CARE HOMES FOR OLDER PEOPLE
Rosslyn 29 Bagdale Whitby North Yorkshire YO21 1QL Lead Inspector
Pauline O`Rourke Unannounced Inspection 13th October 2005 10:00 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 Rosslyn DS0000007728.V258914.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. Rosslyn DS0000007728.V258914.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Rosslyn Address 29 Bagdale Whitby North Yorkshire YO21 1QL 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) 01947 820931 Mr Jeremy William Southgate *** Post Vacant *** Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Rosslyn DS0000007728.V258914.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 18th May 2005 Brief Description of the Service: Rosslyn provides long-term accommodation and personal care for a maximum of eleven older people. The home does not provide any specialist services. A stair lift in lieu of a passenger lift gives access to the first floor for residents with limited mobility and consequently the residents placed in bedrooms on the first floor have to be reasonably ambulant. The home is located on a main route into Whitby and is conveniently situated for the shops and other community facilities including the main transport network. The home does not have its own parking facilities but there is on-road parking within close proximity. Rosslyn is a traditional house with modern extension built on two floors with the communal areas and two bedrooms being located on the ground floor. One bedroom has an ensuite toilet facility. A patio with bench seats and small, sloping lawn are located at the front of the building and there is a ramp leading from the road to the main entrance for wheelchair users. The steps up to the main door have a handrail fixed to the adjacent wall to aid mobility. Rosslyn DS0000007728.V258914.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection including preparation time took place over 8 hours. A tour of the building was conducted. A number of the service users records, staff records and records about the management of the home were inspected. 5 of the 9 service users, and 3 staff on duty were spoken with. What the service does well: What has improved since the last inspection? What they could do better:
An acting manager has been in place now for last two inspections but has not made an application to be registered, this must happen now. The manager must also take action to ensure the concerns listed below are put right. The care plans seen were basic and contained no details, this means that if a new member of staff was to start they would have no understanding of the service users needs from this information. The manager needs to address the record keeping as it is disorganised and does not allow for an audit of information so that training plans can be developed. Staff should have training in the safe handling of medication, adult protection issues, National Vocational Qualification level 2 in care and any further training that allows them to develop their skills. Staff should receive supervision at least 6 times a year. The employment checks are not carried out properly and all staff new to
Rosslyn DS0000007728.V258914.R01.S.doc Version 5.0 Page 6 Rosslyn must have a Criminal Records Bureau disclosure prior to them starting work. All staff should have a contract of employment. The responsible individual has not supplied the Commission with a business and financial plan, this is outstanding from the last two inspections and should be provided now. 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. Rosslyn DS0000007728.V258914.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 Rosslyn DS0000007728.V258914.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): 3 Improvements still need to be made to the admissions process but the service users are more assured of having their needs met EVIDENCE: At the previous inspection it was noted that one service user did not have an assessment of her needs prior to her admission. The acting manager is aware she has to ensure all service users admitted to the home must have an assessment. She does try to visit prospective service users before they come to the home but does not keep a record of this visit. Rosslyn DS0000007728.V258914.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): 7, 8 and 9 The health, social and personal care needs of the service users are met, but this is not reflected in the records maintained. EVIDENCE: Two service user files were seen and one contained a very basic care plan, this did not cover all the support and assistance required by the service user. There was no indication in the plan as to the health needs, emotional, social or physical support the service user required. The care plans should provide enough detail to inform new members of staff about the level of support the individual service users need. Whilst this information is not recorded the staff were aware of what help this service user required. All the information as required by the Care Homes Regulations 2001 on a service user is maintained in different files. The manager is advised to look at this and ensure that information about one person is kept in one place. Staff have not received any training in the Safe Handling of medications. This remains outstanding from the last inspection. Rosslyn DS0000007728.V258914.R01.S.doc Version 5.0 Page 10 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): X None of these standards were assessed at this inspection. EVIDENCE: Rosslyn DS0000007728.V258914.R01.S.doc Version 5.0 Page 11 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): Staff have not had awareness training for the protection of vulnerable adults, which leaves residents’ potentially at risk. The adult protection policy and procedure do not fully inform staff of their responsibilities where abuse is suspected. EVIDENCE: There was no evidence that the requirements made at the last two inspections for staff to receive adult protection awareness training and to provide an updated whistle blowing policy, that is in line with the Department of Health’s document “No Secrets”, have been implemented. The responsible individual must as a matter of urgency ensure that this requirement is actioned. Rosslyn DS0000007728.V258914.R01.S.doc Version 5.0 Page 12 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): 19, 22 and 26 The service users live in a reasonably well decorated home, in which they are encouraged to be as independent as possible. EVIDENCE: The furniture identified at the last inspection as being of a poor standard has been replaced. One of the service users who has difficulty in communicating and who requires assistance with transfers has been given a portable doorbell so that she can attract the attention of the staff when she requires assistance. Soap and towels have been provided in the laundry. Staff are aware of the issues around hygiene when entering the laundry or the kitchen. Rosslyn DS0000007728.V258914.R01.S.doc Version 5.0 Page 13 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): 28, 29 and 30 Service users are not fully protected from possible abuse, as the recruitment policy is not properly implemented and the staff do not receive regular training. EVIDENCE: There is only one member of staff who has a National Vocational Qualification level 2. There was no evidence that any other members of staff are currently undertaking a National Vocational Qualification. Staff files seen contained a Criminal Records Bureau disclosure. However, the last member of staff employed produced a Criminal Records Bureau disclosure carried out by their current employer. Whilst this member of staff continues to be employed by that employer the manager should carry out an updated Criminal Records Bureau disclosure. The staff files seen contained no evidence of further training in support of their employment. The manager did produce evidence that the training organisation she had approached have cancelled several courses. The manager was advised to approach other training agencies to access courses for staff. Rosslyn DS0000007728.V258914.R01.S.doc Version 5.0 Page 14 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): 31, 33, 34, 35, 36 and 38. The management of the home is failing to meet the health and safety needs of the service users. EVIDENCE: A manager is in place, however, an application to register her with the Commission has not been received and this remains outstanding from the previous inspection. She has not registered on a National Vocational Qualification level 4 in Care and Management yet. The responsible individual visits the home at least once a month and these reports have been forwarded to the Commission. There was no further evidence of any quality assurance systems in place. The manager said that the service users and/or their families manage their own monies and the staff handles none.
Rosslyn DS0000007728.V258914.R01.S.doc Version 5.0 Page 15 A business and financial plan has not been supplied to the Commission. There was no evidence that staff receive any formal recorded supervision. The working relationship with the manager was seen to be positive and supervision is provided on an informal basis. Following the last inspection a fire risk assessment has been provided. The windows had been restricted to open to 8”, and adjusts have been made to the sash windows to prevent them dropping. The bath hoist has been serviced on the 3rd June 2005. These issues had been identified at he last inspection as requiring attention. Rosslyn DS0000007728.V258914.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 1 8 3 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 1 3 X X 3 X X X 3 STAFFING Standard No Score 27 X 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 1 3 1 X X Rosslyn DS0000007728.V258914.R01.S.doc Version 5.0 Page 17 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 OP7 Regulation 15(1) Requirement All service users must have a detailed care plan that includes all the help and support required by the individual concerned Ensure all staff responsible for administration of medicines receive appropriate training Previous requirement of 31.07.05 not met. Ensure service users are protected from abuse by raising staff awareness through training and amending the whistle blowing policy in line with the department of health document No Secrets Previous requirement of 31.08.05 not met. A POVA 1st check and/or a Criminal Records Bureau disclosure must be requested for new staff employed to work at the home, before they start work. Previous requirement of 16/05/05 not met. Information about staff listed in Schedules 2 and 4 of the Care Homes Regulations must be kept
DS0000007728.V258914.R01.S.doc Timescale for action 18/11/05 2. OP9 13(2) 18/11/05 3. OP18 13(6) 19(5)b 18/11/05 4. OP29 19 13/10/05 5. OP29 19 13/10/05 Rosslyn Version 5.0 Page 18 6. OP31 8, 9 7 OP33 24 7. OP34 17, 25 8 OP36 18(2) in the home. A statement of terms and conditions (contract of employment) must be agreed and issued to all staff including the manager. Previous requirement from 18.10.04 and 16.05.05 not met. The manager appointed to run the care home must be registered with the Commission. Previous requirement of 31/08/05 not met. The registered person must establish and maintain a system for reviewing the quality of care provided at Rosslyn. There must be a business and financial plan for the establishment open to inspection. Previously requirement of 16/05/05 not met The care staff must receive formal recorded supervision at least six times a year. 18/11/05 18/11/05 18/11/05 13/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP28 Good Practice Recommendations The manager should work towards achieving a 50 ratio of staff who have a National Vocational Qualification level 2. The manager should develop a training plan to ensure the staff have the skills to do their job. The manager should have an NVQ IV qualification in care and management by the end of 2005 2 3. OP30 OP31 Rosslyn DS0000007728.V258914.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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