CARE HOMES FOR OLDER PEOPLE
Roop Cottage Wakefield Road Fitzwilliam Pontefract West Yorks WF9 5AN Lead Inspector
Mr Tony Brindle Unannounced Inspection 18th November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Roop Cottage DS0000006207.V265719.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Roop Cottage DS0000006207.V265719.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Roop Cottage Address Wakefield Road Fitzwilliam Pontefract West Yorks WF9 5AN 01977 610918 01977 610918 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) Dr R R Kanani Mrs M R Kanani Mrs Anne Egley Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35), Physical disability (13) of places Roop Cottage DS0000006207.V265719.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 20th June 2005 Brief Description of the Service: Roop Cottage, a home providing accommodation and care with nursing for a mixed category of residents (Older People and Younger Adults), is situated on the outskirts of the village of Fitzwilliam, a small village 8 miles from the city of Wakefield. The home is not too far from a small number of local shops and a pub. The home is privately owned and registered for older people and for younger adults with a physical disability who are accommodated in dedicated units. The accommodation is provided over two floors, older persons being based on the upper floor, younger persons on the ground floor. The rooms are single occupancy and two rooms have en-suite facilities. The gardens are accessible and of a good size. Roop Cottage DS0000006207.V265719.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was a positive and enjoyable one, undertaken by 2 inspectors, who spent 3.5 hours taking to residents and staff, looking at care plans, daily records, health and safety records, the complaints log, the menus and the staff recruitment and training files. The inspectors would like to take the opportunity to thank the residents, the deputy manager and support workers for their hospitality and patient cooperation throughout the inspection. A resident’s invitation to see their bedroom was welcomed and accepted, and the building and gardens were seen. Since the last inspection, the Commission received a complaint from a resident regarding alleged poor care practice. The manager of the home was asked to investigate the issues raised by the complainant, which she did successful. Action was taken by the manager to improve the care practices within the home. . There have been no changes to the Registered Persons registered with CSCI. What the service does well: What has improved since the last inspection?
Roop Cottage DS0000006207.V265719.R01.S.doc Version 5.0 Page 6 A number of the staff team have received training in relation to supporting people with a learning disability. The carpets on the upstairs corridor have been replaced, which has improved the environment and living space for the residents. 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. Roop Cottage DS0000006207.V265719.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Roop Cottage DS0000006207.V265719.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s):
Older Person’s Standard 3 and the relating Younger Adult Standard was assessed The work of the staff and the systems operated at the home make sure that residents only move into the home once assurances have been given that their assessed needs can be appropriately met. EVIDENCE: There have 2 new admissions to the home since the last time it was inspected. The deputy manager said that the manager or her deputy assesses the strengths and needs of new people who want to move into the home. The information they receive is used to decide if a placement can be offered to the new person. He continued saying that when people first move into the home, they are welcomed by staff and are introduced to the other people living there. The information contained within a sample of the files of the people who live at the home at the moment, backed up the comments of the deputy manager. Roop Cottage DS0000006207.V265719.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Older Person’s Standard 7,8,9 and 10 and the relating Younger Adult Standards were assessed. The resident’s health, personal and social care needs are set out in individual plans of care. The work of the staff and the systems operated at Roop Cottage make sure that resident’s health care and medication needs are met, and that residents are treated with respect and dignity. EVIDENCE: Resident care plans contain detailed information about support and healthcare needs. The plans have a straightforward approach, concentrating on aspects of daily living. Restrictions are only placed on the residents following an appropriate risk assessment. Discussions with the staff showed that they have a good understanding of the support and care needs of the residents. People can expect the staff to be aware of issues of assessing and managing any symptoms, including pain, that they may have, and how to access specialist services. If people want to, they are encouraged to take part in physical activities in or outside the home which help maintain a healthy lifestyle. One resident who had recently moved into the home explained that she had been very well treated with the staff showing her respect. Her final Roop Cottage DS0000006207.V265719.R01.S.doc Version 5.0 Page 10 comment about her care at the home was that she was very happy and comfortable. Roop Cottage DS0000006207.V265719.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Older Person’s Standard 12,13,14 and 15 and the relating Younger Adult Standards were assessed. Depending on their individual capabilities, people make choices and decisions about day-to-day aspects of their life and about how they spend their time. The work of the staff and the systems operated at Roop Cottage makes sure that appropriate activities are provided for residents to get involved with. Residents maintain contact with family/representatives and the local community as they wish. Residents benefit from a wholesome, appealing and balanced menu. EVIDENCE: One resident said that she likes to take part in a various activities in the home such as bingo, quizzes and raffles. Another said that she just likes to watch the others take part, and joins in only now and again. Another resident explained that she really enjoys it when her relatives visit, and the deputy manager explained that relatives are welcome to visit as they please. One visitor was seen during the visit, who said that she is happy with the care her mother receives at the home, and feels that the home is run very well. Two residents said that they have a varied, appealing, wholesome and nutritious diet, which is suited to their individual requirements. The menus confirmed this. Roop Cottage DS0000006207.V265719.R01.S.doc Version 5.0 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Older Person’s Standard 16 and 18 and the relating Younger Adult Standards were assessed. The work of the staff and systems operated at Roop Cottage makes sure that residents and their relatives can raise complaints with the confidence that they will be listened to and taken seriously. There are suitable arrangements in place for responding to and reporting suspected or alleged abuse. EVIDENCE: The deputy manager explained that people can freely discuss any concerns their have with a member of staff, other residents or any member of the care home’s management. The records show that people are given information on how to make a complaint or comment to the home about the service. People are also aware of the procedure for making formal complaints directly to the Commission. The records show that the management of the home deals with concerns and complaints quickly and sympathetically, and provides full information about what will happen as a result of the complaint. People are encouraged and can be supported to use an independent and confidential advocacy service that can act for people. If people have an independent representative (for example, an independent advocate), staff will listen to what he or she has to say on people’s behalf, as if people were expressing the views themselves. Roop Cottage DS0000006207.V265719.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Older Person’s Standard 19 and 26 and the relating Younger Adult Standards were assessed. The systems and procedures operated at the home, and the work of the staff ensure that the residents live in a homely, comfortable and clean environment. The home is clean, pleasant and hygienic. EVIDENCE: The nature of the design of the home, its facilities and equipment were found to be satisfactory. The premises are kept clean, hygienic and free from offensive odours and intrusive sounds throughout. There are systems in place to control the spread of infection. People can bring personal belongings with them when they move in, including items of furniture. One resident said that she enjoys that fact that she can sit in her room and enjoy the view. She added that since arriving at the home, she has felt very comfortable and happy. The rooms and corridors are kept in good decorative order and the home and furnishings are well maintained. The carpets on the upstairs corridor have been replaced, which has improved the environment and living space for the residents. The deputy manager explained that the proposed redecoration of the upstairs dining room, would further enhance the environment.
Roop Cottage DS0000006207.V265719.R01.S.doc Version 5.0 Page 14 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Older Person’s Standard 29 and the relating Younger Adult Standards was assessed. Residents are not supported and protected by the home’s recruitment policy and practices. EVIDENCE: The rota showed that there is a satisfactory mix staff working at the home, appropriate to the assessed needs of the residents, the size, layout and purpose of the home. The deputy manager explained that the staffing levels had recently been increased following a review and a requirement made by CSCI at the last inspection. The deputy manager explained that a number of staff had attended training in learning disability and the training records show that the staff training and development programme based on the assessed needs of the resident group. The recruitment records relating to one member of staff were found to be lacking a Criminal records check. The deputy manager explained that the check had been carried out, but must have been misplaced. Roop Cottage DS0000006207.V265719.R01.S.doc Version 5.0 Page 15 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Older Person’s Standard 38 and the relating Younger Adult Standards was assessed. The health and welfare of the service users and staff is protected by the safety systems operated by the home. EVIDENCE: The records relating health and safety including fire alarm testing, water temperatures, emergency lighting and environmental risk assessments were seen to be up to date and in good order. Roop Cottage DS0000006207.V265719.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 3 Roop Cottage DS0000006207.V265719.R01.S.doc Version 5.0 Page 17 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 OP29 Regulation 19 Requirement A new worker may only start work, pending receipt of a CRB check, if the manager has received full and satisfactory information via a POVA check and a CRB has been applied for. Timescale for action 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Roop Cottage DS0000006207.V265719.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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