CARE HOME ADULTS 18-65 Rookvale 3 Carlton Drive Heaton Bradford BD9 4DI
Lead Inspector Michael Smithson Unannounced 5 April 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 Version 1.10 Page 3 SERVICE INFORMATION
Name of service Rookvale Address 3 Carlton Drive, Heaton, Bradford, West Yorkshire BD9 4DI 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) 01274 543898 01274 783700 Mr Jamail Singh Bassan Mrs Angela Lowles Care Home 19 Category(ies) of Mental Disorder (14), Physical disability over 65 registration, with number (1), Mental Diisorder over 65 (4) of places Rookvale Version 1.10 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19 October 2004 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 Version 1.10 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the first visit for this inspection year 2005/6. The inspection was unannounced with the next inspection being announced. The inspection took place over the morning and early afternoon of 5th April 2005. It focused on issues outstanding from the last inspection, records, the premises and discussions with service users. A total of 9 service users were spoken with during the inspection. Three were detailed discussions relating to their care plans. Brief discussion did take place with the staff regarding general issues relating to the home. What the service does well: What has improved since the last inspection?
The general organisation of the service user records has improved. The care plans and reviews are now held together and are the focus of the information in the daily reports. This makes the information held up to date and reflects the needs of the service users. Positive comments were expressed by service users regarding the food. A new cook has been employed who is planning to look at the menus following talks with the staff and service users. The recruitment and training records are well organised and all the required checks have been completed. Fire safety training has now been updated and training provided for the night staff. Rookvale Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Rookvale Version 1.10 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 Version 1.10 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) 1,2,3 and 4. The service users have a degree of choice of placement, however they are guided by the placing agent and health care professionals. EVIDENCE: There had been no new admissions to the home since the last inspection. The records for 3 existing service users were checked. Detailed assessment information was provided and there was some evidence that service users had been offered a degree of choice. The admissions were organised by the placing social workers who provided the assessment information. A trial period is offered and is reviewed prior to a final decision being made. The statement of purpose has been completed and a user guide produced. The statement includes information about the current details of ownership, however it is unclear whether Rookvale has been included in the new company group, which has changed name and will require a change of registration details. The home has produced a new brochure which is given out to placing agents and hospitals. The information includes details of the admission process and procedure. Discussions took place with a number of service users who confirmed they are offered a choice and can maintain a degree of control over their daily lives. Many of the service users remembered being offered a trial visit. Rookvale Version 1.10 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) 6,7,8 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 3 service users. The care plans were well recorded and include assessments and identified aims and objectives. Service users care plans are reviewed on a daily basis using structured daily reports. In house reviews take place every 3 months with both the service users and the key workers involved. The service users are encouraged to sign the review notes. Discussions took place with a number of service users including those chosen for the case studies. The service users confirmed they have the opportunity to attend reviews and influence the information held in the care plans. The care records are monitored and overseen by a key worker system. The service users were aware of their allocated key worker. Risk assessments are provided to determine the level of risk and action required to maintain independence and safety.
Rookvale Version 1.10 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) 11,12,13,14,15,16 and 17. The home provides an enviroment where service users are encouraged to develop friendships and enjoy communal living. A range of leisure activities are offered. The service users enjoy organising their own interests and also join in with the group activities. EVIDENCE: The service user records include information regarding personal relationships and personal development. Service users confirmed they were given the opportunity to develop relationships. All the service users spoken to during the inspection had a positive view of the home and had formed friendships with other people living at the home. Six service users regally attend day centres for both social and educational benefits. A holiday is organised each year for those wishing to go. The destination of the holiday is discussed at the service user meetings. Nine service users are going to Scotland this year. Rookvale Version 1.10 Page 11 The home is visited by staff from Shipley College who provide training with basic education and life skills. One of the staff is also teaching an Asian service user to improve his language skills. One service users has been encouraged to attend an Asian Men’s Group and they are arranging for him to have a holiday to Pakistan. The home had been without a cook for over 12 months. A new cook has now been employed and the service users commented on how much the food had improved. They also confirmed that a choice is offered for most meals. The new cook has continued to use the previous 4 week menu, however she is planning to produce her own menus following discussions with the staff and service users. Rookvale Version 1.10 Page 12 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) 18 and 19. The health care needs are monitored and are regularly updated. The home is able to meet a range of both physical and mental health needs. EVIDENCE: The records include the health care needs of service users. One record was specifically checked for a service user whose health had recently deteriorated. The care plan had been updated to reflect the changing needs and the staff showed a good knowledge of his condition. The in-house reviews include monitoring health care needs and a key worker system allows staff to focus on individual needs. The service users also have formal reviews held with health care professionals. Rookvale Version 1.10 Page 13 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: Complaints are recorded and investigated. The service users felt able to raise issues with staff and the stable staff team provides consistency. Policies and procedures are available which include information and guidance for staff. Training regarding adult protection issues are provided for the staff. Complaints are well recorded and the manager took on board the advice offered at the last inspection that more detailed information was required in some of complaints investigations. Rookvale Version 1.10 Page 14 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) 24,25,26,27,28,29 and 30. The premises meet the needs of service users. However the premises are an adapted building which was not specifically designed for the purpose. The building took take a lot of wear and tear staff find it difficult to keep clean. The building needs regular maintenance and upgrading to maintain adequate standards. EVIDENCE: A full tour of the premises was undertaken during the inspection accompanied by the registered manager. Areas of the building are in need of refurbishment, including redecoration, fixtures and fittings. The communal areas have been redecorated and now look brighter and more welcoming, however some of the bedrooms and the bathrooms now require improvement. At the last inspection broken windows were noted in the external smoking room door. These have not been replaced. A bedroom on the second floor has a particularly strong odour problem. The staff are taking steps to try to improve the situation but with little success. The carpet in this bedroom must be replaced. A full washable floor covering may be a better alternative for this service user.
Rookvale Version 1.10 Page 15 An area of the garden has been converted to provide additional parking. The area needs to be finished and properly resurfaced. To create a better initial impression of the home the owner should avoid using this area to park cars not used by staff or visitors. Rookvale Version 1.10 Page 16 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) 31,33,34 and 35. 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 well organised and through. EVIDENCE: The staffing has remained stable with few changes since the last inspection. One member of staff has been employed. The recruitment records were checked and all the required information was available, including references and a Criminal Records Bureau check. One CRB check for an existing member of staff is still outstanding. The documentation has now been resubmitted and should be completed in the near future. A good level of training is provided for the staff and this is well recorded in individual staff files. The company has a training facility which is well used by the staff at the home. Positive comments were noted during brief discussions with staff. The levels of support and guidance offered helps staff to provide care geared to the individual needs of service users. A programme of staff supervision provides a forum to formalise issues raised by both staff and the manager.
Rookvale Version 1.10 Page 17 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) 37,38,40,41 and 42. Good lines of communication have been established at the home. The views of staff and service users are sought. EVIDENCE: Discussions took place with the manager regarding the day to day operation of the home. The manager showed a good knowledge of the home and the needs of service users. She is involved in service user reviews and staff supervision. The provider visits the home to provide support and monitoring. The monthly reports were not seen at the inspection. The owner has recently changed the company name which appears to include Rookvale. All the information for the business is now on the new company headed paper. The manager has not applied to change the registration certificate to reflect the changes. Detailed health and safety information is provided for staff in the form of policies and procedures and training. Since the last inspection training Rookvale Version 1.10 Page 18 regarding fire safety has now been provided for new staff and the night staff. This was a requirement from the last inspection. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 3 3 x Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 3 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 3 3 2 3 3 2 Standard No Standard No 31 32 Score 3 x
Page 19 Rookvale Version 1.10 11 12 13 14 15 16 17 3 3 3 3 3 3 3 33 34 35 36 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 3 3 x Rookvale Version 1.10 Page 20 NO 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. 2. 3. 4. Standard YA 25 YA 27 YA 28 YA 30 Regulation Reg 23(2)(d) Reg23(2)( d) Reg 23(2)(b) Reg 16(2)(k) Requirement A programme of refurbishment of service user bedrooms must be put in place. The bathrooms must be refurbished. The broken windows in the conservatory door must be replaced. The bedroom on the 2nd floor identified with an odour problem requires attention. The carpet must be replaced. A suitable washable floor covering was suggested. Timescale for action 01/06/05 01/08/05 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 YA 24 Good Practice Recommendations The new car parking area should be resurfaced. Rookvale Version 1.10 Page 21 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
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