Inspection on 14/09/05 for Royley House

This inspection was carried out on 14th 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.

Other inspections for this house

Royley House 15/11/06

Royley House 11/05/06

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 14th September 2005 09:15 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.V249724.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. Royley House DS0000005518.V249724.R01.S.doc Version 5.0 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 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.V249724.R01.S.doc Version 5.0 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). 18th April 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 toilet facilities. Royley House DS0000005518.V249724.R01.S.doc Version 5.0 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 14th September 2005. Action had been taken in relation to the requirements, which were made as a result of previous inspections. Some had been fully addressed, but others required further improvement to achieve full compliance with the National Minimum Standards and the Regulations. The inspector’s spoke with some of the residents, and members of staff, carried out an inspection of the premises, and examined records. Verbal feedback of the findings of the inspection was given to the registered manager, and Mr Athar Mahmood, at the end of the visit. What the service does well: What has improved since the last inspection? What they could do better: Care plans were required for all the needs of residents. Staff needed further training to meet the needs of residents with dementia, and some staff need training in the protection of vulnerable adults. Support systems for staff need to be improved. Improvements in record keeping were necessary. This was particularly noted in care records and staff records. Royley House DS0000005518.V249724.R01.S.doc Version 5.0 Page 6 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.V249724.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 Royley House DS0000005518.V249724.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): 1,2,3 and 4 Information about the home, which is provided for residents prior to admission, needed to be clarified. Resident’s needs are assessed by social services before they are admitted to the home. The home could confirm that they are able meet the needs of all the residents. EVIDENCE: The Statement of Purpose and Service User Guide had been revised since the last inspection, and improvement was noted. Some re-organisation of the information was needed between the two documents to provide the more detailed information on the Statement of Purpose, and a summary of the Statement of Purpose in the Service User Guide, as stated in the regulations and national minimum standards, and making the Service User Guide a slimmer, and more ‘manageable’ document, for the reader. Amendments were needed to clarify some of the information, including the complaints procedure, as detailed in standard 16. Royley House DS0000005518.V249724.R01.S.doc Version 5.0 Page 9 The residents’ files which were selected for inspection, contained terms of residency which were signed and dated by the resident or their relative, but did not include details of the fees payable to home. The care files, which were inspected contained assessments of residents’ needs which had been provided by social services. Issues about care plans noted in standard 7, and training in dementia care and challenging behaviour, which are noted in standard 30, have an impact on the home’s ability to meet the needs of some of the residents, and the home cannot, therefore, confirm they can meet the needs of certain resident’s. Royley House DS0000005518.V249724.R01.S.doc Version 5.0 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 and 10 Recording in relation to care planning and health care monitoring, did not demonstrate that all of the health, personal and social care needs of residents are identified and met. Improvements are needed in the recording of medication. EVIDENCE: The care files for 3 residents were selected for inspection. All files had admission details and assessments of the residents long term needs, but information about how those needs were to be met was not recorded in detail, (e.g. Hygiene – “requires full assistance”). Another file contained references to the resident having “ frequent aggressive outbursts”, but there was no corresponding care plan or any recorded strategies to enable staff to manage the outbursts. Information on the files was not consistently signed or dated, and the content of reviews/evaluations of care plans was limited, (i.e. “no change”). Files did, however show that residents or a relative had been involved in the care planning process and had agreed to the plan. Royley House DS0000005518.V249724.R01.S.doc Version 5.0 Page 11 A system of charts was in use for recording various aspects of care practice. The recording on the charts was however, intermittent, (e.g. one resident was recorded as having one bath since August 2005). On discussing this with the manager, she said this was not a true reflection of the amount of care, which had, in fact been provided, and agreed that the charts were only useful if they were properly completed. Residents weight had been recorded, but the records for 2 residents showed weight loss, which was not reflected in nutritional assessments, and a nutritional assessment had not been recorded for a resident who had special dietary needs. Records were available for visits by health and social care professionals. Medication was checked and found to be in order with the exception of the following: entries in the controlled drugs administration book were not consistently signed by a second member of staff; and hand written information on medication administration record sheets had not always been signed. Overall residents felt that they were treated with respect, and that their rights to privacy and dignity were upheld in the home. Royley House DS0000005518.V249724.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: The standards in this section, all of which were met on the last inspection, were not fully assessed on this inspection. Reference was, however made to certain aspects of these standards during the inspection, and the comments subsequently made by residents, and observations made by the inspectors, were positive. Royley House DS0000005518.V249724.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18 Information about the procedure for making complaints was not clear. Some staff did not have the necessary training to protect residents from abuse. EVIDENCE: A copy of the home’s complaints procedure was on display at the entrance to the home, and also included in the Statement of Purpose. However the Service User Guide contained 2 different complaints procedures, a third version of the procedure was included in the terms and conditions of residency, and a fourth was in the front of the complaints log. One procedure, which meets regulation 22 and standard 16, must be used consistently to avoid confusion for residents, visitors, and staff. A complaints log was kept showing that 3 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. At interview some members of staff said that they had not had training in relation to ‘Abuse’ and the protection of vulnerable adults. Without proper training, staff may fail to recognise an incident of abuse occurring in the home, and be unaware of the actions they would need to take should they witness, or be informed of, an incident of abuse occurring. Royley House DS0000005518.V249724.R01.S.doc Version 5.0 Page 14 Royley House DS0000005518.V249724.R01.S.doc Version 5.0 Page 15 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): 19,21,22,23,24 and 25 The owners were safely maintaining the property, and providing equipment and pleasant accommodation, for the people who live there. EVIDENCE: Since the last inspection the corridors on the ground floor had been redecorated, and external rendering and painting of the building, which was in progress at the time of the last inspection, had been completed. 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 several rooms had been redecorated and some re-carpeted, since the last inspection. Radiators had ‘cool touch’ surfaces, emergency call points were accessible to residents, lockable facilities were provided, and doors were lockable from inside the room, without the use of a key. Royley House DS0000005518.V249724.R01.S.doc Version 5.0 Page 16 It was noted that the door to one of the bedrooms, which were inspected, needed repair to enable it to close properly. The manager stated that this was one of 2 doors that needed repairing, and that the maintenance man had this in hand. The manager was requested to make sure that the work was done as a matter of urgency, because the doors are fire doors, and for reasons of security and privacy. Aids to independence were provided in bathrooms and toilets, there was ramped access to the property, and 3 mobile hoists were available in the home. An occupational therapist had recently done an assessment of the accommodation at the owner’s request, and a copy of the report was included in the Service User Guide. Royley House DS0000005518.V249724.R01.S.doc Version 5.0 Page 17 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 and 30 The staffing levels within the home were sufficient to meet the needs of the residents. Staff training in certain areas needed to be improved. 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. Information which was provided for inspection showed that 15 of the 26 care staff (i.e. 57.69 ), had achieved an NVQ level 2 qualification or higher, and NVQ 3 training was in progress for 5 members of staff. Two of the cooks had achieved NVQ 2 qualifications in hospitality. Information was provided regarding training which had been provided for staff since the last inspection and that which was planned. The records stated that some training had been provided for all staff, (e.g. elder abuse), but as stated when reporting on standard 18, some members of staff had not received it. The manager explained that training was arranged for all members of staff, but for various reasons some staff did not attend. She was requested to keep records of those who actually attend training courses, identify where training is still required, and arrange alternative training dates where necessary. Royley House DS0000005518.V249724.R01.S.doc Version 5.0 Page 18 Training had been provided regarding dementia and challenging behaviour, but staff reported that the 1 day course which had been provided was not in sufficient depth to assist them in caring for the residents in this category, who were living at the home at the time of this inspection. An induction programme was noted on the file of one member of staff who was appointed at the beginning of this year, but it did not meet the national minimum standards. There was no evidence of induction training on the file for another member of staff who appointed at the same time. Royley House DS0000005518.V249724.R01.S.doc Version 5.0 Page 19 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 and 38 Staff did not receive sufficient supervision and training. Record keeping must be improved to safeguard resident’s rights. Opportunities were provided for residents to comment on the running of the home. Overall arrangements for promoting health and safety were satisfactory. EVIDENCE: Training was continuing for the manager regarding the Registered Manager’s Award, and for the deputy manager regarding an NVQ 4 qualification. Action had been taken in relation to the requirements, which were made as a result of previous inspections. Royley House DS0000005518.V249724.R01.S.doc Version 5.0 Page 20 Some had been fully addressed, but others required further improvement to achieve full compliance with the National Minimum Standards and the Regulations. An anonymous residents’ satisfaction survey was carried out in July 2005. Of the 41 questionnaires distributed, 19 were returned, and comments were overall positive. Results of the survey, and the owners’ responses to residents’ comments were included in the Service User Guide. Surveys for other interested parties were to be carried out in due course. Structured supervision for staff was in the form of appraisals, but the frequency of the supervision did not meet the national minimum standards. During the inspection, staff gave the following information about supervision/appraisals: one had received 1 appraisal in 4 yrs; another had never had supervision; whilst another said she had “several appraisals”. Records showed that 3 members of staff had each had one appraisal since the beginning of 2005, and there was no record of an appraisal/supervision for a member of staff who was appointed in May 2005. Reports of visits to the home made by the registered person in accordance with regulation 26, have been sent to the Commission for Social Care Inspection. Some of the records, which are required by statute, did not meet the standard, as noted previously in this report when reporting on standards 7,8 and 9. Issues were also noted in relation to staff records, which were inspected, e.g. some essential documents were not in place on the 2 staff files which were inspected, although one of the files contained documentation which related to a different member of staff; there were 3 letters on each file confirming the offer of employment, one of which was from the owner, one from the manager, each giving a different date for employment to commence, and a third, unsigned letter bearing the home’s logo, which was dated one month before applications for the jobs were completed. The owner and the manager were puzzled by this letter and could not confirm they knew anything about it. Records regarding residents personal allowance were inspected and were found to be in order, with the following exception: 2 signatures should be provided against entries on the record sheets. Staff confirmed that they had received updates regarding various aspects of health and safety training. Records of health and safety maintenance were available. It was noted that monitoring of sample water temperatures at wash hand basins was needed. Fire precautions records showed that the relevant tests and checks of equipment and means of escape from fire had been completed as required. Royley House DS0000005518.V249724.R01.S.doc Version 5.0 Page 21 Royley House DS0000005518.V249724.R01.S.doc Version 5.0 Page 22 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 2 2 3 2 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 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 2 17 X 18 2 3 X 3 3 3 3 3 X STAFFING Standard No Score 27 3 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 2 2 2 Royley House DS0000005518.V249724.R01.S.doc Version 5.0 Page 23 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 OP1 Regulation 4,5 Requirement The registered person must ensure that the statement of purpose and service user guide are reviewed and amended in accordance with the regulations and national minimum standards. The registered person must ensure that residents are provided with a fully completed statement of terms and conditions of residency. The registered person must ensure that further training regarding dementia care and challenging behaviour is provided for management and staff. The registered person must ensure that care plans identify all the assessed needs of residents and provide guidance for care staff in meeting those needs, and are reviewed in detail. (Previous timescale for immediate action not met). Timescale for action 01/12/05 2 OP2 5 30/09/05 3 OP4 OP30 18 01/12/05 4 OP7 15 30/09/05 Royley House DS0000005518.V249724.R01.S.doc Version 5.0 Page 24 5 OP8 12,13,14, 15 The registered person must ensure that residents’ weight are recorded on admission and subsequently, and monitored, and any concerns investigated. 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. The registered person must ensure that handwritten medication details are signed and dated, and that all entries in the controlled drugs administration records, are validated by an additional member of staff. 30/09/05 6 OP8 12,13,14, 15 30/09/05 7 OP9 OP37 17 (1)(a) 30/09/05 8 OP16 22 9 OP18 13,18 10 OP30OP31 12,18 (Previous timescale for immediate action not met) The registered person must 01/10/05 ensure that a complaints procedure, which meets the National Minimum Standards and regulations, is used consistently in documentation for residents, visitors and staff. The registered person must 01/12/05 ensure that all members of staff are provided with training in relation to ‘Abuse’ and the Protection of Vulnerable Adults. The registered person must 01/11/05 ensure that a staff induction, and development programme, which meets the National Training Organisation (NTO) workforce training targets, is implemented. (Previous timescales not met) 11 OP31OP36 18 The registered person must ensure that staff are supervised and supported in accordance with the National Minimum DS0000005518.V249724.R01.S.doc 30/09/05 Royley House Version 5.0 Page 25 12 OP38 13 Standards. The registered person must ensure that water temperatures at wash hand basins are monitored. 30/09/05 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 OP35 Good Practice Recommendations The registered person should ensure that 2 signatures are provided against entries on the residents’ personal allowance record sheets. Royley House DS0000005518.V249724.R01.S.doc Version 5.0 Page 26 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.V249724.R01.S.doc Version 5.0 Page 27 - 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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