Inspection on 01/08/07 for The Rookery

This inspection was carried out on 1st August 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Rookery 15/02/07

The Rookery 11/01/06

The Rookery 19/01/05

The Rookery 13/09/04

The Rookery 25/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood Hall

Muston Road (70)

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

CARE HOME ADULTS 18-65 The Rookery Woodland Lane Chapel Allerton Leeds West Yorkshire LS7 4PD Lead Inspector Carol Haj-Najafi Key Unannounced Inspection 1st August 2007 09:45 The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 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 Rookery DS0000001494.V344868.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 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. The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Rookery Address Woodland Lane Chapel Allerton Leeds West Yorkshire LS7 4PD 0113 2689598 F/P 0113 2689598 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) Leeds MENCAP Mrs Michelle Wilks Care Home 12 Category(ies) of Learning disability (11), Learning disability over registration, with number 65 years of age (1) of places The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th May 2007 Brief Description of the Service: The Rookery is situated in a residential area close to Chapel Allerton in the north of Leeds. The home is easily accessible via public transport and there is parking at the home for several cars. Local amenities including shops, banks, library, pubs and the post office are all within easy walking distance. Accommodation is provided over two floors with the less mobile service users having rooms on the ground floor. Communal areas consist of a lounge, quiet lounge, dining room, several bathrooms, laundry, and a domestic style kitchen. All laundering is undertaken on the premises. The home has a vehicle, which is utilised by service users on a regular basis. The standard fee charged by the home is £337.44 per week. This information was provided on 1 August 2007, during the inspection. The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out a site visit that started at 9.45am and finished at 6.00pm. During the inspection process all of the key standards were looked at to try and find out what it was like to live at the home. The last key inspection was carried out in February 2007. A random inspection was carried out in May 2007 and some of the details of this visit have been included in this report. An annual quality assurance assessment (AQAA) was completed by the home and this information was used as part of the inspection. Surveys were sent to staff and their responses have been included in the inspection report. One survey was received from a person who lives at the home. Feedback was given to the manager at the end of the visit. During the visit the inspector looked around the home, spoke to people who live at the home, staff and the manager. Care plans, risk assessments, healthcare records, meeting minutes, and staff recruitment and training records were looked at. A second inspector visited the home between 3.00pm and 6.00pm and spent two hours observing the care being given to a small group of people. Feedback was given to the deputy manager at the end of the observation period. What the service does well: What has improved since the last inspection? Care plans have been re-written, they were very good and a big improvement on previous care plans. Each file had good information about health and personal care. Staff said the new care planning process was much better and because everyone was involved they were real working documents. The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 6 One person who lives at the home discussed their care plan and said their keyworker had asked them what they wanted to do and had read through everything with them. A new complaints procedure, whistle blowing policy, vulnerable adults policy and procedure have been introduced. Guidance for transport charges have also been agreed. The home is brighter, more refreshing and more homely. Several areas have been decorated which has made a big difference; the kitchen, staircase and corridors, the small office and some bedrooms had been painted. Pictures, photographs and additional décor have been put up in communal areas. A new leather suite has been purchased for the lounge. New window blinds have also been purchased. The organisation is providing more support to the management team and this has resulted in better overall management of the home. The manager has worked hard and has successfully introduced changes that benefit people who live and work at the home. Staff are happier and feel staff morale and team work has improved. What they could do better: There is still some work to do on the care planning process. Some care plans had not been transferred to the new system and others needed more information, risk assessments had not been reviewed. Staffing levels have been low during the past few months. Staffing levels have limited the amount of quality time that staff have spent with people at the home. Staff and the manager said this was the main area that needed addressing and it would make a big difference if the home had a full staffing capacity. Staff still need to do some more training to make sure they have the right knowledge and skills. Staff need training that relates to learning disability and the specific needs of the people living at the home, safeguarding adults and challenging behaviour. There are plans to continue with the building work and the next phase is improving the ground floor bathrooms and fitting new vanity units in eight bedrooms. The manager said bedrooms that required decoration would be done after the vanity units were fitted. Requirements and recommendations to address the shortfalls have been made and appear at the end of the report. The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 7 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. The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Previous inspections and procedures indicate that a thorough admission process is carried out to make sure the home can meet the needs of people who move into the service. EVIDENCE: The same people have lived at the home for seven years so there was very little recent evidence for many aspects of this outcome group. The admission process was looked at during previous inspections and the relevant National Minimum Standards were met. The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s individual needs and choices are being clearly identified and the home is more focused on providing person centred care and supporting people to achieve their personal goals. EVIDENCE: Since the last inspection a new care planning system has been introduced. Staff said the new care planning process was much better and because everyone was involved they were real working documents. Three people’s care records were looked at. Care plans have been re-written, they were very good and a big improvement on previous care plans. Records explained what people like and dislike, what people want to do and how their needs should be met. For example one plan stated ‘I enjoy helping staff with chores like shopping, sweeping leaves, emptying bins and drying up’. Another plan stated ‘I lock my door when I go out’ and another one stated ‘I find it difficult to clean and dry my back’. The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 11 There was also good information about meeting any special needs. For example the plan for one person who does not communicate verbally clearly described how their communication needs should be met. Staff provided very specific details about the people who live at the home and how they look after them. These were consistent with what had been recorded in care plans. Plans were written in large print and plain English and had several photographs to support the written information. For example photographs of family members had been included. One person who lives at the home discussed their care plan and said their keyworker had asked them what they wanted to do and had read through everything with them. Some care plans had not been transferred to the new system and others needed more information, risk assessments had not been reviewed. The manager said she anticipated that all care plans and risk assessments should be in place by the end of October. Every Saturday or Sunday people attend a meeting and they discuss which staff will be on duty and they agree the menu for the following week. They also talk about other issues that relate to the home. This is good practice and engages people in the running of the home. The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The service is relaxed and homely and people have opportunities to do different things, although insufficient staffing levels restrict the lifestyle for people who need a lot of staff support. EVIDENCE: People who live at the home said they were happy. The following comments were made, ‘you have a crack with the staff, the food is good, I’ve got friends here, the holidays are good, I like it, staff are nice, and I like my key worker’. Interaction between people who live at the home and staff was observed. People were very relaxed, there was lots of conversation and humour, and it was evident relationships were very good. Two hours were spent observing the care being given to a small group of people. During this period staff interactions with people were good. They The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 13 showed warmth and respect. Staff gave explanations and reassurances for any interventions. Appropriate levels of support were given. Staff recognised the uniqueness of people’s needs. People were helping around the home and assisted with laying the table for the evening meal, washing and drying pots and preparing juice. People who live at the home also talked about cleaning their bedrooms, doing their washing and going out to do the food shopping. The AQAA stated that one person was in paid work, one person does voluntary work, one person attends college and three people attend evening classes. Others attend day centres. Staffing levels have been low during the past few months. Staffing levels have limited the amount of quality time that staff have spent with people at the home. Staff and the manager said this was the main area that needed addressing and it would make a big difference if the home had a full staffing capacity. Staffing levels were identified as a problem at the key inspection in February 2007 and the random inspection in May 2007. Staff said if they had more time with people who live at the home, they would be able to accompany them on more outings, help them to develop daily living skills and engage in more meaningful activities. Staff said they had to do many of the domestic tasks because they did not have time to support people who live at the home to do some tasks because it was more time consuming. The daily records for three people, covering a four-week period, were looked at. One person who goes out independently had an active and fulfilling lifestyle. They regularly went out and visited their relatives, went to local shops and into town, had been to the pub and had been busy around the home. There was less activity for the other two people. There was evidence of health and personal care and some engagement in daily tasks, for example preparing packed lunches, and they regularly attended day services but there was no evidence of other outings. Staff surveys were sent out before the inspection visit. There were mixed responses in relation to people’s lifestyles and the following are a sample of responses: • • • • • People who live at the home are happy most of the time The home puts people who live there first We promote and encourage independence Staff do not have enough quality time with people who live at the home There should be more stimulation and a better range of activities for people living at the home The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 14 Staff said people meet every Saturday or Sunday to decide what they want to eat the following week and a menu is drawn up. Staff and people who live at the home said the meals were good. Menus were looked at for the last three weeks. These were varied and nutritionally balanced. Staff said they make sure the menus are varied and monitor nutritional content. The inspector sat with people for the evening meal. It was well organised and relaxed, and people enjoyed the food. The AQAA completed by the home stated that people access their own mail and are supported by staff to read this. They are supported to maintain contact with families by letter and phone, and visitors are made welcome. It also acknowledged that they need to continue to make progress in areas such as being more person centred. The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Health and personal care needs are met and people receive the right support from healthcare professionals. EVIDENCE: Each file had good information about health and personal care. Care plans and assessments outlined healthcare needs and there was information about all healthcare appointments. One sheet confirmed the person had recently seen a GP, dentist, chiropodist and optician. Individual weight records were also maintained. One person had put on weight; this had being monitored. People who live at the home are supported to take their medication. The administration of medication was observed and this was administered appropriately. Medication is stored securely and only administered by staff who have been trained to do so. Medication records were looked at and had been completed correctly. The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Better systems have been introduced for dealing with complaints and protection but because staff have not received training in safeguarding adults, people who live at the home are not fully protected. EVIDENCE: People who live at the home said they talk to staff and the manager and would tell them if they were unhappy. All staff said they knew what to do if anyone raised a concern about the home. Since the last key inspection, the Commission received a complaint which related to a poor environment, insufficient recreational activities and inadequate staffing levels. These issues were looked at during the random inspection in May 2007 and it was found that the home was not meeting the required standard in these areas. As stated throughout the report since the inspection in May there have been some good improvements and everyone has worked hard to address these shortfalls. A new complaints procedure, whistle blowing policy, vulnerable adults policy and procedure have been introduced. Guidance for transport charges have also been agreed. The information has been given to people who live at the home, their relatives and staff. The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 17 A member of the Board of trustees from Leeds Mencap has completed training that equips her to train people in safeguarding adults and the manager said she would be doing a training session with the team. The manager had not received safeguarding training and only three out of eight staff had attended the training. Three people’s financial records were looked at. Personal monies were recorded on individual sheets. Every transaction was recorded and balances corresponded with the monies. Receipts were available. People who are able sign to confirm they have received monies. At the key inspection in February it was identified that staff should receive training to manage behaviours that challenge. The training had been arranged for June but the trainer had cancelled and it has been rearranged for the end of August. The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28 & 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The environment is brighter, more refreshing and more homely but because there is still outstanding building work, people do not yet live in a comfortable and pleasant environment. EVIDENCE: A tour of the building was carried out. All communal areas and bathrooms were visited and the majority of bedrooms were seen. The home was reasonably clean and tidy and was odour free, with the exception of one bedroom. There is an enclosed garden that people freely access. Bedrooms were personalised and each room had a lot of items that reflect individual preferences. This is good practice and demonstrates that everyone is encouraged to make their rooms homely. A new kitchen was installed and flooring laid at the beginning of the year. The last key inspection stated they were waiting for a new cooker, this had still not The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 19 been provided; the area manager said funding was available and they were exploring options. A new small domestic cooker has been installed and the manager said people who live at the home would use this. Several areas have been decorated which has made a big difference to the environment; the kitchen, staircase and corridors, the small office and some bedrooms have been painted. Pictures, photographs and additional décor have been put up in communal areas. A new leather suite has been purchased for the lounge. New window blinds have also been purchased. When people who live at the home showed the inspector their rooms, they also pointed out the photographs. One person said they liked having the photographs on the wall. The manager and staff said the improvements had made a vast difference and having a brighter and cleaner environment had improved the lives for people living and working at the home. The inspections in February and May 2007 identified that there were several areas of the premises that did not meet the National Minimum Standards and the Care Homes Regulations. Since May, Leeds Mencap has made a lot of improvements although some problems are still outstanding. This applies mainly to the bathrooms and decoration of bedrooms. Some flooring also needs replacing. There are plans to continue with the building work and the next phase is improving the ground floor bathrooms and fitting new vanity units in eight bedrooms. The manager said bedrooms that required decoration would be done after the vanity units were fitted. On the day of the inspection the area manager was meeting a plumbing engineer to discuss the next phase. The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. A caring and committed staff team support the people who live at the home. Better staffing levels would improve the quality of care because staff would have more time to spend with people who live at the home and support them to lead a more fulfilling lifestyle. EVIDENCE: On the day of the inspection, people who live at the home were supported by skilled staff who were caring, warm and knowledgeable about the people they care for. Staff were friendly and it was evident that people who live at the home were relaxed and comfortable with them. Staff said the team works well together and communication was good. They said teamwork and staff morale had improved. Staff said staffing levels were still a problem. The staff rota was looked at and most evenings there had only been two staff on shift and some weekends there were only two. Staff said when three staff were on duty, they could spend quality time with people in the home and take The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 21 them out. Staff are responsible for caring for people who live at the home, cleaning, cooking, laundry and shopping. The manager discussed what they have done to address the staffing shortfalls and they appear to have been very unfortunate because two staff were due to start work but had given back word at short notice. A domestic had started work but left after a short time. A relief member of staff has been regularly working at the home as a support worker and has been covering some domestic hours but this has not covered hours to the full staffing capacity. The manager has used some agency hours but agreed to look at increasing this to increase the number of shifts when three staff were on duty. She said sometimes they managed to get the same agency workers which helps with continuity. They were still actively trying to recruit staff. There is more information in the lifestyle section that confirms staffing levels have affected the quality of the service. Staff surveys were sent out before the inspection visit. There were mixed responses in relation to staffing and the following are a sample: • • • • • Staff thought the recruitment process was fair and thorough Generally staff said they thought they received up to date information about the needs of the people living at the home Staff thought the training was relevant to the role and it keeps them up to date with new ways of working Staff thought they would benefit from having more training about specific needs and equality and diversity Staff thought they needed more time to meet the needs of the people who live at the home and several thought having to complete domestic tasks took up a lot of time. Staff meetings are held every month. Minutes from the meetings were looked at and these demonstrated that new systems such as care plans and policies were discussed with the staff team. Staff said they received regular supervision. Staff training records were looked at. Staff had completed several mandatory courses and generally safe working practice training was up to date. The manager said they had worked through basic training and now wanted to look at training that would equip staff with specialist skills. She had been exploring options for specific learning disability training. Three staff hold National Vocational Qualifications (NVQ), level 2 or above. The deputy manager was completing her NVQ level 4. The manager said other staff The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 22 would have an opportunity to complete NVQs once they had done the learning disability training. A requirement to identify staff training needs was made at the key inspection in February 2007. Because management have concentrated on updating basic training it was agreed to extend the timescale for this to the end of October 2007. The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41 & 42 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The organisation is providing more support to the management team and this has resulted in better overall management of the home. The manager has worked hard and has successfully introduced changes that benefit people who live and work at the home. EVIDENCE: The manager has worked at the home for over sixteen years. She has completed NVQ level 4 in management and had just handed in her NVQ level 4 in care for it to be verified. The last key inspection and a random inspection identified that there were a lot of problems at the home. Since May 2007, there have been some good The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 24 improvements and even though there were still things that need doing, everyone was happier about the standard of care that was being provided. The manager talked at length about the changes that have been introduced and had a clear vision of areas that still needed to be developed. A new area manager started work in June and had spent a considerable amount of time at the home. A member of the board of trustees had also spent time at the home and helped the manager sort out some of the administration tasks. Staff and the manager said the involvement of the area manager and the board of trustees had made a big difference and they felt much more supported. At least once a month a senior manager or representative should visit the home and look at the general conduct, these visits are called Regulation 26 visits. A report must then be sent to the Commission. There have been regular visits to the home but Regulation 26 reports have not been completed. Several new policies and procedures have been written. Staff said these had been discussed at staff meetings. Copies of the complaints procedure were sent out to the relatives of the people who live at the home. A comments and suggestions form had also been sent out to relatives. Several forms were returned and the management team were looking at any suggestions. Quality assurance systems that are based on the views of people who live at the home were still being developed. It was agreed to extend the timescale for introducing a quality assurance system to the end of November to make sure there was sufficient time to introduce an effective system. As stated in the previous section, staff have completed safe working practice training. In the last six months, staff had attended food hygiene, first aid, health and safety and fire safety training. The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 2 32 2 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 1 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 3 3 3 X The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 3. Standard YA9 Regulation 13 Requirement Risks to people who use the service must be identified and assessed, and relevant action taken. This will make sure people who live at the home are protected and enabled to take responsible risk. (It was agreed that the timescale for completion should be extended from 30/09/07). This should make sure that risks are reduced. People who use the service must have opportunities to engage in community activities to make sure people living at the home have a more fulfilling lifestyle. (Timescale of 30/06/07 not met) Staff must be trained in safeguarding adults to make sure people who live at the home are protected from abuse. Staff must be trained in dealing with violence and aggression to make sure people who live at the home are safe and they receive appropriate support. The home must be reasonably decorated and properly maintained to make sure people live in a pleasant and safe DS0000001494.V344868.R01.S.doc Timescale for action 31/10/07 4. YA13 16 30/09/07 7. YA23 13 30/09/07 8. YA23 18 30/09/07 11. YA24 2313 30/09/07 The Rookery Version 5.2 Page 27 environment. 13. YA24 2313 There must be sufficient hot water supply for people who use the service to have a bath. Showers must be safe to use and in good working order. This will make sure people living at the home have safe and satisfactory bathing facilities. (Timescale of 31/07/07 not met). Staff roles and responsibilities must be defined. Catering and domestic tasks must not prevent care staff from carrying out their care responsibilities. This will make sure staff have enough time with people at the home to meet their needs. (Timescale of 30/06/07 not met). There should be more staff that have undertaken a nationally recognised qualification in care. (NVQ level 2 or equivalent) This will help staff to meet the needs of people living at the home. (It was agreed that the timescale for completion should be extended from 30/09/07) There must be sufficient staff working at the home to meet the needs of the people who use the service. This will make sure people living at the home have their needs met. (Timescale of 30/06/07 not met) A system must be introduced to identify staff training needs to make sure suitably trained staff are working with people who use the service. (It was agreed that the timescale for completion should be extended from 31/08/07) This must include training that relates to learning disability and the needs of the people who live The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 28 30/09/07 15. YA31 18 30/09/07 16. YA32 18 28/02/08 18. YA33 18 30/09/07 20. YA35 18 31/10/07 at the home. 24. YA39 24 A quality assurance system must 30/11/07 be introduced that measures the success in achieving the aims and objectives of the home. This will mean people living at the home have their views listened to and action taken to make sure the home continues to improve. (It was agreed that the timescale for completion should be extended from 30/09/07) The registered provider must 30/09/07 ensure regulation 26 visits are carried out at least monthly and these generate a report, a copy of which should be sent to the Commission. Visits must include obtaining the views of people who live and work at the home. This will make sure the organisation is aware of what is happening in the home and keep CSCI informed. 27. RQN 26 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 YA14 Good Practice Recommendations People who use the service should be given more support to engage in activities in the home. This should include spending quality time with staff and supported with daily living tasks. The Rookery DS0000001494.V344868.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 The Rookery DS0000001494.V344868.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. 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!