Inspection on 18/04/05 for Royley House

This inspection was carried out on 18th April 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 14/09/05

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 18/04/05 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. Royley House Version 1.10 Page 3 SERVICE INFORMATION Name of service Royley House Address Lea View Royton Oldham OL2 5ED 0161 633 4848 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) Roche Care Limited Mrs Jane Ann Archer CRH 41 Category(ies) of DE(E) Dementia over 65 - 15 registration, with number OP Old Age - 41 of places PD(E) Physical disability over 65 - 10 SI(E) Sensory Impair over 65 - 5 Royley House Version 1.10 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). Date of last inspection 15th November 2004 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 Version 1.10 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 18th April 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 a partial 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? The statement of purpose and service user guide had improved, but further work was needed to ensure that prospective and current residents had up to date information about the home. More information was available about residents care needs, and there was some improvement in how the information was used to help plan the care for each resident. There were more choices of food and activities for residents. Further training had been provided for management and staff, which included the protection of vulnerable adults. Meetings for staff, and residents had taken place. The views of relatives, doctors and social workers had been obtained about the service provided at the home. Royley House Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Royley House Version 1.10 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 Royley House Version 1.10 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) 1.2.3.4. Residents do not always have sufficient information about the home prior to admission. Resident’s needs are properly assessed before going into the home. The home cannot confirm they can meet resident’s needs due to the lack of specific training for some staff. EVIDENCE: The statement of purpose and service user guide had improved since the last inspection, but they needed to be reviewed, and checked for accuracy against the National Minimum Standards and the Regulations. This was discussed in detail with the owner’s representative and the registered manager during the inspection. Statements of terms and conditions of residency were in the resident’s files which were inspected, but the complaints procedure which was included in the document needed to be amended. Royley House Version 1.10 Page 9 The files which were inspected contained assessments of residents needs which had been completed before they moved into the home. Issues about training in dementia care and challenging behaviour, which are noted in standards 27-30, have an impact on the home’s ability to meet the needs of some of the residents. Royley House Version 1.10 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 standard(s) 7,8,9 There had been some improvement in care planning and health care monitoring, since the last inspection, but more work is needed to ensure that all of the health, personal and social care needs of residents are identified and met. Improvements are needed in the recording, storage, and disposal of medication. EVIDENCE: There had been an improvement in the quality of care plans since the last inspection, but further work was needed, to ensure that all identified needs had a corresponding care plan, which was an issue on the 4 files which were inspected. An example of this was a resident who was prone to falls. Whilst the records showed that the risk of falls had been identified, and crash and pressure mats had been provided, there was no specific risk assessment or associated plan of care to provide staff with comprehensive information about the falls, and the ways in which they could assist in preventing them. The resident had a care plan regarding ‘mobility’, but there was no reference to falls in the plan. Royley House Version 1.10 Page 11 Another example was that there was no corresponding care plan regarding risks identified in a nutritional assessment. Residents weight was not recorded regularly, and instances of weight loss and weight gain were not monitored or investigated. More detailed reviews were needed which showed whether health or other professionals had been involved regarding particular needs/ areas of concern. Residents and/or their representative also need to sign care plans and reviews to confirm that they have been involved in the process and agree with the care plan. One resident was concerned because she had asked staff to rub cream on her arm but they had not done so. These comments were passed on to the registered manager during the inspection, for her to investigate the matter. Residents were clean, nicely dressed and attention had been paid to details such as hair and nails. Records showed that residents had access to doctors, district nurses, podiatrists, and other health care services. Residents said that they felt that their rights to privacy were respected in the home. Medication was inspected and details of matters which needed attention were passed on to the registered manager. These included recording; overstocking of medication; some handwritten entries not signed or dated; eye drops out of date, and medication trolleys needing cleaning. Royley House Version 1.10 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 standard(s) 12.13.14.15. The choices of food available had improved since the last inspection, as had the provision of activities. Residents were able to make choices in various aspects of their daily life within the home. EVIDENCE: Activities were not observed during the course of the inspection, but examples of handicrafts, and information about entertainment were displayed, and residents confirmed that activities and entertainment were available, which they could take part in if they wished to do so. It was confirmed that residents were asked about their interests on admission. One resident who showed her room to the inspectors, had furnished it with her own furniture. It was very comfortable and homely, and she had a key to lock the door when she went out. She was very pleased with the room, and enjoyed watching her television late at night and having a ‘lie-in’ in the morning. Residents confirmed that relatives and friends were able to visit when they wished, and that they were made welcome by the staff. Royley House Version 1.10 Page 13 The residents who spoke with the inspectors were mainly satisfied with the meals provided, although one lady said that she preferred “plain food”, such as potato pie and meat puddings. The food which was sampled at lunchtime, was hot and tasty, and choices were available. Menus were displayed, and showed that cooked breakfasts and alternatives to sandwiches at teatime, were available. A staff member was observed offering choices of evening meal to a resident. Royley House Version 1.10 Page 14 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 Information about the procedure for making complaints was not clear, and the home could not ensure that those making a complaint would know whether their complaint had been taken seriously and acted upon. EVIDENCE: Whilst appropriate information about the procedure for making a complaint was displayed in the home, the complaints procedure, which was included in some of the documents referred to earlier in this report, did not meet with the legislation and National Minimum Standards. A record was kept of complaints made, but there was no information to show whether the complainant had been notified of the action taken by the home and the outcome. Without this the manager could not demonstrate that the complainant knew whether their complaint had been taken seriously and acted upon. Royley House Version 1.10 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 standard(s) 22.26. The home was clean, and the owners were maintaining the property, and providing equipment and pleasant accommodation, for the people who live at Royley House. EVIDENCE: Redecorating of the corridors was in progress the time of the inspection, and other parts of the home had been redecorated since the last inspection. A hoist was available on both floors of the building. The parts of the home which were inspected were clean, and residents confirmed that this was the normal standard of cleanliness within the home. The laundry was appropriately equipped, and kept in an orderly fashion. Residents were satisfied with the laundry service in the home. Royley House Version 1.10 Page 16 Royley House Version 1.10 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 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) 27.29.30 The staffing levels within the home were sufficient to meet the needs of the residents, and procedures for recruiting new staff were satisfactory. Staff training in certain areas needed to be improved. EVIDENCE: The information which was provided for the inspection, indicated that staffing levels within the home met the standards. The residents and staff who spoke to the inspectors, felt that the home was adequately staffed at that time, but said that there had been staff shortages in previous weeks. This was not said as a criticism, and the overall opinion of staff was favourable. The Registered manager disputed that the home had been short staffed. She said that despite finding it difficult to recruit suitable staff for a period, existing staff had covered vacant posts by doing extra shifts. A total of 5 new care staff had started work on the day of the inspection. Rotas need to show the seniority of staff. The files of 3 of the new members of staff were inspected. Criminal Records Bureau checks and 2 written references, which had been obtained prior to employment commencing, were in place on the files. The registered manager reported that an application had been made for induction training for 13 members of staff, with ‘Learn Direct’, which was said to meet the National Minimum Standards. Royley House Version 1.10 Page 18 Whilst records showed that some staff training had taken place since the last inspection, training regarding dementia care and challenging behaviour had not been provided, despite a requirement made previously for management and staff to be provided with training to meet the needs of all service users who were living at the home. Royley House Version 1.10 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 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) 31.33.36.37. The manager does not provide staff with sufficient support, supervision and training. Record keeping could be improved to safeguard resident’s rights, and more opportunities were needed for residents to comment on the running of the home. EVIDENCE: A system of meetings for residents and for staff had been implemented, and questionnaires had been sent to resident’s relatives and visiting doctors and social workers, to ask their views about the service provided at Royley House. An analysis of the survey had also been produced. Mr Athar Mahmood represented Roche Care at the inspection. He said that he had been involved in producing the results of the survey, and that they had found it useful and intended to continue to do the surveys regularly. Royley House Version 1.10 Page 20 He was agreeable to extending the distribution of questionnaires to include residents and other interested parties, and including details of the action taken by Roche Care to address any criticisms of the service, which had been made in the questionnaires returned. The registered manager had begun training for the Registered Manager’s Award, and the deputy manager had resumed training for an NVQ 4 qualification. Action had been taken to comply with most of the requirements made by the Commission for Social Care Inspection during previous inspections. Many of the issues had been resolved, and progress was noted regarding others, although further work was required. Some problems with medication remained outstanding, as did some training needs. A member of staff told the inspectors that an incident had occurred with a resident, which she had been unable to deal with because she had not been given the necessary training, and she did not feel that the manager had given her any support regarding the matter. Records showed which staff had received a supervision session, and the dates when it was planned for others, but further work was required to ensure that staff are supervised and supported in accordance with the National Minimum Standards. The records, which are required by statute had improved, but some did not meet the standard, as noted previously in this report when reporting on standards 7,8 and 9. Royley House Version 1.10 Page 21 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 2 2 2 x Na 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x 2 x 2 3 x 2 2 x Royley House Version 1.10 Page 22 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 1 Regulation 4&5 Requirement The registered person must ensure that the statement of purpose and service user guide are reviewed, and checked for accuracy against the National Minimum Standards and the Regulations. Timescale for action 1/7/05 2 4, 30,31 18 3 7, 37 13,15, 17 4 3, 7 15 (Timescale of 1/1/05 not met) The registered person must 1/7/05 ensure that training regarding dementia care and challenging behaviour is provided for management and staff. (Timescale of 1/2/05 not met) The registered person must Immediate ensure that care plans are provided for all the assessed needs of residents, and are reviewed in detail, to provide guidance for care staff in meeting those needs. (Timescale for immediate action not met). The registered person must Immediate ensure that residents and/ or their representative are involved in drawing up the plans, and sign them to confirm this. Royley House Version 1.10 Page 23 5 8,37 12,13,14, 15 The registered person must ensure that residents weight is recorded on admission and regularly recorded, monitored and any concerns investigated. The registered person must ensure that handwritten medication details are signed and dated, and the details are validated by an additional member of staff. (Timescale for immediate action not met) The registered person must ensure that medication trolleys are kept clean, the date of opening is noted on eye drops, medication is returned to the pharmacy when no longer required, and temperatures of the medicines fridge are recorded daily. The registered person must ensure that the complaints procedure is amended to meet the National Minimum Standards and regulations. Immediate 6 9,31,37 17 (1) (a) Immediate 7 9,31 17 (1) (a) Immediate 8 16 22 Immediate 9 30,38, 31 12,18 1/6/05 The registered person must ensure that a staff training and development programme, which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users, is implemented. (Timescale of 1/2/05 not met) Royley House Version 1.10 Page 24 10 33,31 24 The registered person must 1/9/05 ensure that the distribution of quality assurance questionnaires, is extended to include residents and other interested parties, and that details of the action taken by the home to address any issues noted in the questionnaires returned, is included in the analysis of the survey. The registered person must ensure that staff are supervised and supported in accordance with the National Minimum Standards. immediate 11 36, 31 18 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 2 Good Practice Recommendations The registered person should ensure that residents are provided with a copy of the home’s terms and conditions on admission to the home. Royley House Version 1.10 Page 25 Commission for Social Care Inspection 2nd Floor, Heritage Wharf Portland Place Ashton under Lyne OL7 OQD 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. 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