Inspection on 20/07/06 for Roop Cottage

This inspection was carried out on 20th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Roop Cottage 16/07/07

Roop Cottage 18/11/05

Roop Cottage 20/06/05

Roop Cottage 17/01/05

Roop Cottage 07/07/04

Roop Cottage 01/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Roop Cottage Wakefield Road Fitzwilliam Pontefract West Yorks WF9 5AN Lead Inspector Mr Tony Brindle Unannounced Inspection 20th July 2006 10:30 Roop Cottage DS0000006207.V306687.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 Roop Cottage DS0000006207.V306687.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 Older People and 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. Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 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.V306687.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th November 2005 Brief Description of the Service: Roop Cottage, a home providing accommodation and care with nursing for a mixed category of service users (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. The current fees for July 2006 are £373 plus a nursing care contribution. per week per person. The service provider ensures that information about the service is available to prospective service users and the current service users by way of the home’s Statement of Purpose, the Service User Guide and through CSCI inspection reports. Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this inspection two inspectors from the Commission for Social Care inspection (CSCI) undertook a visit to the home. The inspectors, Tony Brindle and Gillian Walsh, visited the home from 10:30hrs to 16:30hrs. Whilst at the home, key documents such as care assessments, care plans, daily records and the home’s policies were looked at, and so were the rooms and garden. 5 members of staff were spoken with, along with the manager. Six service users were spoken with. The manager had been asked to complete a pre-inspection questionnaire, this she did, and returned it to the Commission before the inspection as requested. Comment cards were sent to service users, their relatives, visiting professionals and GPs. 16 out of the 17 comment cards were returned (94 ) What the service does well: Prospective service users and their representatives have the information needed to choose a home which will meet their needs. They have their needs assessed and a contract which clearly tells them about the service they will receive. The health and personal care support that a person receives is based on their individual needs. The principles of respect, dignity and privacy are put into practice. Staff develop plans of care with people giving details of their needs and preferences, and information about how these needs are to be by the staff. Individuals are involved in decisions about their lives, and play a limited role in planning the care and support they receive (this is dependent upon their capabilities). People who use services are supported to make choices about their life style, and supported to develop some life skills. People receive a varied diet according to their assessed needs and choices. The health and personal care that people receive is based on their individual needs. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. The management and administration of the home is based on openness and Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 6 respect, has effective quality assurance systems developed by a qualified, competent manager. 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. Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Younger Adult 2 and Older People Equivalent Standards as listed above The work of the staff and the systems operated at the home make sure that people only move into the home once assurances have been given that their assessed needs can be appropriately met. Prospective service users and their representatives have the information needed to choose a home, which will meet their needs. They have their needs assessed and a contract which clearly tells them about the service they will receive. Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. EVIDENCE: Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 9 The manager explained that she ensures that an assessment is carried out before offering a place to a potential service user, she said that as a matter of good practice, the assessment process would continue after admission so that the staff could get to know everything about the person. If a visit is possible, the manager said that she would make sure the prospective service users would be shown around the home and given the opportunity to have a meal and meet the other people living there. If people were able to stay for a meal, the staff said that they would try and find out what the person’s likes and dislikes were, and if they needed assistance while eating their meal. The care records were found to contained recent assessments and information relating to the likes and dislikes of new service users. The home does not provide intermediate care services. Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Young Adult 6,7 and 9 and Older People Equivalent Standards as listed above The health and personal care support that a person receives is based on their individual needs. The principles of respect, dignity and privacy are put into practice. Staff develop plans of care with people giving details of their needs and preferences, and information about how these needs are to be by the staff. Individuals are involved in decisions about their lives, and play a limited role in planning the care and support they receive (this is dependent upon their capabilities). Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. EVIDENCE: Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 11 People’s care plans contain information about support and healthcare needs. The plans have a straightforward approach, concentrating on aspects of daily living. The plans of care were found to set out the actions that need to be taken by care staff to make sure people’s personal and social care needs are to met. The staff said that they make sure that they found out what the healthcare needs of people are, and that these are recorded. The staff confirmed they frequently make arrangements on behalf of people living at the home, to make sure these needs are met by talking to the home’s nursing staff, and by contacting GP’s and other external healthcare staff if necessary. Restrictions are only placed on the service users following an appropriate risk assessment. These were found to be on file. Discussions with the staff showed that they have a good understanding of the support and care needs of the service users. The records show that a person trained to do so assesses people’s needs, and appropriate interventions to meet those needs are recorded in the plan of care. The manager said that she and the staff could access professional advice about the promotion of independence, healthcare and skill development from outside agencies and experienced staff within the company. This the manager has done. Despite this, some of the younger adults living at the home still have not been offered suitable daytime placements or occupations (this is discussed further within this report). The records show that other agencies and professionals are involved in people’s lives, and a service user confirmed that they visit the doctor, and another said they see and speak to their social worker from time to time. Staff were observed to work in partnership with people, promoting independence, showing respect and maintaining people’s dignity. Comment cards received made positive remarks about the ways in which the staff support people appropriately. People said they the staff talk to them about their interests and what they want to do. They added that staff support them to use community activities, see friends, make and attend appointments. The care records and discussions with the people living at the home supported these comments. Care staff confirmed that they are involved in maintaining the personal hygiene people at the home, and that wherever possible, support the person’s own capacity for self-care. This was supported by comments from people at home such as, “the staff help me when I can’t do something myself”. The records show that a sensible balance is offered to people in everyday events and activities, between the reasonable risks they want to take and the safety of the staff and other people living at then home. This results from the home’s individual risk assessment approach. Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Young Adult 12,13, 14, 15,16 and 17 and Older People Equivalent Standards Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 13 People who use services are supported to make choices about their life style, and supported to develop some life skills. The home provides some social, cultural and recreational activities, including keeping in contact with their family and friends. However, these choices are limited due to the extent of the social, cultural and recreational activities available both inside and outside of the home. People receive a varied diet according to their assessed needs and choices. Quality in this outcome area is adequate. This judgement is based on evidence gathered both during and before the visit to this service. EVIDENCE: The routines of daily living and activities made available to service users were found to be flexible and service users said that they are varied to there needs, preferences and capabilities. The home has a limited daily activity schedule, with some service users saying that they would like to have more choice over the activities they were involved with. The activities include spending time in the garden, and sitting and chatting with each other and the staff. Activities undertaken by people are recorded within individual care plans. Some of the younger adults said who live at the home, do not attend daytime placements such as day centres or educational or work placement. The staff said that there are little or no opportunities for people to follow educational interests or training courses. The records show that the management team have made efforts to make contact with external service providers, such as local social services departments and educational establishments, with a view to securing appropriate daytime placements for people living at the home, but no placements or opportunities have been offered. One person said that they do have a lot of free time, which is spent either sitting in the garden or watching TV. This person said that they would like to do more during the day, but realises that the staff are usually quite busy. It was quite clear from observations made on the day, and by way of the records that the leisure time among the majority of people living at Roop Cottage often involves passive and solitary activities such as watching TV, or listening to music. When one person was asked if they would like to go out and do different activities, this person said that if a chance came up to do something, then they would ’Have a go.’ People said that the catering and other staff make sure that they get to know their food choices and any ethnic, cultural, faith or other preferences they have. Any special diet (for example, vegetarian) is recorded in people’s personal plans. The menu’s show that the daily meals reflect people’s preferences. Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 14 The menus vary regularly according to people’s comments, and fresh fruit and vegetables are provided. People said that they are given a choice of a cooked breakfast, and choices at the midday and evening meals. The menus indicate that the meals are nutritionally balanced for people’s dietary needs. Service users confirmed that they can have snacks and hot and cold drinks whenever they like. One staff member said that if the staff think that people are not getting enough of the right things to eat or drink, they will keep an eye on this, and take appropriate action. The catering staff supported this, saying that they would always try and change the menus to make sure people or individual got what they wanted or needed. The records show that the staff take any action needed, including seeking advice from a dentist, dietician, speech and language therapist or the person’s GP if there is anything that may affect a person’s ability to eat or drink. This is done with the agreement of the person (depending on their abilities). One person living at the home has quite specific dietary requirements, which could be seen by some as detrimental to their health and wellbeing. The person themselves is aware of this. However, following discussions with external agencies such as the person’s social worker, the manager and staff support this person with their individual requests as the person has the capacity to make their own decisions about food intake. The person’s health and wellbeing is monitored closely, and external professionals are informed of any changes. The staff said that people are free to eat your meals wherever they like, for example, in their own room or in the dining room. One person spoken with confirmed this. People were supported to eat their meals in an unrushed manner. One person spoken with, living on the first floor, said that the meals are sometimes cool when they arrive. Furthermore, they said that cups of tea are often cool, and not always served at an appropriate time. This person said “Most people like to have a cup of tea after their meal, but the staff serve the tea before the meal. The tea then ends up being cold, and if you ask for another cup, the staff say that there’s no more tea. I like a hot cup of tea after my dinner”. Staff were seen to provide appropriate help, for example, adapted cutlery and crockery, a liquidized diet, or someone to assist with eating and drinking in a discrete manner, and in ways that suited and respected the person’s dignity. Meals were seen to be well presented. A recent environmental health report showed that food handling was good, following good food-hygiene practices. Some recommendations were made regarding the fabric and condition of the kitchen. Work is due to start to replace some items such as the grill, and to improve the fabric of the kitchen. Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Young Adult 18, 19 and 20 and Older People Equivalent Standards as listed The health and personal care that people receive is based on their individual needs. Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. EVIDENCE: The staff explained that people’s preferences about how they are guided, moved and supported are recorded in their care plans. The plans confirmed this. People living at the home said that times for getting up/going to bed, baths, meals and other activities are flexible, and that they can choose their own clothes and hairstyle, which reflects their personality. However, one person said that they their request for a hair appointment had come to nothing because the hairdresser had failed to turn up. The manager said that she had Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 16 tried to contact other mobile hairdressers in the area who had all declined to visit the home. The manager said that she would continue to locate a hairdresser willing to visit. There are a number of technical aids and equipment for people to use, which enables them to maximize their independence. The arrangements for health and personal care ensure that service user’s privacy and dignity are respected with the staff being heard to speak to people in respectful ways, and with service users themselves saying that the staff are kind, caring and very patience. The records show that each person has a care plan, but practice of involving people in the development and review of the plan is variable. The plan in most cases includes the basic information necessary to plan the individual’s care and includes a risk assessment element. People confirmed that they have access to health care services that meet their assessed needs both within the home and in the local community. People said that their health is monitored and appropriate action taken. The manager confirmed that she seeks professional advice on health care issues, acts upon it and generally is able to provide the aids and equipment recommended. There is evidence in the care plan of health care treatment and intervention, and a record of general health care information including weight monitoring, and nutritional information. The home has a medication policy which is accessible to staff, and the medication records were found to are generally up to date, however there were some minor discrepancies found in the recording and signing of medication for one person recently admitted for respite care. Discussions with staff showed that people are aware of the need to treat people with respect and to consider dignity when delivering personal care. The service arranges for people to enjoy the privacy of their own rooms and provides screens in shared rooms. People said that on the whole they are happy with the way that staff deliver their care and respect their dignity. The home has policies and procedures, which inform staff how they should handle dying and death. Most staff are aware of these and try to work to them. Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Younger Adult 22 and 23 and Older People Equivalent Standards as listed People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. EVIDENCE: There is a straightforward complaints procedure based on delivering outcomes. The manager explained that people could freely discuss any concerns their have with a member of staff, other people 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 said that they are aware of how to approach the Commission with concerns about the service they receive. The records show that the manager deals with concerns and complaints quickly and sympathetically, and she provides full information about what will happen as a result of the complaint. Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 18 The home has an adult protection and whistle blowing policies that contain clear information and procedures for staff to follow. The home has an out of date copy of the local authority adult abuse and protection policy and procedures, therefore a copy of the new procedures needs to be obtained. Discussion with some of the staff indicated they have a basic understanding of the adult protection procedures and they were able to discuss how different types how abuse impact on people and the ways in which they should respond to allegations or suspicions of abuse. Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Younger Adult 24, 29 and 30 and Older People Equivalent Standards as listed The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment. The service needs to ensure that people’s independence is encouraged in relation to areas of support such as the nurse call system. Quality in this outcome area is adequate. This judgement is based on evidence gathered both during and before the visit to this service. EVIDENCE: Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 20 There is a programme to improve the decoration, fixtures and fittings. There are a number of single rooms and a few double rooms. It is clear that people can personalise their rooms. People said that they are comfortable, and that the home is clean, warm and well lit. People said that there are enough baths and showers. The toilets are situated near to people’s rooms and the communal areas. People and staff said that the home is generally clean and tidy. One person talked about how service users sometimes cannot reach the nurse call button, and they had raised this issue as a complaint. The records showed that this had been recorded and appropriate action taken to rectify the problem. However, on the day of the visit, observations were made that once again, nurse call buttons were placed out of the reach of service users. This was raised with the manager who said that she would ensure this did not continue and ensure that all call buttons were in the reach of people. Some people living on the first floor said that they find the décor, flooring and lighting in the dining room were unappealing, and not a particularly pleasing environment to have their meals. There are infection control measures in place such as the provision of paper towels, liquid soap and details within care plans of ways of avoiding infection, including hand washing, using gloves and aprons (where appropriate). Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Younger Adult 32, 34 and 35 and Older People Equivalent Standards as listed Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. Staff in the home receive training, and efforts should continue to be made to make sure that least 50 of the staff team are NVQ II qualified. Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. EVIDENCE: People are generally satisfied that the care they receive meet their needs, but there are some times when no one is available to immediately help them. One Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 22 person talked about how service users sometimes cannot reach the nurse call button, and they had raised this issue as a complaint. The records showed that this had been recorded and appropriate action taken to rectify the problem. However, on the day of the visit, observations were made that once again, nurse call buttons were placed out of the reach of service users. This was raised with the manager who said that she would ensure this did not continue and ensure that all call buttons were in the reach of people. The staffing rotas were seen to take into account the times of high and low activity. The manager talked about the importance of training, and the records show that a training programme is followed that meets the statutory requirements. The records confirmed this, and there was evidence that staff had received specialist training such as learning disability and dementia training. Discussions with staff showed that people are clear regarding their role and what is expected of them. People living at the home said that staff working with them know what they are meant to do, and that they are generally able to meet their needs. The records show that that 40 of the staff team are at least NVQ II or above qualified. The records show that the service has a recruitment procedure that is satisfactory and meets the regulations and the national minimum standards although at a basic level. The records show that there is an acceptable use of any agency staff. Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Young Adult 37, 39, 40 and 42 and Older People Equivalent Standards as listed The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager is qualified or has the necessary management experience to run the service. The service has a health and safety policy that meets health and safety requirements and legislation, and this is implemented by way quality assurance and monitoring systems that promote the health and wellbeing of people living and working in the home. E.g. fire safety checks. The records were found to be up to date although some gaps were found in recording of medication. Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 25 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT Standard No Score 37 3 38 X 39 3 40 3 41 X 42 3 43 X 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Roop Cottage Score 3 3 2 X DS0000006207.V306687.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA12 YA13 YA14 Good Practice Recommendations The manager and staff should continue to make contact external providers and commissioners to ensure that people living at the home are able to enjoy a full and stimulating life style with a variety of options to choose from. The manager should seek the views of people and considered their varied interests and abilities when planning the routines of daily living and arranging activities both internally and externally. The manager should ensure that medication is correctly signed for and administered appropriately. The manager should obtain an up to date copy of the Wakefield local authority adult protection policies and procedures The manager and proprietor should consult with the people living at the home to obtain their views of the décor of the upstairs dining room. The manager should ensure that the nurse call system is accessible at all people living at the home at all times. The manager should ensure that work continues to make sure that at least 50 of the staff team are at least NVQII qualified. 2 3 4 5 6 YA20 YA23 YA40 YA24 YA29 YA32 Roop Cottage DS0000006207.V306687.R01.S.doc Version 5.2 Page 28 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 © 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. Roop Cottage DS0000006207.V306687.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. 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