CARE HOMES FOR OLDER PEOPLE
ROTHERWOOD RESIDENTIAL HOME Doncaster Road Rotherham South Yorkshire S65 2DA Lead Inspector
Robert Curr Unannounced 12 May 2005 09:00. 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 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. ROTHERWOOD RESIDENTIAL HOME J55-J07 S3108 Rotherwood V213949 120505 Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Rotherwood Residential Home Address Doncaster Road Rotherham South Yorkshire S65 2DA 01709 820025 01709 820025 None Heltcorp Limited 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) Mrs Margaret Morton CRH Care Home 24 Category(ies) of Old Age 24 registration, with number of places ROTHERWOOD RESIDENTIAL HOME J55-J07 S3108 Rotherwood V213949 120505 Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1. One specific service user over the age of 65, with learning disability, named on variation dated 17 December 2004, may reside at the home. Date of last inspection 14 January 2005 Brief Description of the Service: Rotherwood provides care for amaximum of 24 older people with varying degrees od dependency, within a domestic type setting, which has accommodation on three levels. The home has apassenger lift to facilitate access within the home. The home has seating areas outside of the home for residents to use if required. The accommodation is close to shops, and has other local facilities close by, particularly Clifton park, which is popular with a number of service users. ROTHERWOOD RESIDENTIAL HOME J55-J07 S3108 Rotherwood V213949 120505 Stage4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place from 9.00hrs to 16.00hrs. The inspection process included a tour of the premises, inspection of a sample of records and policies, discussions with staff, residents and relatives and observation of staff carrying out their duties. The majority of residents and staff were seen during the inspection and the inspector had the opportunity to speak to three staff and three residents in some detail. What the service does well: What has improved since the last inspection?
The manager has completed the Registered Managers Award. Some refurbishment and redecoration had taken place within the home and further equipment had been supplied to the kitchen. ROTHERWOOD RESIDENTIAL HOME J55-J07 S3108 Rotherwood V213949 120505 Stage4.doc Version 1.30 Page 6 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. ROTHERWOOD RESIDENTIAL HOME J55-J07 S3108 Rotherwood V213949 120505 Stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection ROTHERWOOD RESIDENTIAL HOME J55-J07 S3108 Rotherwood V213949 120505 Stage4.doc Version 1.30 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 standard(s) 3 and 5 Resident’s records included a detailed assessment of their needs, which ensured that staff had all the required information to decide if they could meet the needs of the resident. EVIDENCE: Three care plans included assessments carried out by staff at the home, and information from the placing authority. Three residents stated that they had been asked for information prior to their admission. ROTHERWOOD RESIDENTIAL HOME J55-J07 S3108 Rotherwood V213949 120505 Stage4.doc Version 1.30 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 standard(s) 7, 8, 9, 10 and 11 The care planning system was not always sufficient to enable staff to deliver the care to residents who had specific identified risks. Residents must be given the opportunity to agree and sign their care plan, so that they are fully aware of the care they can expect to receive. Arrangements for dealing with service users health issues were adequately met by staff at the home. Staff have the necessary skills and knowledge to ensure service users are treated with respect and dignity. EVIDENCE: A number of care plans were examined and they contained sufficient information to enable staff to deliver the required care to residents. The plans were reviewed monthly although not all the care plans had been updated as required. One residents care needs had changed considerably and the documents examined did not reflect the changes. This may result in inconsistencies when delivering care. Not all care plans were signed on behalf
ROTHERWOOD RESIDENTIAL HOME J55-J07 S3108 Rotherwood V213949 120505 Stage4.doc Version 1.30 Page 10 of the residents, and a resident stated that he had not signed his care planning documents. Risk assessments examined were not always comprehensive or up to date, which potentially could endanger the health and welfare of individuals. There was clear evidence that resident’s healthcare needs were met. An audit of the medication records was undertaken and the residents health and safety was maintained in that all medication administered had been signed for. During the inspection there were examples of good practice by staff and there were good interactions between staff and residents and the visiting relatives. Resident’s wishes regarding dying and death were recorded. ROTHERWOOD RESIDENTIAL HOME J55-J07 S3108 Rotherwood V213949 120505 Stage4.doc Version 1.30 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 standard(s) 12, 13, 14 and 15 Residents were not happy with the activities and outings. The manager needs to review the activities programme in order to enhance the residents lifestyle experience. Mealtimes were well managed and the facilities promote a calm environment with dining areas to accommodate all service users. There were clear visiting policies and procedures to ensure that residents can maintain contact with their family and friends. Residents are encouraged to bring in personal items of furniture and ornaments to help them settle into their own bedroom. EVIDENCE: Visitors to the home praised the staff and confirmed that they liked to visit their relative in the main lounge, while others preferred to see their relative in their own bedroom. ROTHERWOOD RESIDENTIAL HOME J55-J07 S3108 Rotherwood V213949 120505 Stage4.doc Version 1.30 Page 12 Residents receive support from other people visiting the home, e.g. hairdresser, optician, chiropodist and representatives from the local church, maintaining contact with the local community. A partial tour of the building provided evidence that service users were able to personalise their bedrooms, many had brought in small items of furniture and pictures of their family. The mealtime was well organise and the inspector was able to observe residents being assisted with their meal where required, and the atmosphere was calm. Staff were unhurried and there were sufficient numbers to ensure those residents who were being cared for in their bedroom were taken a meal that looked appetising. ROTHERWOOD RESIDENTIAL HOME J55-J07 S3108 Rotherwood V213949 120505 Stage4.doc Version 1.30 Page 13 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 standard(s) 16, 17, and 18 Residents are provided with information to enable them to raise concerns about the home and their care. Adult Protection Policies and Procedures and training of staff ensure the protection of residents from abuse. EVIDENCE: There was a complaints procedure that is available to residents. The procedure is also referred to in the service user guide, identifying the stages to follow; this includes the time scaled to respond to complaints. The address and telephone number of the Commission for Social Care Inspection is included in the procedure. The inspector examined the complaints records. There had been one complaint since the last inspection, which had been dealt with appropriately, offering the person a satisfactory outcome. Several other residents said they would ‘’tell the manager if they were upset about something’’. One resident told the inspector that he had recently used the postal voting system. There was an Adult Abuse and Whistle blowing Policy. The manager investigates fully any allegations of abuse and would follow the necessary procedures if they were substantiated. There are discussions with the staff to talk over issues and how to recognise different forms of abuse.
ROTHERWOOD RESIDENTIAL HOME J55-J07 S3108 Rotherwood V213949 120505 Stage4.doc Version 1.30 Page 14 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 standard(s) 19, 21, 22, 23, 24, 25, and 26 There were sufficient bathing facilities but one bathroom was being used to store spare equipment and therefore not available for residents to use. A call system was available in all rooms used by the residents so that they could summon assistance at all times. There was a hole under the carpet outside one of the bathrooms that needed to repaired immediately to ensure the safety of the residents EVIDENCE: All residents spoken to were happy with their bedrooms and the furniture provided. A lack of storage space was evident as one of the resident’s bathrooms were being used to store spare equipment. ROTHERWOOD RESIDENTIAL HOME J55-J07 S3108 Rotherwood V213949 120505 Stage4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, and 30 There were no staff vacancies at the time of the inspection, which assists in maintaining continuity of care for the residents and their well-being. The manager could identify the training needs of the staff and 85 of the staff were qualified to NVQ level 2 standard. This achievement ensure that residents are cared for by competent and well trained staff. EVIDENCE: Staff rotas examined showed sufficient staff were employed to meet the needs of the residents. A number of staff recruitment files were examined and discussed with the person in charge, and there was evidence that all the required employment checks had been undertaken prior to staff commencing their employment at the home. Some staff that had achieved NVQ level 2 were working towards achieving a higher award. ROTHERWOOD RESIDENTIAL HOME J55-J07 S3108 Rotherwood V213949 120505 Stage4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, 36, 37, and 38 The registered manager had the required skills and competencies to ensure the safety and protection of the residents. Health and Safety policies are in place for the health, safety and welfare of those individuals who work and live at the home although not all risk assessments were up to date. Fire drills were incomplete that indicated that not all staff had undertaken a fire drill practice. The lack of this experience could endanger the lives of staff and residents. Staff supervision takes place at the recommended frequency, which enhances the care of the residents. ROTHERWOOD RESIDENTIAL HOME J55-J07 S3108 Rotherwood V213949 120505 Stage4.doc Version 1.30 Page 17 EVIDENCE: The registered manager has been in post for a number of years and has recently completed the NVQ level 4 in Management. Servicing of equipment takes place within the recommended timescale and records examined provided evidence of this. Fire records were maintained of fire alarm tests, but the fire drill records indicated that some staff (including night staff) had not undertaken a fire drill practice within the last year. One member of staff was seen to mobilise a resident in a wheelchair without footplates in place. ROTHERWOOD RESIDENTIAL HOME J55-J07 S3108 Rotherwood V213949 120505 Stage4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3
COMPLAINTS AND PROTECTION 3 3 2 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 3 3 2 ROTHERWOOD RESIDENTIAL HOME J55-J07 S3108 Rotherwood V213949 120505 Stage4.doc Version 1.30 Page 19 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. Standard 7 Regulation 15 Requirement All care plans must contain the current needs of the resident and the resident must be offered the opportunity to contribute to and sign thir care plan. Residents must be consulted over their recreational and social needs. Bathrooms must not be used for the storage of spare equipment All staff must undertake a fire drill practice at least twice a year. Residents must not be transported in wheelchairs without footplates The hole in the corridor floor must be repaired Timescale for action 1/7/05 2. 3. 4. 5. 6. 12 and 14 21 38 38 25 and 38 16 23 13 13 13 1/7/05 1/7/05 1/7/05 13/6/05 13/6/05 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 Good Practice Recommendations ROTHERWOOD RESIDENTIAL HOME J55-J07 S3108 Rotherwood V213949 120505 Stage4.doc Version 1.30 Page 20 Commission for Social Care Inspection First Floor Barclay Court Heavens Walk Doncaster South Yorkshire DN4 5HZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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