Inspection on 11/05/06 for Royley House

This inspection was carried out on 11th May 2006.

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.

Other inspections for this house

Royley House 15/11/06

Royley House 14/09/05

Royley House 18/04/05

Royley House 15/11/04

Royley House 28/04/04

Royley House 28/01/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Royley House Lea View Royton Oldham OL2 5ED Lead Inspector Carol Makin Unannounced Inspection 11th May 2006 09:00a 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 Royley House DS0000005518.V291074.R02.S.doc Version 5.1 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. Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Royley House Address Lea View Royton Oldham OL2 5ED 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) 01616334848 01616339191 Roche Care Limited Mrs Jane Ann Archer Care Home 41 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (41), of places Physical disability over 65 years of age (10), Sensory Impairment over 65 years of age (5) Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 41 OP, up to 15 DE (E), up to 10 PD (E) and up to 5 SI (E). 14th September 2005 Date of last inspection Brief Description of the Service: Royley House was opened in October 2000 and is a purpose built residential care home for 41 older people. The home is located off Middleton Road in Royton and is close to shops and amenities. Accommodation is provided over two floors, both floors having separate lounges, dining rooms and bathrooms. All bedrooms are spacious, single rooms and many provide en-suite facilities. Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by two Inspectors on 11th May 2006. The inspector’s spoke with some of the residents, and members of staff, carried out an inspection of the premises, and examined records. Some of the requirements, which were made as a result of previous inspections, had been fully addressed, others required further improvement to achieve full compliance with the National Minimum Standards and the Regulations, and there were those for which no progress had been made. Verbal feedback of the findings of the inspection was given to the registered manager, and the deputy manager at the end of the visit. What the service does well: What has improved since the last inspection? The statement of purpose and service user guide had been amended since the last inspection, which improved the information available to prospective residents to assist them in making an informed choice about where to live. There had been a significant improvement in the procedures used for recruiting new staff, making the process safer, and providing some protection for residents. Lounge areas and some bedrooms had been redecorated since the last inspection, and the accommodation in general looked very smart. During that time a small ‘smokers lounge’ had been created by fully enclosing an area at the bottom of the main dining room. An increase was noted in the provision of training for staff, which covered a range of topics. Royley House DS0000005518.V291074.R02.S.doc Version 5.1 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. Royley House DS0000005518.V291074.R02.S.doc Version 5.1 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 Royley House DS0000005518.V291074.R02.S.doc Version 5.1 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): 1, 2 & 3 Quality in this outcome area is poor. Information is available to prospective residents to enable them to make an informed choice about where to live, but contracts were not signed to provide a legal basis for their conditions of residency. Comprehensive assessments of prospective residents care needs are not consistently completed before they move into the home, and management are therefore unable to ensure that the home is able to meet residents’ needs. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The statement of purpose and service user guide had been amended since the last inspection, to provide prospective residents with the information they need to make an informed choice about where to live. Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 9 Contracts of residency were in place on the 3 files, which were inspected, but 2 of the contracts had not been signed by the residents or their advocate. One of the files inspected contained a comprehensive summary of assessed needs which had been faxed to the home prior to the prospective resident being admitted. There was, however no reference to the assessment in the file, or care plans to meet the needs identified in the summary, to indicate that the home had utilised the information. (See standard 7). The pre admission assessment on another file contained only very basic information. The needs of prospective residents must be fully assessed and utilised, to enable the management of the home to form a judgement about whether the needs can be met at the home. Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 10 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, 9 & 10 Quality in this outcome area is poor. Assessments, care planning, and reviews of residents health and social care needs was inadequate, and needed to be improved to ensure that the health and welfare of residents is protected and promoted at all times. Some further improvement was needed in relation to recording of medication administration, to ensure safety for the residents. Residents were treated with respect and their rights to privacy were upheld. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The care files for 3 residents were case tracked during the inspection. Two of the residents were admitted earlier this year (2006), and the third was admitted to the home early in 2004. Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 11 The inspectors noted that there had been a general deterioration in care planning during the period since the last inspection. The majority of assessed needs within the 3 files that were seen, did not have a corresponding plan of care to provide guidance for staff, in meeting those needs. As noted in relation to standard 3, in one of the files there was no reference to, or acknowledgement of, the care management assessment, which included several specific health care needs, e.g. pressure areas, dietary needs. In the 2 newer care files, assessments and care plans that were available were incomplete and inadequate, e.g. no assessments or care plans regarding moving and handling, falls, nutrition or skin. The older care file had no care plans for basic needs, and only one care plan, which was for a specific need, was well written. There was a lack of reviews/ evaluations on the file, and care plans that were there, were not up to date. When giving feedback to the manager and the deputy later, this care plan was referred to by the inspector as an example of a satisfactory care plan, to assist them in improving care planning. There were no references to activities, socialisation, or preferences, on any of the files seen. In addition to the lack of some health care assessments previously noted, there were also concerns about other health care issues, e.g. on one file there had been no response by the home when weight records for the resident showed a significant weight loss. A nutritional risk assessment had been done for this resident, but there was no corresponding care plan. All of these issues were fed back to the manager and her deputy. There was detailed discussion about the inadequacy and poor standard of care planning and documentation, and the inspectors stressed their concern about this. The manager said that she had trained senior care staff in care planning, but she had not undertaken any auditing of plans to assess the quality. The manager and her deputy were advised that they needed training regarding care planning, and that a requirement would be made accordingly. Medication was checked and found to be in order, with the exception of the following: hand written information on medication administration record (MAR) sheets had not been signed or dated, (outstanding from the last inspection), and details of the actual nebulising solution prescribed must be recorded on the MAR sheets rather than the word ‘neb’. Overall residents felt that they were treated with respect, and that their rights to privacy and dignity were upheld in the home. One resident described staff as being “quite pleasant”, and confirmed that they were helpful and respectful, another resident said, “staff look after me, there’s no bullying here”. Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 12 Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 13 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): 12, 13, 14, 15. Quality in this outcome area is good. Activities are limited providing residents with insufficient opportunities to be stimulated and fulfilled. Residents were able to maintain contact with relatives and friends, providing them with links with the wider community. There was evidence that residents were offered a wholesome and varied diet, and that they were able to exercise control over their diet. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Residents were indifferent about the provision of activities in the home, their comments included, “There’s bingo and some days arm chair exercises”, “No activities - I’m not interested – there’s bingo”, another resident said that she didn’t really “get involved in activities”, but she did “play ball sometimes”. Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 14 The manager informed the inspectors that the Activities Organiser was off sick at the time of the inspection, and as she had taken the ‘Activities file’ home with her, they were unable to provide any written information about the activities programme for inspection. Action must be taken to improve the provision of activities/entertainment to provide stimulation and enjoyment for the residents. Residents confirmed that visitors were able to visit when they liked. Comments from residents included, “I have lots of visitors”, “ my sister and my daughter visit and take me out for the day”, “my son visits a lot”. The routine was said to be flexible, one resident said, “we do what we want”, and comments about the food were favourable, e.g. “the food is good, I have a good appetite”,” I can’t grumble at the meals, if you don’t like it just tell them and they’ll do what they can”, “you pick what you want, I’m having a jacket potato”. Breakfast was observed at 9.0am. It was served in the dining room, which was very pleasant with tables set much like a restaurant, i.e. cups and saucers, milk jugs and sugar bowls, porridge/cereals, orange juice and tea. Staff were wearing gloves and aprons. The deputy manager was giving out medication. Lunch was at 1pm, tea was at 5pm, and supper was at residents’ choice. The dining rooms were attractively presented, residents were treated with courtesy, meals were nicely served, and assistance was provided discretely. Staff were observed offering drinks frequently throughout the day, which was particularly beneficial as the weather was warm and sunny. Notices displayed in the home advertised that snacks and drinks were available for residents and visitors at any time. Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 15 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 & 18 Quality in this outcome area is good. Information about the procedure for making complaints had been clarified and was displayed in the home, to ensure that all interested parties would know how to make a complaint. Further training had been provided for staff in relation to the protection of vulnerable adults from abuse, to improve measures within the home, for protecting residents from possible risk of harm. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home’s complaints procedure was on display at the entrance to the home, and was included in the statement of purpose, and contracts of residency. One resident said, “I’m quite happy to tell someone if I’m not happy, I’d tell Irene” (the deputy manager). A complaints log was kept, which showed that 2 had been made since the last inspection. A separate report was available regarding each complaint, including action taken by the home in response to the complaints, and copies of correspondence to the complainants informing them of the outcome. Much progress has been made in relation to this standard which has now been met. Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 16 Since the last inspection training regarding ‘Identifying Abuse’, had been provided for a further 15 members of staff. The manager said that only new staff coming into the home now needed this training. A POVA investigation, which was being carried out by Oldham Social Services, had not been concluded at the time of the inspection. Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 17 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 & 26 Quality in this outcome area is good. The accommodation was clean and decorated to a satisfactory standard, and residents were able to benefit from a programme of routine maintenance and renewal of furniture and fittings. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Standards of cleanliness within the home continued to be maintained, and no unpleasant odours were detected. A programme of redecoration continued to be implemented with lounges having been redecorated since the last inspection, and in general, the environment looked very smart. During that time a small ‘smokers lounge’ had been created by fully enclosing an area at the bottom of the main dining room. Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 18 The bedrooms inspected were personalised to varying degrees according to residents’ choice, including some items of their own furniture. The rooms were decorated and furnished to a good standard, and some rooms had been redecorated since the last inspection. Comments from residents included, “It’s a lovely bedroom, everything is very nice here”, “ my bedroom’s like a museum. I’ve got lots of my own stuff in there.” Aids to independence were provided in bathrooms and toilets, and there was ramped access to the property. The only matter relating to the environment, which was noted on this inspection as requiring attention, was a problem with the hot water supply to one of the bedrooms. The manager said that so far, contractors’ attempts to resolve the problem had failed, but further investigations were to be made to regarding this matter. Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 19 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): 27, 28, 29 & 30 Quality in this outcome area is good. There had been a significant improvement in the procedures used for recruiting new staff, making the process safer, and providing some protection for residents. Staffing levels within the home were sufficient to meet the needs of the residents, and there had been an improvement in staff training, which included some specialist training relating to the categories of need for which the home is registered. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The information, which was obtained for the inspection, indicated that staffing levels within the home at the time of the inspection met the standards, and were sufficient to meet the needs of the residents. One member of staff commented, “ We have been short staffed a lot but we’re ok’ now. “Upstairs is very busy - the residents are very dependent”, “staffing is usually 4 care assistants, 2 senior care assistants, and the deputy manager”. In discussion with the manager, she reported that the programme of NVQ training was continuing, and new staff were being employed on the understanding that they enrol to undertake the training. Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 20 A training programme for the period November 2005 to October 2006 was in place. The programme included some specialist training relating to the categories of need for which the home is registered, i.e. osteoporosis and falls, dementia & challenging behaviour, principles of transferring, toe nail cutting, and oral health, together with identifying abuse (See S18), and some safe working practices (See S38). Deletions had also been made in the programme to show where staff had not attended training. Records showed that new staff were receiving some basic induction training in house, which was monitored by the deputy manager on a weekly basis. The manager said that she was trying to obtain a new format for induction training from ‘Skills for Care’ to meet the national minimum standards. It was however noted that new staff had been included in the general training programme. At interview a new member of staff said that induction training was mainly observing, and added, “I can help with some things such as feeding, but I haven’t had lifting training so I can’t do much until I have it”. She had seen policies, and had worked on both floors. Other comments made by staff about induction included “It’s not intense training”, it involves “shadowing someone”, “the induction was shadowing another carer & reading policies and procedures”. A more structured and formal induction programme was needed, which meets the NTO standards. The staff files which were inspected, contained POVA first checks and written references, which had been obtained prior to employment commencing. This demonstrated a significant improvement in recruitment practices, but the manager must ensure that specific dates of previous employment are noted on the application form, and that all documentation is signed and dated. Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 21 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, 35, 36, 37 & 38 Quality in this outcome area is poor. Management and administration systems are in place, but are not consistently adhered to by the manager, resulting in the home not being well managed or run in the best interests of the residents. The health, safety and welfare of residents’ continues to be compromised by the failure of the management to recognise the importance of providing satisfactory assessments, care plans, and reviews. This judgement has been made using available evidence including a visit to the service. Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 22 EVIDENCE: Training was continuing for the manager regarding the Registered Manager’s Award, which she said was due to be completed in July 2006. Some of the requirements which were made as a result of previous inspections had been fully addressed, others required further improvement to achieve compliance with the National Minimum Standards and the Regulations, and there were those for which no progress had been made. The continued failure to provide satisfactory assessments, care plans, and reviews of residents’ health and social care needs potentially places them at risk, and has an impact on standard 31. At interview a member of staff said “it is hard now for seniors, we have to do all the appraisals and care plans, and work on the floor for the residents”, “there is no time for paperwork when we are caring”. When this was fed back to the manager she denied this was true, saying that they had plenty of time to do it. The manager should review staff work loads, and distribution of staff. The inspectors spoke with 4 members of staff. One member of staff said that manager was supportive, and staff morale and team work were good. Another member of staff also said that team work was good, but felt that management was “not always constructive”, and that in her opinion there was “not enough recognition of the good work”, and staff were “always criticised”. Staff meetings were held for senior carers, and 2 for carers in November 2005 and February 2006. Records stated that meetings had not been held for night carers, domestic and catering staff. When asked about this the manager said that they attended general staff meetings. There was, however no information to indicate that these meetings had taken place. A satisfaction survey was carried out in 2005, and the manager said that a further survey would be done later this year (2006). The manager and her deputy had completed a pro forma for a management review, but it was undated. Various other internal audits had also been done, one of which showed the month when procedures needed to be reviewed, which had been initialled when completed. An individual audit report in relation to a ‘Residents Committee’ dated 24/1/06 stated, “Meetings held erratically, to be held on a new, regular basis”. On speaking to the manager about this she said that the activities organiser had held 2 meetings this year, but had not given any notes to her, and had since gone off sick. The manager said that she had subsequently arranged for care staff to do them. Improvements were needed to the home’s system of quality monitoring to ensure that all members of staff and residents have an opportunity to voice their opinions and have a say in the running of the home, and that all activities in relation to this are properly recorded. Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 23 Recording in relation to staff supervision was poor, with the majority of records in the 8 supervision/appraisal files seen, being unsigned and/or undated. Supervision contracts showed dates when supervision was to take place but with no documentary evidence to demonstrate that it had done so, e.g. 1 file seen contained blank supervision record sheets. Appraisals were noted on the files for 2 members of staff. Only 1 of the 2 appraisals on each file was dated, therefore providing no indication of the frequency of appraisals. Some records, which are required by statute, did not meet the standard, as noted previously in this report when reporting on standards 3,7,8 and 9. Reports of visits to the home made by the registered person, in accordance with regulation 26, had not been sent to the Commission for Social Care Inspection every month as agreed with the owners, although the missing reports were provided during the course of the inspection. In relation to training in safe working practices, the training programme showed that 9 members of staff had received training in moving & handling since the last inspection. Infection control, food hygiene, health & safety and first aid training were not included in the programme. The manager said that 5 staff had current first aid certificates which was enough for 1 per shift, and she would check to find out when the other areas of training were due to be updated. A record of the information should be kept. Fire precautions records showed that the relevant tests and checks of equipment and means of escape from fire had been completed as required. The accident book showed that approximately 50 accidents/ incidents had occurred during the period 21/2/06 – 14/4/06. It was noted that 18 falls were recorded for one resident. A comprehensive care plan was available on the residents file in response to falls. On discussing this with the manager she informed the inspectors that she was monitoring the situation, and had taken action e.g. provided staff training regarding ‘falls’, involved the NHS falls assessor, residents’ families and social workers. Some reports were available of services, call outs and repairs to the passenger lift, but all copies need to be kept, and there was no evidence that the lift had been independently inspected at 6 monthly intervals as required. Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 24 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 3 2 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 2 1 1 2 Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 25 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 OP2 Regulation 5 Requirement Timescale for action 30/06/06 2. OP7 9,18 3. OP7 15 The registered person must ensure that residents are provided with a fully completed statement of terms and conditions of residency, which they have signed, or has been signed by an advocate on their behalf. (Previous timescale of 30/09/05 not met). The registered person must 31/08/06 ensure that the registered manager and the deputy manager receive training in relation to assessment and care planning. The registered person must 20/06/06 ensure that residents’ health and social needs are fully assessed, and corresponding care plans are completed and reviewed, to provide guidance for care staff in meeting those needs. (Previous timescales for action not met. Timescale from last inspection 30/09/05). Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 26 4. OP8 12,13,14, 15 5. OP8 12,13,14, 15 6. OP9 17 (1)(a) 7. OP9 17 (1) (a) 8. OP12 16 9. OP25 13,23 10. OP30 12,18 The registered person must ensure that residents’ weight is monitored, and any concerns investigated. (Requirement not fully met within the previous timescale of 30/09/05). The registered person must ensure that nutritional screening is carried out routinely, and records regarding the provision of personal care for residents are fully completed. (Previous timescale of 30/09/05 not met). The registered person must ensure that handwritten medication details are signed and dated. (Requirement not fully met within the previous timescale of 30/09/05). The registered person must ensure that specific information about the actual nebulising solution prescribed is recorded on the medication administration record sheet. The registered person must ensure that action is taken to improve the provision of activities/entertainment for the residents. The registered person must ensure that the hot water supply in residents’ bedrooms is fully functional, and that the temperature is monitored to ensure safety. The registered person must ensure that a staff induction programme, which meets the National Training Organisation (NTO) workforce training targets, is implemented. (Requirement not fully met within the previous timescale of 01/11/05). DS0000005518.V291074.R02.S.doc 20/06/06 20/06/06 20/06/06 20/06/06 30/06/06 01/07/06 01/07/06 Royley House Version 5.1 Page 27 11. OP33 24 12. OP36 18 13. OP37 26 14. OP38 13 15. OP29 19 The registered person must ensure that an effective quality audit system is provided, which enables all residents and members of staff to voice their opinions and have a say in the running of the home, and that all activities in relation to this are properly recorded. The registered person must ensure that staff are supervised and supported in accordance with the National Minimum Standards, and that records of supervision/appraisal are kept accordingly. (Previous timescale of 30/09/05 not met). The registered person must ensure that monthly reports done in accordance to regulation 26 must be forwarded to the Commission for Social Care Inspection. The registered person must ensure that all reports of services, call outs and repairs to the passenger lift, and 6 monthly independent inspections of the lift, are available for inspection by the Commission for Social Care Inspection. The registered person must ensure that job application forms are fully completed and include more detailed information about dates of previous employment. 01/08/06 20/06/06 20/06/06 01/07/06 30/06/06 Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 28 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 OP35 OP27 OP38 Good Practice Recommendations The registered person should ensure that 2 signatures are provided against entries on the residents’ personal allowance record sheets. The registered person should ensure that the distribution of staff and staff work loads are reviewed. The registered person should ensure that a record is kept of the dates when training regarding safe working practices needs to be updated. Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Royley House DS0000005518.V291074.R02.S.doc Version 5.1 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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