. The care staff provide the meals at the weekend. A new menu has been produced following consultation with the service users. The service users provided positive feedback regarding the meals provided. The home can cater for special diets and the cultural needs of service users. Halal meals are available for an Asian service user. Rookvale 20051004 Rookvale Ann Stage 4 S1286 V197844 J52.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 The home provides appropriate safeguards for medication administered by the staff team. Further work is required regarding self-medication. EVIDENCE: A monitored dosage system is used at Rookvale. The pharmacist has recently carried out an inspection of the medication administration system and a report produced. The manager and the pharmacist provide the staff with training. They have also enrolled on a drug administration course at a local college. One service user looks after his own medication. However a risk assessment was not available. The risk assessment must include safe storage and monitoring of the medication. A policy and procedure for self medication must also be provided. Rookvale 20051004 Rookvale Ann Stage 4 S1286 V197844 J52.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. The home provides an enviroment where service users feel protected and can raise concerns with a range of different staff, specialist support agencies and care professionals. EVIDENCE: No complaints had been received since the last inspection. The complaints procedure is provided for service users and any complaints made are investigated and recorded. Adult protection training is included in the staff induction training format. An adult protection policy and procedure is available together with the local authority No Secrets guidance. During discussions with service users it was evident that they had a reasonable understanding of complaints procedure. One service user had raised concerns with the manager and felt she got a positive outcome. Rookvale 20051004 Rookvale Ann Stage 4 S1286 V197844 J52.doc Version 1.40 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not inspected. EVIDENCE: A full building inspection was not undertaken during this inspection. However the requirements and recommendations from the last inspection did include work to the building. A programme of improvements is in place and a number of bedrooms on the 2nd floor have been redecorated. The bathrooms have been repainted and new flooring provided in the bathroom on the 2nd floor. Rookvale 20051004 Rookvale Ann Stage 4 S1286 V197844 J52.doc Version 1.40 Page 14 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35 and 36. The staffing levels were adequate and geared to meet the needs of service users. Training and support are provided for the staff team. Staff recruitment is adequate, however further checks are required for staff transfers. EVIDENCE: The records for the last 2 members of staff employed at the home were checked. One had all the information required including application form, references and a CRB check. The second member of staff was transferred from one of the providers Older Person homes. No information was available. No evidence of a completed CRB check, references or application form. This information must be obtained. Discussions took place with members of the staff team. They demonstrated a good understanding of the daily routines and the needs of individual service users. Induction training is provided for all new staff. A basic day induction is provided at the home. A more detailed induction is provided by the organisations training officer. The training includes the required mandatory training. Rookvale 20051004 Rookvale Ann Stage 4 S1286 V197844 J52.doc Version 1.40 Page 15 A new staff supervision format has been produced which is linked to the staff training programme. The required numbers of staff supervision sessions had not been completed. This must now be addressed. Rookvale 20051004 Rookvale Ann Stage 4 S1286 V197844 J52.doc Version 1.40 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 41 and 42. The home is well managed and the records kept up to date. EVIDENCE: The registered manager is qualified to a standard equivalent to NVQ level 4. She demonstrates a good understanding of the Care Homes Regulations and Minimum Standards. The homes records were well organised and kept up to date. Health and safety information is available for the staff and training is provided. A portable heater was being used in one of the bedrooms. The radiator must be guarded or removed. Rookvale 20051004 Rookvale Ann Stage 4 S1286 V197844 J52.doc Version 1.40 Page 17 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x 3 x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x 3 x x x x 3 Standard No 31 32 33 34 35 36 Score x x x 2 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Rookvale Score x x 2 x Standard No 37 38 39 40 41 42 43 Score 3 x x x 3 3 x 20051004 Rookvale Ann Stage 4 S1286 V197844 J52.doc Version 1.40 Page 18 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 YA20 Regulation Reg 13(2) Requirement A policy, procedure and risk assessment must be produced for service users who self medicate. The programme of refurbishment of the premises must be completed. All the required recruitment checks must be completed for all staff. A staff supervision system must be introduced. The portable radiators must be removed or guarded Timescale for action 01/12/05 2. 3. 4. 5. YA25 YA34 YA36 YA42 Reg 23 Reg 19(1) Reg 18(2) Reg 12(1)(a) 01/01/06 Immediate Action Immediate Action Immediate Action 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 Good Practice Recommendations Rookvale 20051004 Rookvale Ann Stage 4 S1286 V197844 J52.doc Version 1.40 Page 19 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Rookvale 20051004 Rookvale Ann Stage 4 S1286 V197844 J52.doc Version 1.40 Page 20 - 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!