Inspection on 01/11/05 for The Raikes

This inspection was carried out on 1st November 2005.

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

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

Other inspections for this house

The Raikes 20/08/09

The Raikes 07/06/07

The Raikes 08/06/06

The Raikes 13/05/05

The Raikes 16/11/04

The Raikes 08/06/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE The Raikes Bradley Road Silsden Keighley West Yorkshire BD20 9JN Lead Inspector Carol Haj-Najafi Unannounced Inspection 1st November 2005 09:30 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 The Raikes DS0000001298.V259525.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Raikes DS0000001298.V259525.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Raikes Address Bradley Road Silsden Keighley West Yorkshire BD20 9JN 01535 653339 01535 653952 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) Crabtree Care Homes Mrs Catherine Lynch Care Home 31 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (18), of places Physical disability over 65 years of age (10) The Raikes DS0000001298.V259525.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: 13 May 2005 The Raikes is a detached property on the outskirts of Silsden, halfway between the towns of Keighley and Skipton. The home is set in attractive gardens with views across the surrounding countryside. The home is registered to provide personal care for up to 31 older people. Accommodation is provided in single and twin rooms on the ground and first floor. There are three lounges and a dining room. Two passenger lifts provides access to the first floor. A parking area is provided to the side of the property. The Raikes DS0000001298.V259525.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced inspection between 09.30am and 3.30pm. The purpose of the inspection was to ensure the home was operating and being managed to a satisfactory standard. The inspector spoke to seven residents, three visitors, two staff, the deputy manager and two of the responsible individuals. The inspector also looked around some parts of the home. Records were inspected including care plans, assessments, staff recruitment and training records, accident reports and financial records. Feedback was given to the deputy manager and a responsible individual at the end of the inspection. Currently there is not a registered manager in post. A new manager is due to start the week after the inspection. The deputy manager has been covering on a temporary basis. What the service does well: What has improved since the last inspection? The home records a more detailed and personal admission assessment to make sure they can meet the needs of residents who are moving into the home. The information that is recorded covers the reason why the resident needs to move into the home, family involvement and the type of help they need. Service user guides are given to each resident. Staff are more careful with administration and storage of medication. The same person who administers medication completes the medication record and medication cupboards are locked when not in use. Several staff have attended adult protection training. The deputy manager discussed how she would ensure residents are protected. The Raikes DS0000001298.V259525.R01.S.doc Version 5.0 Page 6 More regular staff meetings are held. This provides opportunities for staff to discuss things as a team. 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 Raikes DS0000001298.V259525.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Raikes DS0000001298.V259525.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3 The pre admission assessment process is good. Residents receive a guide which gives them information about the home, however, residents do not receive a statement of terms and conditions when they move into the home. A new statement of purpose should be available shortly, which will give residents and others more information about the home. EVIDENCE: The last inspection identified that more information about potential residents should be gathered before they move into the home. Pre admission assessments were looked at for two residents. The manager had visited them in their own home. A pre admission form was completed. A summary report outlining the reason for admission, family contact and key areas of need had also been completed. The reports were informative and gave a good overview of the individual’s personal circumstances. The last inspection also identified that the home’s statement of purpose should relate more specifically to ‘The Raikes’. This will then give clear information The Raikes DS0000001298.V259525.R01.S.doc Version 5.0 Page 9 about the home’s aims and objectives, its services and facilities. The document has been written and is currently being published. The responsible individual said the brochure should be ready in the next two to three weeks. This would then be discussed with staff and residents. Staff were familiar with the service user guide and confirmed the guides are issued to residents. Most residents have contracts in their personal file, however, the two residents recently admitted had not been given a statement. The deputy manager said contracts are generally sent out to relatives after the admission. Everyone should receive a statement when they move into the home so they are aware of the conditions that apply at the beginning of their stay. The Raikes DS0000001298.V259525.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Residents and relatives are very happy with the service. The home meets residents’ needs but their plans of care and assessments do not contain enough information, therefore it is not possible to confirm that needs are being met in the most appropriate way for each individual. Health care needs are met. Medication systems are well organised but staff are not trained to carry out invasive procedures. EVIDENCE: The inspector looked at four service user plans. Several assessments had been completed for each resident. Some assessments identified that extra care was needed to meet the resident’s needs. An example of this is the prevention of pressure care. Staff are taking the proper measures but this information is not included in the care plan. Staff said they do not read the care plans on a regular basis. All care plans need more information about the resident and should be reorganised to ensure the information is accessible. The Raikes DS0000001298.V259525.R01.S.doc Version 5.0 Page 11 Each staff is responsible for reviewing one or two care plans. These have been done on a regular basis. The responsible individual is looking at setting up a new care planning format that will be more person centred and accessible. Three residents talked about health care arrangements. They confirmed that a GP visits the home once a week, and they have an opportunity to see him in their room if they are unwell. They also said district nurses visit on a regular basis. A chiropodist visits every three months. All appointments are recorded. Residents and visitors were very positive about staff. When asked if the home provides good care, a relative said ‘the home does better than that it provides exceptionally good care’. Two relatives said the home contact health professionals promptly. Other comments included; the home provides a personal touch, staff always have time to talk, and they laugh with the residents. The last inspection identified that improvements should be made to medication procedures. These have been implemented and a new medication trolley has been purchased. Medication records were checked and correctly completed. One resident has suppositories administered on a regular basis. Staff who have not received training are administering them. This practice should only be carried out by staff who have received additional training. The Raikes DS0000001298.V259525.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 The menu accurately reflects the meals that are being served. EVIDENCE: Standards in this section were looked at and met at the last inspection. A recommendation to update the menu was made. Since the last inspection the menu has been updated to accurately reflect what meals are served. Therefore, residents are now more aware of what they will be eating. The Raikes DS0000001298.V259525.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Residents are comfortable in discussing and reporting concerns. An appropriate complaint’s procedure is in place. Service users are safeguarded from abuse. EVIDENCE: Residents were asked ‘what they would do if they were unhappy about something in the home’. They said they would discuss it with staff. The deputy manager said no complaints have been received during the past twelve months. The complaints procedure is included in the service user guide and is displayed in the home. The deputy manager and four staff have attended adult protection training, which was facilitated by Bradford social services. The deputy manager explained the procedure for reporting any allegations of abuse. Other staff have been allocated places on the adult protection training over the next six months. The Raikes DS0000001298.V259525.R01.S.doc Version 5.0 Page 14 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): 26 The home is clean and tidy and has a good laundry service. Some good improvements have been made to the bedrooms since the last inspection. EVIDENCE: The inspector looked around parts of the home, including bathrooms, communal areas, the laundry and some bedrooms. The home was very clean and tidy with no malodours. Residents, visitors and staff confirmed the home was always clean and tidy. Residents also said the laundry service was good. The person responsible for the laundry has a well-organised system to ensure clothing is properly laundered and returned. Several bedrooms have new furniture, carpets, curtains, and bedding. The deputy manager said approximately 75 of the rooms have the new furnishings. The Raikes DS0000001298.V259525.R01.S.doc Version 5.0 Page 15 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): 28, 29 & 30 Staff are very caring and provide good care. The recruitment process is poor, which could result in unsuitable persons working at the home. Staff have not received adequate training to equip them with the skills and knowledge to carry out their duties in line with legal requirements. EVIDENCE: Residents and visitors were very complimentary about staff. Positive comments have been highlighted throughout the report. Records for three staff recently recruited at the home were looked at. References and proof of identification had been obtained for all three employees. A satisfactory employment history was not available for two staff. And two staff had started working at the home even though a criminal records check or POVA first check had not been completed. Four staff have completed NVQ level 2. Three of the four staff have also completed level 3. However, there are still 75 of staff that are not qualified. No unqualified staff are enrolled or completing NVQ level 2. New employees should complete a planned induction and workbook. New staff have not had a formal induction or completed the relevant workbooks. The Raikes DS0000001298.V259525.R01.S.doc Version 5.0 Page 16 Five staff are completing a distance learning, administration of medication, course. The majority of staff have not completed recent mandatory training they require to perform their duties. This includes moving and handling training, fire safety, basic food hygiene and first aid. The Raikes DS0000001298.V259525.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Some financial records do not provide an accurate account of all financial transactions, therefore residents’ monies are not safeguarded. Staff have opportunities to discuss issues at staff meetings but they do not receive supervision which would enable them to discuss things individually. Shortfalls identified at this and previous inspections, such as training needs and financial records would have been picked up if regular and effective Regulation 26 visits were conducted. EVIDENCE: The registered manager has recently left her post. The deputy manager has been covering on a temporary basis. A new manager is due to start on the 6th November. Residents meetings are held, although there has not been a meeting since July. There are no formal quality assurance systems in place that are based on The Raikes DS0000001298.V259525.R01.S.doc Version 5.0 Page 18 seeking the views of residents. Visits to make sure the home is running properly should be carried out once a month. These are called Regulation 26 visits. The last visits were completed in June and July. Since the last inspection more regular staff meetings have been introduced. A supervision format is in place but staff do not receive regular formal supervision. Financial records are available for monies that are held in the home, on behalf of any residents. Although money that is obtained from bank accounts on behalf of two residents are not satisfactorily recorded. A discrepancy of £20 was identified. The last inspection highlighted the need to confirm financial arrangements for two service users who have the responsible individual acting as an agent/appointee on their behalf; this has still not been carried out. The responsible individual was unable to confirm the arrangements at the inspection but did agree to contact the relevant agency. One person signs financial records. A second signature should verify the transaction has taken place. The last two inspections have required the registered provider to confirm in writing that a competent person has serviced the hoists; the home has not yet confirmed this and service records were not available. On the day of the inspection, the responsible individual was arranging for the bath hoists to be serviced. A new accident monitoring system has been introduced, this enables the management to audit accidents that occur in the home. Weekly fire checks are carried out. The Raikes DS0000001298.V259525.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X 3 STAFFING Standard No Score 27 X 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 2 2 X 2 The Raikes DS0000001298.V259525.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 6 Requirement The registered person must review the statement of purpose, and ensure staff are familiar with the contents of the document. (Timescale of 28/02/05 & 31/07/05 not met). The registered person must ensure service user plans set out in detail how health, personal and social needs are to be met. (Timescale of 31/08/05 not met). The registered person must ensure staff receive appropriate training to administer medication. This refers specifically to administration of medicines by an invasive route. The registered person must not employ a person unless all the relevant information has been obtained. This refers to employment history and criminal record checks. The registered person must arrange for staff to receive suitable training in fire prevention. The registered person must DS0000001298.V259525.R01.S.doc Timescale for action 31/12/05 2 OP7 15 31/01/06 3 OP9 13 30/11/05 4 OP29 19 30/11/05 5 OP30 23 31/12/05 6 OP30 13 & 18 31/01/06 Page 21 The Raikes Version 5.0 7 OP33 24 8 *RQN 26 8 OP35 17 9 OP35 17 10 OP38 23 ensure staff have received training appropriate to the work they are to perform. This refers to moving and handling, first aid, basic food hygiene and induction The registered manager must introduce a system for reviewing the quality of care; this must include consultation with residents. The registered provider must conduct monthly visits and make available to the Commission a copy of reports produced under Regulation 26. (timescale of 31.08.04 & 31.01.05 31.07.05 not met) The registered provider must make available in the home financial arrangements and records for monies that are held on behalf of residents. This relates to the residents who have the responsible individual acting as an agent/appointee on their behalf. (timescale of 31.07.05 not met) The registered person must ensure all financial transactions carried out on behalf of service users are documented. This relates to cash/cheque withdrawals from resident’s bank accounts. The registered person must ensure bath hoists are serviced by a competent person (timescale of 31.07.05 not met) 28/02/06 31/12/05 31/12/05 31/12/05 31/12/05 The Raikes DS0000001298.V259525.R01.S.doc Version 5.0 Page 22 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 2 3 4 Refer to Standard OP2 OP28 OP35 OP36 Good Practice Recommendations The registered person should issue statements of terms and conditions to residents when they move into the home. A minimum ratio of 50 of care staff should have achieved level 2 or equivalent. All financial records should be signed by two people to verify the transaction has taken place. Staff should receive supervision at least six times a year. The Raikes DS0000001298.V259525.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 The Raikes DS0000001298.V259525.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!