Inspection on 23/02/06 for Ryelands

This inspection was carried out on 23rd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ryelands 10/07/07

Ryelands 22/06/06

Ryelands 28/10/05

Ryelands 01/03/05

Ryelands 30/11/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Ryelands 15 Beddington Gardens Wallington Surrey SM6 0JF Lead Inspector Deborah Yapicioz Unannounced Inspection 23rd February 2006 09:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ryelands DS0000007194.V285217.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ryelands DS0000007194.V285217.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ryelands Address 15 Beddington Gardens Wallington Surrey SM6 0JF 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) 020 8647 6837 020 8254 7047 home.wal@mha.org.uk home.fxg@mha.org.uk Methodist Homes for the Aged Mrs Sandra Carole Roche Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Ryelands DS0000007194.V285217.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 3 Rooms to be used as Double Rooms for the use of husbands, wives, partners, brothers or sisters only. Room number 42 (Dementia Unit) size 19 Sq.m Room number 23 (Personal Care Unit) size 20.709 Sq.m Room number 25 (Personal Care Unit) size 23.256 Sq.m 28th October 2005 Date of last inspection Brief Description of the Service: Ryelands is owned by a voluntary organisation ‘Methodist Homes for the Aged’ and is situated a short distance from Wallington town centre. The home is open to all regardless of gender, race, financial position or religious faith. The home is now registered to provide care to 48 elderly persons (32 personal care and 16 dementia care). Methodist Homes for the Aged has just completed a major building programme. This included demolishing the original home on the site and rebuilding the home to include a residential unit (Ryelands), supported independent living flats (Moorlands), and a separate dementia unit (Brooklands). For the purpose of this inspection report both the residential units (Ryelands and Brooklands) are referred to as Ryelands. The new building it is generally well thought out and has been designed specifically for the purpose. There has been good involvement of the service users. The gardens are thoughtfully designed with level paths and handrails allowing full access to less mobile residents. The garden at Ryelands is shared with the residents of Moorlands. The garden at Brooklands (the dementia unit) is designed to stimulate the senses with safe water features and scented, colourful plants. Accommodation in both units includes spacious single bedrooms on both floors. All service users’ rooms have en-suite facilities and a kitchen area. There is a lift serving all floors. The conditions for registration included recommendations that the three double rooms are only used for husbands, wives, partners, brothers or sisters only. Ryelands DS0000007194.V285217.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second inspection for the year 2005/6. The inspection was unannounced and took place at 9.45 on the morning of 23rd February 2006. The home was inspected under the National Minimum Standards Care Homes for Older People. A previous inspection took place on 28th October 2005 when most of the standards that the Commission for Social Care Inspection considers as key standards were inspected. Therefore some areas were not reassessed at this inspection. Methods of inspection included meeting with the service users, a partial tour of the premises, observations of contact between staff and service users, meeting with members of staff. The inspector would like to thank the service users and the staff team for their help in facilitating the inspection. The home manager Sandra Roche has resigned from the post of manager at Ryelands and a temporary management structure has been put in place until a new manager is appointed. Overall the inspection confirmed that the home continues to provide a good standard of care to the people living there. What the service does well: What has improved since the last inspection? The home has a policy on the receipt, recording, storage, handling, administration and disposal of medication. Although there has been some improvement in the recording on Medicine Administration Record Sheets, there were still some gaps in the medication records. The home must ensure all medication records are filled in correctly. The supervision record at the home demonstrated that there has been an improvement in the frequency of staff supervisions at the home although they Ryelands DS0000007194.V285217.R01.S.doc Version 5.1 Page 6 are still not happening as frequently as they should. This will be monitored again at the next inspection. 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. Ryelands DS0000007194.V285217.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ryelands DS0000007194.V285217.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The standards that the Commission for Social Care Inspection considers as the key standards were inspected at the previous inspection visit and found to be Met. Ryelands DS0000007194.V285217.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9 The service users have individual care plans, which include consultation with service users and their families. Care plans are regularly updated to ensure the service users changing needs are met. Residents’ medication is well managed to ensure good health, although there were still some gaps in recording. EVIDENCE: The service users are registered with a local General Practitioner at a local surgery. Service users who are prone to pressure sores had the necessary equipment for the promotion of tissue viability and prevention or treatment such as airbeds, soft cushions and heavy-duty foam cushions. Pressure sore risk assessments (Waterlow) are carried out and districts nurses routinely visit the home. The home has care plans in place that carries on from the original assessment. In the care plans sampled during the inspection, residents’ individual needs were identified and details on how those needs should be met were on files. The care plans are reviewed regularly and the staff team at the home monitor the plans and make regular entries to record daily activities and any areas of concern. Ryelands DS0000007194.V285217.R01.S.doc Version 5.1 Page 10 The home has a policy on the receipt, recording, storage, handling, administration and disposal of medication. Although there has been some improvement in the recording on Medicine Administration Record Sheets, there were still some gaps in the medication records. The home must ensure all medication records are filled in correctly. Ryelands DS0000007194.V285217.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not inspected on this visit. The standards that the Commission for Social Care Inspection considers as the key standards were inspected at the previous inspection visit and found to be Met. Ryelands DS0000007194.V285217.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 There is complaints policy and procedure, which facilitates good access to the complaints system for the residents, their family or their representatives. The home has the appropriate policies in place to ensure the protection of vulnerable service users. EVIDENCE: Ryelands has a complaints procedure, which outlines how a complaint is dealt with and timescales for action. The home keeps a record of any positive comments or complaints made about the service. The complaints record was available for inspection and the complaints received were appropriately recorded and investigated. The home has an Abuse policy and any concerns would be referred in line with the local authority Vulnerable Adults Procedure. The home has a copy of the local authority Adult Protection Policy on site. The staff team have access to training on Adult Abuse. Ryelands DS0000007194.V285217.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not inspected on this visit. The standards that the Commission for Social Care Inspection considers as the key standards were inspected at the previous inspection visit and found to be Met. Ryelands DS0000007194.V285217.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The staff team at the home have a range of skills and abilities, which enable them to meet the needs of the service users living at the home and ongoing training is provided to build on staff skills and safeguard the service users. The staff team have all had Criminal Records Checks, as a safeguard to offer protection to the home’s service users. EVIDENCE: The Care staff at the home is divided between the two units and the staffing levels were agreed during the registration process. Staff rotas were available at the time of the inspection. The Staff files hold copies of the staff contracts, copies of passports/birth certificates, references, confirmation that Criminal Records Checks have taken place were seen on all staff files, as well as induction records. The home offers training opportunities to staff at all levels within the home. The home has compiled a training profile of the staff team, which details the training completed by the staff team. The staff at the home have accessed a range of different training courses over the last twelve months including, Dementia care mapping, Care of medicines, person centred care, Reminiscence, National Vocational Qualification at level two and three, manual handling, first aid and challenging behaviour. Ryelands DS0000007194.V285217.R01.S.doc Version 5.1 Page 15 The staff members spoken to during the inspection made positive comments on their experience of working at the home. The job descriptions for staff at the home staff clearly states what is expected of its employees in terms of their roles and responsibilities and the values that should underpin their conduct. The service users spoken to during the inspection said that the staff team treated them well. Observations of the contact between the staff team and service users confirmed this. Ryelands DS0000007194.V285217.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,36,38 The management style is open and the home appears to be well run, although the manager post is vacant. The interests of the service users are safeguarded and their safety and welfare are protected. EVIDENCE: The home manager Sandra Roche has resigned from the post of manager at Ryelands and a temporary management structure has been put in place until a new manager is appointed. The registered provider must ensure that a suitably qualified individual submits an application to register as the homes manager. Service users’ personal allowances are kept separately and secure facilities are provided for the storage of this. Service users have lockable spaces in their rooms for the storage of their valuables or they can use the home’s secure facilities. Ryelands DS0000007194.V285217.R01.S.doc Version 5.1 Page 17 The manager and members of the senior staff team carry out the formal supervision sessions at the home. The supervision record at the home demonstrated that there has been an improvement in the frequency of staff supervisions at the home although they are still not happening as frequently as they should. This will be monitored again at the next inspection. Records indicate that fire drills at the home are not happening as often as they should. Fire drills should be undertaken quarterly, in line with good fire safety guidance. A fire risk assessment for the home has been completed. Ryelands DS0000007194.V285217.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X 2 X 2 Ryelands DS0000007194.V285217.R01.S.doc Version 5.1 Page 19 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 OP31 Regulation 9(1) (2) Requirement The registered person must ensure a ‘suitably’ qualified and competent individual submits an application to register as the homes manager, subject to a fit person interview with the Commission. The home manager must ensure that all members of the staff team receive regular supervisions. Timescale for action 31/05/06 2. OP36 18(1) 31/05/06 3. OP9 17 (1)(a) 33. (I) The registered person must 23/02/06 ensure medication administration records are correctly filled in at all times. The home manager must ensure fire drill take place quarterly in keeping with good practise. 23/02/06 4 OP38 23. (4)(e) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Ryelands DS0000007194.V285217.R01.S.doc Version 5.1 Page 20 No. Refer to Standard Good Practice Recommendations Ryelands DS0000007194.V285217.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ryelands DS0000007194.V285217.R01.S.doc Version 5.1 Page 22 - 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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