Inspection on 28/09/07 for Ruksar

This inspection was carried out on 28th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Ruksar 06/02/09

Ruksar 29/04/08

Ruksar 10/04/07

Ruksar 09/01/07

Ruksar 12/09/06

Ruksar 05/05/06

Ruksar 08/03/06

Ruksar 15/12/05

Ruksar 14/09/04

Ruksar 21/04/04

Ruksar 16/12/03

Similar services:

Aston Court Nursing Home

Breme

Ravenhurst

Westmead

Ashcroft Hollow Nursing Home

Bricklehampton Hall Nursing Home

Briar Hill House

Radbrook Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Ruksar 26 Park Avenue West Park Wolverhampton West Midlands WV1 4AH Lead Inspector Keith Salmon Key Unannounced Inspection 28th September 2007 09:30 X10029.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 Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 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 and Care Homes for Adults 18 – 65*. 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. Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ruksar Address 26 Park Avenue West Park Wolverhampton West Midlands WV1 4AH 01902 420605 01902 561199 mariamathet@aol.com 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) Mr Mustak Jalal Post vacant Care Home 27 Category(ies) of Physical disability (27), Physical disability over registration, with number 65 years of age (27) of places Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No number division between categories Date of last inspection 10th April 2007 Brief Description of the Service: Ruksar is a care home registered to provide personal and/or nursing care, for up to 27 adults, of all ages, with physical disabilities. Located close to Wolverhampton City Centre the home benefits from easy access to local shops, pubs, parks, and other amenities. The property is a two-storey building with accommodation on both floors comprising bedrooms, communal rooms, bathroom, and toilet facilities. The first floor is accessed via a passenger lift, and there is provision of an access ramp to the front of the home. However, whilst the home enjoys a garden area to the rear there is limited access for wheelchair users. Fees range from £297 - £483.00 per week. Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Inspection of ‘Key’ Standards commenced at 9.30am, concluded at 3.30pm, and was conducted by Mr Keith Salmon. Present on behalf of the Home was Mrs Marcelle Alparaque (Manager), who was later joined by Mr. Mustak Jalal (Proprietor). In addition to inspecting ‘Key’ Standards, this Inspection also sought to review progress made in meeting ‘Requirements’ arising from the previous ‘Key’ Inspection held in April 2007, and a ‘Random’ Inspection held in July 2007. The Inspector also reviewed action taken by the Proprietor following a ‘Management Review’ undertaken by CSCI in June 2007. This Report is based on observations made during a tour of the premises, a review of care related documentation, staff duty rotas and staff files, plus a range of other documents/records reflecting the general operation of the Home. The Inspector also held individual discussions with 5 Residents, 1 Visitor, the newly appointed Manager, the Proprietor, and several members of Care Staff. What the service does well: What has improved since the last inspection? Since the previous Key Inspection, held in April 2007, eight of eleven outstanding Requirements – some of which had been unresolved from earlier Inspections - have now been met, either wholly, or substantially in part. This is a significant step forward, and whilst it is early days, there are encouraging signs of progress. The Home has also responded positively to a number of Recommendations made in previous Inspection Reports. There is clear evidence that previous ineffective management, and the subsequent decline in the quality of care, is being addressed and reversed. Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 6 Specific areas of improvement include: Appointment of new Manager New furnishings Revision of various aspects of care related documentation and information for Residents/’supporters’ Administration of medicine practices 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. The summary of this inspection report can be made available in other formats on request. Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): OP 1, 3. YA 1, 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective Residents (or their Representative) are provided with the information they need to make an informed choice about ‘where best to live’ Processes to ensure appropriate and thorough care needs assessment, prior to admission, are effectively applied. EVIDENCE: A Requirement under this ‘Outcome Area’, which had been outstanding from previous Inspections, was “The statement of purpose and service user guide must be reviewed and updated to contain current and accurate information of the service Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 9 provision, so people can make informed choices about the home’s service and understand what is offered.” Review of the now revised Statement of Purpose, and the Service User Guide demonstrated the requirements of the relevant National Minimal Standard (NMS) are now met. Six Residents (comprising a selection of older people and younger physically disabled Residents) were ‘case tracked’ – that is, all aspects of their care were examined in detail. These included the three most recently admitted and three chosen at random. The review of their care documentation provided evidence that all had been fully assessed by a suitably experienced member of Care Staff prior to their admission and all had individual contract/terms and conditions documentation. Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 11 OP 7,8,9, & 10. YA 6,9,16,18,19 & 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the care plan model (as yet) remains unchanged, it is noted that improvements in the quality of entries indicate a Resident’s individual assessed care needs are now being more reliably met. The care provided is delivered considerately and effectively with Residents’ privacy and dignity being respected. With medication records now being satisfactorily completed the storage, reception, disposal, and record keeping, relating to medicines administration are all in accordance with accepted ‘good practice.’ This Outcome Group was rated ‘Poor’ at the previous Key Inspection, but, given improvements noted in respect of administration of medicines, and the use of care planning documentation, it is possible to change the rating from ‘Poor’ to ‘Adequate’. However, this should not disguise the fact that there is still room for improvement in relation to this ‘Outcome Group’. EVIDENCE: A Requirement outstanding from previous Inspections was “The service users plan of care must accurately detail and record all assessed heath, personal and social care needs, so that individual needs of the residents are met consistently.” Review of the care planning documents, relating to the five Residents, selected at random for ‘case tracking’, demonstrated the Home uses an ‘in-house’ design of care plan, with areas of care addressed, including – a full range of risk assessment based on ‘activities of daily living’, pressure sore risk assessment, nutritional state including daily food and fluid intake, regular weighing (frequency determined by assessed need), and records of visits by clinical/social care professionals, e.g. GP, Community Nurse, Social worker, Optometrist. Residents’ interests, hobbies, and preferences are now also recorded. Whilst this potentially provides a satisfactory basis for ensuring provision of care which meets assessed care needs, previous Inspections have noted a degree of failure in the Home’s performance in this area, in that Care Staff have sometimes failed to reliably maintain said documentation. At this Inspection it was observed there has been some improvement in this area, and the new Manager was able to display an understanding of the need to effect Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 12 further improvements, with clear ideas as to how this can be implemented and achieved. It is expected there will be further improvement evident at the next inspection. An ongoing area of ‘positive’ performance was seen in the evidenced involvement by Residents/’supporters’ in the needs assessment and care planning process, together with regular review (at least monthly, sometimes more frequently), and with change where necessary. The above Requirement was assessed as being met. A Recommendation in this ‘Outcome Group’ was “It is strongly recommended that procedures are adopted for the Medication Administration Record charts to be completed at the time of administering the medications.” A review of Medication Administration Record charts, and observation of medicines being administered, evidenced practices in respect of this are now satisfactory. This Requirement can be considered met. A review was also undertaken of the policies/procedures relating to the management/administration of medicines, i.e. records relating to the supply, storage, and disposal of medicines (including records of ambient and medicine refrigerator temperatures). All aspects were found to be satisfactory It was also noted the Home did not have a medicine trolley – medicines being administered from monitored dose cassettes, which are pre-loaded on to an open trolley for each ‘medicine round’. The Home now has an appropriately designed medicine trolley, and the administration of medicines is recorded at the time of administration. From observations made during the Inspection, and comments made by Residents, there was no evidence to suggest that Service Users’ privacy and dignity were not being maintained. Staff were observed to address Residents and Visitors in an appropriate manner. Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 14 OP 12,13,14 & 15. YA 12,13,15 & 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Leisure opportunities offered are generally consistent with Residents’ capabilities. However, the uptake of activities, by a large proportion of Residents, is very low. The Home facilitates achievement of desired lifestyle through Residents conducting the pattern of their day, where possible, as they wish, including contact with family and friends, and continuation of religious practices. There is a daily choice of attractive and nutritious meals, particularly in respect of meeting ethnic preferences. EVIDENCE: At the previous Key Inspection concern was expressed that there was little or no evidence relating to programmed, or actual, social/leisure activities for many of the Residents, with Requirements with regard to this area of care being outstanding from previous Inspections. A subsequent Random Inspection, held in July 200, found some improvement in this and noted – Care plans had been developed for attending to religious beliefs and social/leisure activity preferences, with daily and weekly routines detailed. Records showed that Residents have opportunities to partake in a range of activities including: o Visiting singers, and a touring drama group o Celebration of cultural festivals e.g. Christmas, Diwali, Eid o Videos and talking books (English and Asian languages) o Art sessions, ladies traditional hand decoration o Ball games, skittles, and exercise sessions o Bingo, quizzes, jigsaws o Darts, dominoes and traditional board games (snakes and ladders, Ludo) Care Plan documentation and leisure/social activity ‘diaries’ appertaining to individual Residents evidenced continuing availability of these activities. However, it was noted that the same records, plus comments made by Staff and Residents, indicate the uptake of activities is very low. Whilst it is accepted this is in part due to the very independent lifestyle of some of the younger Residents, it is ‘Recommended’ the Manager and Staff readdress this Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 15 issue and renew efforts to encourage/enable Residents to take part in the activities programme. It was also noted that – “Cultural dietary requirements were recorded in the plan with the people living and working at the home confirming that the meals are prepared in accordance with personal preferences.” At this Inspection a review of menus, discussion with Residents, one Relative, and Staff, confirmed the Home performs well in meeting ethnic food preferences of all Residents, with the provision of two menus, one aimed at more traditional English fare and other offering more ethnic options. Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 16,18. YA 22,23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems relating to the protection of Residents from abuse have shown some advancement since the previous Key Inspection, although there is need for further improvement before this aspect of service can be assessed as better than adequate. EVIDENCE: A Requirement outstanding from previous Inspections was “The registered person must ensure that systems are in place so that vulnerable people are protected from potential or actual abuse.” The statement of purpose seen at the time of this inspection now includes contact details for the Commission for Social Care Inspection. In addition, the complaints procedure displayed in the home’s lobby is printed in both English and Punjabi. Since the inspection in April 2007 no complaints were recorded as having been made nor had the Commission for Social Care Inspection received any Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 17 complaints. Three Residents and a Visitor informed the Inspector they were confident any concerns they might have would be well received and acted upon, but stressed they had no complaints and were more than happy with the care received. However, notwithstanding the above, it was not possible to gain a clear picture of systems in place to ensure protection of Residents, and ensure an accessible and responsive complaints system. The new Manager accepts the ‘Adult Protection’/complaints systems, in addition to other management systems, require a complete review, e.g. complaints response, management and recording. The Inspector was shown some initial work being undertaken by the Manager to improve systems in this area, together with a prospective programme for training staff in ‘adult protection’, which is to be activated in the coming months. The positive note offered by the Manager’s appreciation of the need to ensure improvement in this area, is considered a concerted step forward and bodes well for future inspections, but will remain a Requirement of this inspection Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 19 OP 19, 26. YA 24, 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The overall condition of the home is showing signs of improvement in terms of refurbishment in some areas. However, there remains the important need to continue with refurbishment/ redecoration in order that comments made at the previous Key Inspection, i.e. “…people are living in an environment that is not particularly homely, and appears shabby…” and “The home does not have an on-going maintenance programme in place, so that essential maintenance is only done when a problem has already arisen”, can be responded to effectively. EVIDENCE: A tour of the Home demonstrated some necessary work had been completed, e.g. the provision of new tables and chairs in the dining room, the provision of replacement curtains, and the fitting of window opening restrictors in the first floor lounge. In addition, work is well advanced in replacing the (reportedly underused and leaky) first floor shower facility, with a new shower/wet room on the ground floor – this is due for completion by the end of October 2007. However, as reported at the previous Key Inspection, the majority of communal areas appear shabby, with the décor badly in need of refurbishment and redecoration. Bathrooms, toilets and the shower room are basic and rudimentary, possessing a clinical ambience and not homely in any way. It was also noted the Home does not have the benefit of a written plan for refurbishment, redecoration, and the renewal of furnishings and fabrics. The Proprietor informed the Inspector that repair, replacement, refurbishment and redecoration is undertaken “whenever necessary.” Clearly, redecoration and refurbishment has now reached a necessary stage and both the Proprietor, and the new Manager, accept that a written programme, with proposed completion dates, would help facilitate, and maintain, improvements in the quality of the environment, to ensure Residents are enabled to reside in safe and pleasant surroundings. With this in mind it will be a Recommendation of this inspection that the home’s Management given strong consideration to the establishment and implementation of a redecoration/refurbishment programme. Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff numbers, and skill-mix, listed on the staff rota are sufficient to meet the assessed care needs of the current number of Residents, and their apparent levels of dependency. However, should the number of Residents and/or levels of dependency increase, care staff numbers deployed to cover the night shift may not be sufficient to meet Resident’s care needs. Whilst staff employment documentation is generally consistent with ensuring the safety of Residents some shortfalls were noted. The commitment of the Home to providing training for Care Staff is generally satisfactory. EVIDENCE: The Manager functions in a supernumerary capacity, and is supported on ‘morning’ shifts by a Registered Nurse plus four Care Staff, and on the ‘afternoon’ shift by a Registered Nurse plus three Care Staff. A Registered Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 21 Nurse, and one member of Care Staff cover the ‘night’ shift. The Inspector expressed concern to the Proprietor and Manager that cover on the ‘night’ shift may be insufficient should the numbers of Residents and/or their individual dependency (and therefore assessed care needs) increase above the current number - at the time of the Inspection the Home had 17 Residents. The Manager informed the Inspector she was aware of her responsibilities, in relation to ensuring levels of staffing/skill-mix at a level consistent with providing a level of care service, sufficient to meet all Residents’ assessed care needs. It is recommended that discussions, in relation to staffing levels, are held between the Manager and the Proprietor, and that a Policy be established in respect of this. The Inspector reviewed staff employment files relating to the three most recently engaged staff and three randomly selected supervision files. These evidenced that, with the exception of one element, items required by the relevant Standard and Schedule were found. The exception being the files did not contain copies of birth certificates. Given all files did have evidence of completed ‘POVA’ and CRB checks, it is accepted Employees must have, at some point, presented satisfactory documents of identity. The Manager was reminded of the documents, which must kept at the Home, as per Schedule 2 of the Regulations. The Manager undertook to obtain copies of birth certificates relating to current, staff where such documents were missing, and to adhere to this in future. A Requirement will be issued in this respect. With regard to formal ‘supervision’, evidence of an annual appraisal, and ongoing formal ‘supervision’ for all staff was observed. Notwithstanding this, the Manager explained this was an area on the agenda to receive attention in the near future, with plans to make the process more ‘user friendly’ for the staff member and ‘supervisor’. These plans were discussed with the Inspector, who is satisfied there should be improvement in this area by the next Inspection. Staff training files showed that three staff are undertaking National Vocational Qualification (NVQ) Level 3 in Care, and nine of the staff have undertaken NVQ Level 2 equating to more than 50 of the care staff team. A Requirement arising from previous Inspections was “The registered person must ensure that all staff receive an induction programme that meets the Skills for Care specifications, so that they can work safely.” The Inspector discussed this matter with the Manager and observed evidence that work had begun to address the shortfall. It is accepted that sufficient progress has been made to consider this Requirement met. Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 23 OP 31,33,35,38. YA 37,39,42. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The Home has experienced a serious lack of leadership over the past 12 months, a situation which both the Proprietor and Manager accept and, in turn, plan to resolve. There has been some improvement in the management of the home since the appointment of the new Manager. However, a number of management issues remain to be addressed so as to ensure the health and well being of Residents is safeguarded, and promoted. Nevertheless, there are good early signs that the new Manager is motivated and able to effect the necessary changes. EVIDENCE: The newly appointed Manager has been in post since August 2007. Conversation between the Inspector, Manager, and Proprietor, indicated the Manager had spent the time effectively in pursuing on-going projects, e.g. improvements to bathing/shower provision, and taking stock of the position of the Home with regard to shortfalls in care provision, including those identified in CSCI Requirements and during a recent CSCI Management Review. Furthermore, observation by the Inspector, comments from Residents, Staff, and a Visitor, evidenced the Home is now being better managed. All of the Requirements arising from previous Inspections pre-date the current Manager’s tenure in the post, and it was clear to the Inspector that many have been effectively addressed. For those not yet met, there is sufficient evidence to indicate these will be confronted and met within a reasonable timescale. A review of staff records revealed one specific area in which improvement is both desirable and necessary, i.e. record keeping relating to formal supervision of staff. Once again this is an area the Manager has begun to address. The financial management of small amounts of cash, to cover incidental items, for a few Residents, is conducted by the home, with records audited on a regular basis. The Inspector reviewed transaction records, and found them to be managed in accordance with the Standard. All other records were seen to be secure and well maintained. Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 24 Practices in the context of health, safety and welfare of Residents, Visitors, and Staff were seen to be in accordance with the Regulations, i.e. COSHH requirements were satisfactory, with maintenance and servicing of equipment regularly undertaken, and appropriately documented. Records of regular checks on hot water temperatures at outlets accessible to Residents showed temperatures to be in accordance with the relevant Standard. Other ‘health and safety’ records examined related to fire risk management, nurse call bells, lighting, Legionella, portable electric equipment, hoists. All were found to be satisfactory. It was noted in the previous Key Inspection Report that “In some of the en suite bathrooms unsightly pipe-work needs to be boxed in.” Apart from a visual untidiness, it was thought there might be the possibility of Residents sustaining burns from pipes delivering hot water. To fully safeguard against this possibility it was ‘Recommended’ that All exposed hot water pipes in areas accessible to Residents are ‘risk assessed with regard to the possibility of causing burns to Residents Initially any hot water pipes identified as a possible risk to Residents safety are boxed in as soon as possible Whilst this work has not yet been completed it was clear to the Inspector that work is on-going, progress has been made and should be completed during the coming weeks. Based on this, and evidence of improvements already effected, it is reasonable to move rating for this Outcome Group’ from ‘Poor’ to ‘Adequate’. Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 25 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 3 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 3 18 2 ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 X 25 X 26 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 X 33 3 34 X 35 3 36 X 37 X 38 3 Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 26 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 OP18 Regulation 12(1)(a) Requirement The registered person must ensure that robust systems are in place so that vulnerable people are protected from potential or actual abuse. Previous timescale 30/09/06, 28/02/07, and 31/07/07 not met. Timescale for action 30/11/07 2. OP27 18(1)(a) 30/11/07 The registered person must ensure that the ratios of staff be reviewed with the levels of staff appropriate to the assessed needs of the people living at the home, taking into account the size, layout and service provision. Previous timescale 30/06/06, 30/09/06, 28/02/07, and 31/07/07 not met. 31/10/07 3. OP29 19(1)(2)(3)(4) The registered person must ensure that the personnel files for staff employed post April 2002 contain the documentation required in DS0000017194.V351687.R02.S.doc Ruksar Version 5.2 Page 27 Schedule 2 of the regulations. Previous timescale 30/09/06, 28/02/07, and 31/07/07 not met. 4. OP31 9(1)(2) The Manager must make formal application to CSCI for Registration as Manager 31/10/07 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. OP12 2. 3. OP18 OP19 Refer to Standard Good Practice Recommendations It is recommended that the Manager and Staff address this issue and renew efforts to encourage/enable Residents to take part in the activities programme. It is strongly recommended that the Manager reviews and updates as necessary the ‘Adult Protection’/complaints systems. It is strongly recommended an on-going redecoration/refurbishment plan, with target dates for completion, should be drawn up and a copy provided to the CSCI for their information. It is strongly recommended that discussions, in relation to staffing levels, particularly in respect of ‘night duty’ cover, are held between the Manager and the Proprietor, and that a Policy is established relating to this. The results of service user surveys should be published and made available to service users, interested parties and the commission. 4. OP27 5. OP33 Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Shrewsbury Local Office Commission for Social Care Inspection 1st Floor, Chapter House South Abbey Lawn Abbey Foregate Shrewsbury SY2 5DE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. Ruksar DS0000017194.V351687.R02.S.doc Version 5.2 Page 29 - 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. 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