Inspection on 29/04/08 for Ruksar

This inspection was carried out on 29th April 2008.

CSCI found this care home to be providing an Adequate service.

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 28/09/07

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 28/09/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Ruksar 26 Park Avenue West Park Wolverhampton West Midlands WV1 4AH Lead Inspector Joy Hoelzel Key Unannounced Inspection 29th April 2008 10:00 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.V363333.R01.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.V363333.R01.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 Maricel Distajo Alparaque Care Home 27 Category(ies) of Physical disability (27), Physical disability over registration, with number 65 years of age (27) of places Ruksar DS0000017194.V363333.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No number division between categories Date of last inspection 28th September 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. Information of the home and the provision of the service are available in the statement of purpose, which has recently been revised. The document does not include information on the current level of fees for the service. The reader may wish to obtain more up to date information from the care service. Commission for Social Care Inspection reports for this service are available from the provider or can be obtained from www.csci.org.uk Ruksar DS0000017194.V363333.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced inspection took place over five hours on Tuesday 29th April 2008. Twenty three of the thirty eight National Minimum Standards for Care Homes for Older People and twenty one of the National Minimum Standards for Younger Adults were inspected as they are viewed as key standards for services. Eighteen people are currently living at the home and during the inspection were observed to be accessing all areas of the home. A registered manager was on the premises and in charge of the home, supported by one registered nurse, four care staff and ancillary personnel. A look around the home took place, which included a number of bedrooms as well as communal areas. The care documents of a number of people using the service were viewed including care plans, daily records and risk assessments. Other documents seen included medication records, service records, some policies and procedures and staffing records. Discussions were held with people living and working at the home. Some people were unable to fully comment about their experience of life at the home, observations were made of how they spent the day and of the interactions offered by staff in an attempt to obtain an overview of how they may be feeling. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was posted to the home for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for providers to share with us areas that they believe they are doing well. It is a legal requirement that the AQAA is completed and returned to us within a given timescale. The registered manager completed this document and returned it to us. Comments from the AQAA are included within this inspection report. What the service does well: Ruksar DS0000017194.V363333.R01.S.doc Version 5.2 Page 6 The home is very effective in providing appropriate service to meet the varying needs and preferences of a client group, which covers a wide age range and is also culturally and ethnically diverse. A high proportion of staff are bi-lingual, covering a range of language and dialects, ensuring communication is maintained with people for whom English is not their first language. The manager and management team are developing and are improving and continuing to improve the systems needed to ensure that they provide the service that they say they do. What has improved since the last inspection? What they could do better: A robust approach must be adopted to ensure that the required documentation and checks have been carried out for all staff members and that copies of these checks are in the personnel file and available for inspection. One randomly selected personnel file of a person who has been working at the home for a considerable period of time did not contain any references or criminal record bureau disclosure. Previous statutory requirements have been made and have not been complied with. The home is therefore in breach of Ruksar DS0000017194.V363333.R01.S.doc Version 5.2 Page 7 Regulation 19, (Fitness of workers), of the Care Homes Regulations 2001, which is an offence under the Care Standards Act 2000. This resulted in the serving of a Code B notice, which is used whenever we are involved in an investigation, which may result in a criminal prosecution. A letter and copy of the missing criminal record bureau disclosure was forwarded to us from the home on 15th May 2008, following this inspection, confirming that the document had been found and that checks had been carried out correctly. No further action will be taken on this occasion but the recruitment procedure will again be fully looked at during the next inspection. 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.V363333.R01.S.doc Version 5.2 Page 8 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.V363333.R01.S.doc Version 5.2 Page 9 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 1,3,6. YA 2. Quality in this outcome area is good. Admissions are not made to the home until a needs assessment has been undertaken by a senior member of the staff team, this ensures that the home is confident that all assessed care needs of the individual can be fully met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Details of the service provision are available in a statement of purpose. The document is available on request and was last reviewed in April 2008. It was Ruksar DS0000017194.V363333.R01.S.doc Version 5.2 Page 10 not inspected in depth on this occasion but on general observation the statement of purpose will need to be revised to include the correct contact details of the commission. To comply with the regulations a service user guide must be developed (a summary of the statement of purpose) which is written in a format suitable for the client group and includes information about the current level of weekly fees. The case file of the person who recently moved into the home was looked at to see if information had been sought regarding this persons needs prior to moving into the home. A letter is on file from the local hospital detailing the individual requirements, in addition a member of staff at the home completed an assessment. This person was unable to fully comment on how she found life at the home but appeared to be well cared for and comfortable. Staff commented that they thought this person’s condition had improved since moving into the home. Other case files looked at included social worker reviews, assessments from Primary Care Trusts and community care services. The Annual Quality Assurance Assessment (AQAA) completed by the manager of the home specifies that – ‘A pre-assessment process is provided and prospective service users feel confident that their needs and aspirations are fully understood by the home’s staff’. The home does not provide an intermediate care service. Ruksar DS0000017194.V363333.R01.S.doc Version 5.2 Page 11 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): OP 7,8,9,10. YA 6,9,16,18,20. Quality in this outcome area is adequate Each individual has a care plan that is reviewed and revised on a regular basis. The plan includes basic information necessary to deliver the person’s care but does not consistently reflect the care being delivered. This judgement has been made using available evidence including a visit to this service. Ruksar DS0000017194.V363333.R01.S.doc Version 5.2 Page 12 EVIDENCE: All people living at the home have a plan of care that is based on the information gained prior to admission; the plan is then reviewed on a regular basis. Three case files were selected for inspection and generally contained the information required to ensure staff have the specific details for successfully meeting a persons needs. However there appeared to be omissions of information and some discrepancies when discussing care needs with individuals and observing staff working practice. For example one case file indicated that a person was at risk of injury due to the potential of falling out of bed and as such was assessed as needing a mattress on the floor. On discussion with the staff and observation of this person’s bedroom this information was incorrect, as a new low profile bed had been purchased by the home to assist with this persons safety and care needs. Other observations in the case files were very well recorded, for example, when a person was assessed as being at risk of malnutrition because of a frail and deteriorating condition. The care plan detailed the action to be taken by staff to ensure that good nutritional status is maintained; records indicate that this is being achieved. This was supported by general observations of this person and the support and assistance being given by staff throughout the time of the inspection. The AQAA completed by the manager describes the recent changes and improvements made – ‘Provision of individual care plan that covers every aspects of care of the service users, and the provision of low profile bed for a service user who are at risk of falling’ The AQAA also identifies the further improvements planed for action during the next 12 months – ‘To provide more facilities and equipment necessarily in maintaining the integrity of the pressure areas Monitor the nutritional intake of every service users and more improvement and changes in the choices of menus Achieve the high standard of Health and Personal Care for each service users’ Ruksar DS0000017194.V363333.R01.S.doc Version 5.2 Page 13 The home operates a twenty eight day prescribing regime for the administration of medication using a monitored dosage system with the additional use of boxes and bottles of medicines. The registered nurses administer the medications, the Medication Administration Record appears to be fully completed, and no gaps in the recording sheet were seen in the selection viewed. The care staff were observed to be addressing people in an appropriate manner and it appeared that good relationships had been developed. The home is very diverse culturally with people of varied ethnicities; effective communication with all people is achieved as most of the staff have multi lingual skills. People commented that the ‘staff were very good’ and many expressed a satisfaction with life in the home. Ruksar DS0000017194.V363333.R01.S.doc Version 5.2 Page 14 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): OP 12,13,14,15. YA 12,13,15,17. Quality in this outcome area is good. People living at the home are involved in daytime activities of their own choice and according to their individual interests, diverse needs and capabilities. The meals are balanced and nutritious and cater for the varying cultural and dietary needs of individuals. This judgement has been made using available evidence including a visit to this service. Ruksar DS0000017194.V363333.R01.S.doc Version 5.2 Page 15 EVIDENCE: The manager and staff discussed the recent residents meetings where an attempt was made to offer opportunities for engaging in social, leisure and recreational activities. Many people are reluctant to engage in regular activity and state they are satisfied with staying at the home watching TV. However the quantity of activity being arranged on behalf of the residents has increased with opportunities to participate in quizzes, board games and other pastimes. Religious festivals, celebrations and cultural interests are arranged throughout the year with the staff taking an active part to assist and encourage participation. The AQAA completed by the manager indicates that – ‘Ruksar Nursing Home offers different variations of social activities both internal and external. Every service user has the opportunity to enjoy their choices and are stimulated through leisure and recreational activities to suit their needs’. And goes on to identify that they could better by‘Increase the range of choices in leisure activities of every service users and encouraged more creativeness in the part of the staff’. With plans for the next twelve months to – ‘ Improve the choices of the activities, that will benefit in the life of every service user and send staff to attend for any activity courses to improved skills and knowledge’. Relatives are friends are welcome to visit at times suitable to the resident. The visiting arrangements are detailed in the statement of purpose – ‘There is an ‘open house’ policy towards visitors to the home’. Many of the people living at the home are able to go to the local shops on a daily basis either escorted by staff or on their own. One person uses an electric wheelchair and enjoys going to the shops each day to get their daily newspaper. Ruksar DS0000017194.V363333.R01.S.doc Version 5.2 Page 16 Observation of staff working practices and systems indicate that people are given the opportunity to live their own lives as they wish and are supported with making decisions and choices to maintain maximum independence and to their own ability. Improvements have been made to the appearance of the dining room with new furniture and furnishings being purchased. A variety of cultural diets are available each day to suit the requirements of individuals, people are encouraged into the dining room at mealtimes but are able to have their meals in other areas if they so wish. The cook discussed the recent review of the dietary and cultural requirements of people living at the home to ensure that everyone is offered a suitable diet. The AQAA confirms that they provide a good service in this area by – ‘ Food served daily are presented in attractive and appealing manner, ‘chapatti’ are freshly made everyday and food for Asian service users are served. Asian chef is available all the time, to cook specialised meal’. Ruksar DS0000017194.V363333.R01.S.doc Version 5.2 Page 17 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. The service has a complaints procedure that is available and is displayed on the notice board in the home. There are policies and procedures for safeguarding people who use the service with arrangements in hand to ensure that staff are familiar with the procedures and have an understanding of the protection of vulnerable adults. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaint procedure that is available upon request. Details of the procedure are included in the statement of purpose and a copy is displayed at the entrance to the home. The current contact details of the commission should be added to the document. Two people stated that they would speak with the manager if they had any concerns and said that ‘she would then sort it out’. Ruksar DS0000017194.V363333.R01.S.doc Version 5.2 Page 18 The manager confirmed that no concerns or complaints have been received and no referrals have been made to the safe guarding adults multi agency team. We have not received any concerns or complaints since the last key inspection. The policy and procedure for safe guarding adults and prevention of abuse in the workplace has been reviewed in November 2007. One member of staff confirmed that they had seen a copy of the procedure but was unable to demonstrate an understanding of the action they would take if they suspected abuse had occurred. This was discussed with the manager who offered an assurance that the policy and procedure would be discussed with all staff. Training for staff in safeguarding adults has been arranged for this year. Although not fully inspected on this occasion the manager confirmed that the home offers a facility for residents to deposit personal monies for safekeeping; and that records relating to this have been maintained and fully receipted. Ruksar DS0000017194.V363333.R01.S.doc Version 5.2 Page 19 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): OP 19,26. YA 24,30 Quality in this outcome area is good. The home provides an environment that meets the specific needs of the people who live there, and there are plans to further upgrade the premises and improve the standards of living. The management has a good infection control policy, with advice being given from external specialists, they encourage their own staff to work to the home’s policy to reduce the risk of infection This judgement has been made using available evidence including a visit to this service. Ruksar DS0000017194.V363333.R01.S.doc Version 5.2 Page 20 EVIDENCE: The upgrading and improvements to the environment continue with furniture and soft fittings being replaced. Bedroom carpets are being replaced with a more suitable easily cleanable covering when required and alterations have been made to the bath and shower rooms. The manager discussed the further planned improvements with a bedroom on the first floor being redecorated and refurbished. Following the fire officers’ visit, the requirements made have been complied with, a new fire alarm panel has been installed, fire retardant soft furnishings have been purchased and fire doors have been repaired. The fire officer has revisited with the manager currently waiting a report confirming compliance with the requirements. The Environmental Health Officer visited in June 2007 and awarded the home 3 stars, good standard, with only minor issues being identified. The cook stated that the chopping boards needed replacement but these were in the process of being purchased. The people responsible for the cleaning of the home have worked hard to increase the standard of hygiene to ensure that people are living in a clean environment. The manager has identified one or two areas that would benefit from refurbishment and confirmed this has been planned in to the programme of works. An infection control audit by Wolverhampton Primary Care Trust in March 2008 awarded a green rating, excellent, with score of 87 . The audit identified that foot operated waste disposal bins are needed throughout the building, the manager confirmed that they would be purchased shortly. Further improvements over the next twelve months identified in the AQAA are • • • • • Improve the environment rating in the kitchen area Changing of front stairs connected to the front garden to ramp and for easy access to wheelchair users Completion of beautification of the garden within the set target Provision of big screen television in the lounge Maintenance of the decor and improvement to the highest standard Ruksar DS0000017194.V363333.R01.S.doc Version 5.2 Page 21 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): OP 27,28,29,30. YA 32,34,35. Quality in this outcome area is adequate. All new staff are being recruited through the revised and current procedures with relevant checks being conducted prior to them starting work at the home ensuring the people are fully suitable to work with vulnerable adults. However, the records for people who have worked at the home for considerable periods of time were found to be lacking in essential information. There is an adequate amount of qualified and competent staff to meet the health and welfare of people currently using the service, with the training and development needs being addressed. This judgement has been made using available evidence including a visit to this service. Ruksar DS0000017194.V363333.R01.S.doc Version 5.2 Page 22 EVIDENCE: A duty rota is maintained on a weekly basis to identify the people working in the home at any one time. The manager confirmed that eighteen people are currently residing at the home with staffing at the time of this inspection consisting of 1 registered nurse, 4 care staff, domestic and catering staff. Discussions have been held with the provider to discuss the possibility of increasing the number of staff on night duty. The manager stated that changes would be made when the occupancy of the home increases and if peoples dependency needs increase, she confirms that currently there are sufficient staff on the premises for each 24 hour period. Information recorded in the AQAA confirms that there are sufficient staff trained to National Vocational Qualification (NVQ), level 2 in care to ensure that staff have the skills to meet the needs of people living at the home‘97 of the care staff are all NVQ 2 level and senior care staff have finished the NVQ level 3’. Three staff personnel files were selected, from the staff on duty during the morning of this inspection, to look at the recruitment procedures. Two of the files contained all of the required information needed, with checks obtained from references, criminal record bureau disclosures and confirmation of identity. The other file identified that a person had been working at the home for a considerable period of time without references, criminal record bureau disclosures or protection of vulnerable adults first check being obtained. This person is employed as a care assistant and was observed during the morning attending to the personal care of residents. The manager explained that she had conducted a recent audit on the personnel files and was unsure why there were no references or criminal record bureau disclosure in this persons file. The completed application form recorded the name of one person as a referee, there are no letters or correspondence in the file relating to the request of a reference or that one had been received. There was no record of an application for a criminal record bureau disclosure. The member of staff stated that they bought a criminal record bureau disclosure to the home and ‘gave it to Mr Jalal sometime ago’. This indicated that the home had not conducted the necessary checks prior to this person being deployed. A statutory requirement following previous inspections was made – Ruksar DS0000017194.V363333.R01.S.doc Version 5.2 Page 23 ‘The registered person must ensure that the personnel files for staff employed post April 2002 contain the documentation required in Schedule 2 of the regulations’. Compliance for this requirement has been outstanding since September 2006, this resulted in the serving of a Code B notice, which is used whenever we are involved in an investigation, which may result in a criminal prosecution-in this instance Ruksar Nursing home had breached Regulation 19, (Fitness of workers), of the Care Homes Regulations 2001, which is an offence under the Care Standards Act 2000. Action will now be considered to ensure compliance in this area this will ensure that people suitable to work with vulnerable adults care for people living at the home. A letter and copy of the missing criminal record bureau disclosure was forwarded to us from the home on 15th May 2008, following this inspection, confirming that the document had been found and that checks had been carried out correctly. No further action will be taken on this occasion but the recruitment procedure will again be fully looked at during the next inspection and we will be monitoring the situation. A training matrix has been completed and indicates that the majority of the training is outstanding. The manager confirmed that the training and development needs of staff have been identified with courses, sessions and updates in the mandatory topics and specialist areas being arranged through out the year. Ruksar DS0000017194.V363333.R01.S.doc Version 5.2 Page 24 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.V363333.R01.S.doc Version 5.2 Page 25 OP 31,33,35,38. YA 37,39,42. Quality in this outcome area is adequate. The manager is improving and developing systems that monitor practice and compliance with the plans, policies and procedures of the home. However more work is needed in this area to ensure that effective and efficient systems are in place to adequately ensure that the health, welfare and safety of people living, working and visiting the home are fully met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Mrs Maricel Alaparaque has been the registered manager of the home for the last eight months. Mrs Alaparaque is a first level nurse and is currently working through the Registered Managers Award and plans to complete the course by the end of May 2008. Mrs Alaparaque discussed the aims and objectives of the service and the care needs of the people living at the home. People living and working at the home expressed a satisfaction with her management style commenting that she is ‘very approachable and will listen to them’. Mrs Alaparaque completed the AQAA, which gave clear, relevant information that is supported by a wide range of evidence. The AQAA described the changes that have made and where they still need to make improvements. Quality assurance and monitoring of the service continues with satisfaction surveys being recently distributed to the people living at the home. A random selection of the completed surveys were looked at and indicated a general satisfaction with life at the home. Service user meetings continue to be arranged offering people the opportunity to have their say and to suggest areas of improvement. Although not fully inspected on this occasion the manager confirmed that the home offers a facility for residents to deposit personal monies for safekeeping; and that records relating to this have been maintained and fully receipted. Weekly, monthly and annual testing of the equipment and premises are conducted with records kept and available for inspection. Policies and procedures relating to the service are in the process of being reviewed and revised. All new staff receive induction training to Skills for Care specifications. Ruksar DS0000017194.V363333.R01.S.doc Version 5.2 Page 26 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 2 X 3 3 4 X 5 X 6 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 4 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 3 Ruksar DS0000017194.V363333.R01.S.doc Version 5.2 Page 27 Yes Are there any outstanding requirements from the last inspection? 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 OP29 Regulation Requirement Timescale for action 29/04/08 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 Schedule 2 of the regulations. Previous timescale 30/09/06, 28/02/07, 31/07/07 not met. 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 OP1 Good Practice Recommendations The statement of purpose and service user guide should be reviewed and updated to contain current and accurate information of the service provision, so people can make informed choices about the home’s service and understand what is offered. The service user guide should include information on the current level of fees. The complaints procedure should be reviewed to indicate the current contact details of the commission, so people are able to contact us if they wish to do so. The safeguarding adults and prevention of abuse in the DS0000017194.V363333.R01.S.doc Version 5.2 Page 28 2 3 Ruksar OP16 OP18 4 OP30 workplace policy should be distributed to all staff so that they or potential harm has occurred All staff should have the opportunity to undertake training essential to their work to ensure that they have the skills and knowledge to fully meet a persons needs. Ruksar DS0000017194.V363333.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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.V363333.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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