This inspection was carried out on 19th September 2005.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.
CARE HOMES FOR OLDER PEOPLE
Roughcote Hall Farm Roughcote Lane Caverswall Stoke On Trent Staffordshire ST11 9ET Lead Inspector
Wendy Snell Unannounced Inspection 19th September 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 Roughcote Hall Farm DS0000005101.V251890.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. Roughcote Hall Farm DS0000005101.V251890.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Roughcote Hall Farm Address Roughcote Lane Caverswall Stoke On Trent Staffordshire ST11 9ET 01782 397440 01782 777299 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) Mrs Yvonne Pointon Mrs Yvonne Pointon Care Home 3 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (3), Old age, not falling within of places any other category (1) Roughcote Hall Farm DS0000005101.V251890.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. LD- Minimum age 43 yrs on admission 1 OP relates to current occupancy only Date of last inspection Brief Description of the Service: Roughcote Hall Farm is a large detached property set in seven acres, situated on the outskirts of Stoke On Trent. It is located in a rural area and there are no transport links. The home uses its own transport to reach community facilities and services. The home has a dog and cat and each of the residents take a great interest in them and assist in their day-to-day care. The home is registered for three residents and at the time of this unannounced Inspection. A fourth service user was having a short stay. This had been agreed by the Commission for Social Care Inspection (CSCI). The owner (Mrs Yvonne Pointon) has completed a variation proposal for consideration by CSCI to increase the number of residents to six. The Proprietor and her husband live on site. Roughcote Hall Farm is a large, comfortable family home that has been adapted to provide suitable facilities. On the ground floor, there is a large kitchen/diner, a lounge and conservatory, a separate toilet, laundry room and a two single bedroom, one of which has en-suite facilities. There are two staircases to the first floor one of which has a stair lift in place. On the first floor, there are two single bedrooms and a separate shower room. Roughcote Hall Farm DS0000005101.V251890.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection on a Monday morning. There was a senior support worker and a support worker on duty. The registered manager was off duty. There were four service users present throughout the inspection. All were spoken to about living at Roughcote Hall Farm. A tour of the building was carried out during the inspection. A sample of care files and staff files as well as health and safety recordings were also looked at. The staff on duty were helpful throughout the inspection. There are no outstanding complaints in relation to this home. CSCI are currently considering a proposal by the proprietor to increase the number of service users from three to six. What the service does well:
This is a very comfortable home where staff have good relationships with the service users. All service users were positive about living at the home and about the support they receive from staff. One service user said that the staff ‘are marvellous’. The staff were seen to interact with service users in a positive and friendly way spending time listening and talking together and planning the day. The proprietor of the home has a dog and a cat which one service user, was noted to enjoy spending time with. The staff demonstrated a good understanding of the service users needs and family support networks. The home has a small stable staff team who offer consistent care and support to service users. The home is set in a peaceful rural location. There are extensive grounds, which the service users are able to safely access. Roughcote Hall Farm DS0000005101.V251890.R01.S.doc Version 5.0 Page 6 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. Roughcote Hall Farm DS0000005101.V251890.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 Roughcote Hall Farm DS0000005101.V251890.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 The home has assessments of service users’ needs, which enable staff to support them appropriately. EVIDENCE: A random sample of three service user’s files were inspected. This included a service user who had been recently admitted to Roughcote Hall Farm. Appropriate care management assessments were in place. Roughcote Hall Farm DS0000005101.V251890.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&9 The care planning, risk assessment and medication systems needs to be more robust and detailed to demonstrate how the home is meeting service users needs and keeping them safe. EVIDENCE: Care plans were in place. The care plans consisted of pre completed forms. Care staff had added information or amended the form to fit the identified needs of the service users. The care plans offered basic information and would benefit from further detail as it was noted that some information contained within the assessment documentation was not evident in the care plan. Care plan agreements were noted to be within the file however all service users had not completed these. Care plans should demonstrate how all aspects of care are being delivered and must be drawn up in consultation with service users. There was evidence that the care plans are reviewed. These points were discussed with a senior member of staff at the time of the inspection. Some individual risk assessments were in place and risks were highlighted within the care planning process. However, there were areas of identified risk
Roughcote Hall Farm DS0000005101.V251890.R01.S.doc Version 5.0 Page 10 for which there was no risk assessment or risk management strategy in place. The home did have a separate file this contained environmental risk assessments which addressed identified risks and appropriate management strategies. The need for robust individual risk assessments was recommended in the last inspection report and was also discussed with a senior member of staff at this visit. Some of the areas identified during this visit were the use of the stairs, visual impairment, epilepsy, diet and obesity this list is not exhaustive. The need for robust assessments must now be addressed to ensure that staff are consistently aware of how to keep service users safe. Medication is stored within a locked cabinet. It was noted that the medication administration records (mar) were stored within each service users care file. A gap in recording was noted and brought to the attention of the senior member of staff. Medication recording must take place at the time of medication administration to guard against potential errors or mishandling. The home should consider storing mar sheets in a separate file for ease of use. This will be a recommendation. Staff stated that, in general the senior members of staff administer medication but there are times when other staff members have to carry out this task. It was noted that not all staff have received medication training. Staff must not administer medication unless appropriately trained to do so. Roughcote Hall Farm DS0000005101.V251890.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): 13 Service users are encouraged to maintain contact with their families and friends. EVIDENCE: Three of the four service users were spoken to about their contact with friends and families. One service user spoken with said that she had a lot of contact with her family. She said that she visits them or they visit her. She also had a payphone within her bedroom, which she used on a regular basis. She said that visitors can visit her whenever they want and that they are made to feel welcome. It was noted that the number symbols had worn away on the telephone keypad. It is recommended that these are replaced. Two other service users were spoken to both stated that they had received visitors whilst at the home and that they can choose to see their visitors in private. A senior staff member demonstrated a good understanding of the family networks of each of the service users and stated that visitors are encouraged and made to feel welcome. Roughcote Hall Farm DS0000005101.V251890.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): 16 The home has a satisfactory complaints system with some evidence that service users feel that their views are listened to and acted upon. EVIDENCE: The home has a complaints procedure and a complaints book. There was information regarding how to make a complaint on the wall in the kitchen area. This included information of how to contact CSCI. A previous inspection confirmed that information regarding how to make a compliant is included within the home’s statement of purpose. One service user spoken with about the complaints procedure said that she would know how to complain. Roughcote Hall Farm DS0000005101.V251890.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): 19 7 24 The home offers a good standard of accommodation to the service users. EVIDENCE: Roughcote Hall Farm is set in a rural location and provides a spacious and comfortable environment that has been adapted to provide suitable accommodation and facilities. There is a pleasant patio area with seating situated close to the conservatory and the expansive grounds surrounding the home are also accessible to service users. The environment is very homely and domestic in nature, being shared by residents and the Registered Proprietor/ Manager who lives on the premises. The service users spoken with said that they were happy living at the home and liked their bedrooms. There are presently two bedrooms on the ground floor one of which has en-suite facilities. It was noted that the second bedroom on the ground floor did not have a door lock or a handle. This was brought to the attention of the senior member of staff and must be addressed. There are two staircases to access the bedrooms on the first floor one of which has a stair lift.
Roughcote Hall Farm DS0000005101.V251890.R01.S.doc Version 5.0 Page 14 The proprietor has submitted a proposed variation to CSCI to make some alterations to the premises to increase the number of residents from three to six. There are ongoing discussions between the proprietor, CSCI and fire authority in respect of this proposal. Roughcote Hall Farm DS0000005101.V251890.R01.S.doc Version 5.0 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 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): 29 The home’s recruitment and vetting process is not sufficiently robust to safeguard service user’s. EVIDENCE: Three staff files were inspected. A recently appointed member of staff had an appropriate CRB clearance and two references; an application form, job description and contract were also in place. Another member, whilst all other checks were in place only had one written reference within the staff file. A volunteer who a senior staff member stated ‘helped out as and when needed’ also did not have a CRB or references within her staff file. The senior staff member said that CRB’s and references were in place for this person. These, however, could not be located at the time of the inspection. Evidence that appropriate measures are being taken during the recruitment process to safeguard service users must be available at all times. Roughcote Hall Farm DS0000005101.V251890.R01.S.doc Version 5.0 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 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): 38 The health and safety monitoring is satisfactory however fire training for all staff needs to be implemented. EVIDENCE: A fire risk assessment was in place. There was evidence that regular fire drills and tests take place. The service user’s within the home were aware that they had to leave the building when the alarms sounded and that staff would support them to do this. The senior member of staff confirmed that she had recently received fire training. Another member of staff who has recently started work within the home said that she had been made aware of the fire procedures during her first week. She had not, however, received formal training. This must be addressed. The home has had a recent fire officer’s visit. CSCI understands that the alarm system within the home is to be upgraded. Water temperatures are regularly tested. The fridge and freezer temperature
Roughcote Hall Farm DS0000005101.V251890.R01.S.doc Version 5.0 Page 17 are monitored. It was noted that these had not been completed for a week and this was brought to the attention of the senior member of staff. Environmental risk assessments were in place for areas such as hot water, absence of fire signs and hot radiators. Individual risk assessments are discussed in standard 7 of this report. There was evidence that the gas system had been appropriately serviced. An up-to-date insurance certificate was not displayed at the time of the inspection. However, it has now been confirmed that insurance documentation was in place but replacing the old certificate had been overlooked. This has now been addressed. Roughcote Hall Farm DS0000005101.V251890.R01.S.doc Version 5.0 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 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 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 x x x x 2 x x STAFFING Standard No Score 27 x 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x x x 2 Roughcote Hall Farm DS0000005101.V251890.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? YES 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 OP33 Regulation 24 Requirement The quality assurance system must be fully implemented and outcomes reported to the Commission. (Previous timescale 31.03.05 not met) All staff who work within the home whether paid or unpaid must have the appropriate checks as outlined in schedule 2 of the Care Homes regulations 2001. All staff must receive fire training. All staff who administer medication must receive medication training. The bedroom door on the ground floor must have a door handle and lock. Individual risk assessments and risk management strategies must be in place for all areas of identified individual risk. Timescale for action 31/01/06 2 OP29 19(1)(a)( b) 19/09/05 3 4 5 6 OP38 OP9 OP24 OP7 23(4)(d) 18(1)©(i) 12(4)(a) 13(4)© 20/11/05 19/09/05 20/11/05 20/11/05 Roughcote Hall Farm DS0000005101.V251890.R01.S.doc Version 5.0 Page 20 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 2 3 Refer to Standard 9 7 19 Good Practice Recommendations The home should consider implementing a medication file for all individual medication sheets. Care plans would benefit from further detail regarding how the day-to-day care is to be carried out. The numbers on the telephone in the service users bedroom are worn away and therefore need to be replaced. Roughcote Hall Farm DS0000005101.V251890.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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