CARE HOME ADULTS 18-65
The Rookery Mill Common Road Walcott Norwich Norfolk NR12 0PF Lead Inspector
Mrs Judith Last Unannounced Inspection 2nd October 2007 09:45 The Rookery DS0000027307.V352241.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 DS0000027307.V352241.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 DS0000027307.V352241.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service The Rookery Address Mill Common Road Walcott Norwich Norfolk NR12 0PF 01692 650707 01692 650330 janithhomes.com@btconnect.com www.janithhomes.org Janith Homes Limited 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 Alfred Finlay Care Home 30 Category(ies) of Learning disability (30) registration, with number of places The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 4th August 2006 Brief Description of the Service: The Rookery is a care home providing personal care and accommodation for 30 adults with a learning disability. It stands in a rural area on the outskirts of the Norfolk seaside village of Walcott. The service is owned and operated by Janith Homes Ltd, who also operate four smaller services for the same client group within the same area. It is based around a small farm where rare breed animals are raised. The complex also encompasses holiday accommodation which people use with their own carers. The service operates as a community with people attending for day services. There is also a strong artistic ethos with one of the farm barns having been converted into a large studio where artists work with and alongside service users. A separate company operates the holiday accommodation, working farm and art centre. These do not fall within the Care Standards Act and do not therefore need to be registered. The living accommodation is largely in the main house with some separate purpose built and converted units. Bedrooms are currently a mix of single and double occupancy. Information about fees is not clearly set out in the Service User Guide as published on the internet. Terms and conditions do set out additional charges for transport and staffing for requested activities and outings, (but not for health care appointments,) hairdressing, dry cleaning and personal spending. The website and Service User Guide say that the inspection reports are available on request at the home. The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Care homes are judged against rules that look at outcomes for people living in them. These rules tell us how well a home is doing overall. We visited the home unannounced. One inspector was there for 10 hours. A specialist inspector came too and looked at the way medicines were managed in the home. We got information from 20 comment cards that staff had helped people living at the home to complete. We got information from six staff (four in writing and two we spoke to). Five relatives wrote to us and we spoke to three of them on the telephone. We also spoke to five of the people living at the home, looked at some parts of the home, and listened to what was going on. We got other information from things that the home sent to us and from the records that they keep. We also looked at the history of the home and some of the things people had told us they were worried about. Some things the home does very well. Other things are not so good. Because there are concerns about some things to do with health and welfare, the rules say that the home is a poor one. There are other areas the manager needs to concentrate on that have “slipped”. What the service does well:
The home gets good information about the needs of people who think they might like to move to the home. The manager has tried hard to think of different ways that they can make information about the home easier to understand and get hold of and is still working on this. People told us they have lots of things to do to keep them busy. This includes doing artwork, working on the farm, going on outings and holidays, and going to college. There are lots of the things people have made in the Art Barn around the home, and sometimes there are exhibitions to show these, including exhibitions overseas. The staff team work very hard in sometimes difficult situations to try and make sure that people can do the things they would like to do. Relatives say that people living at the home have a good quality of life and are well supported by staff. They also say that the people they visit are very happy in the home. The home is good at recognising the way people express their sexuality. The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 6 People, especially in the cottages, have nice, clean homely places to live in where they can choose what their room looks like. Some people like to have lots of things they have collected or made around them. Others like things to be tidier. New staff have to have an introduction to the home to make sure they have some basic training to help them understand the work they are going to do. They get through this quite quickly and say that it covers things they need to know quite well. People can study for the National Vocational Qualifications they need. What has improved since the last inspection? What they could do better:
There are 23 things that the home needs to do by law, and we think that the manager has not been able to monitor things to make sure that things are kept up to date properly. The guide for people who might want to live at the home does not contain the information the law says it must have. The law about this was changed in September last year, and the information needs to be revised so that people or their representatives can make an informed decision about whether they want to live at the home. Six of the things that must happen are to do with the way medicines are kept, given to people and recorded, as well as the training that staff have about medication. The management of medicines is poor. We have written to the manager separately about these as well as putting them in this report.
The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 7 There are some things the home needs to do to make sure that people are not at risk of harm or abuse. These include things like being clear in writing how staff are to manage behaviour for each person, and training staff in understanding the behaviour they are faced with. The manager also needs to make sure that decisions made about people’s money are handled properly and transparently to protect people and the service from allegations. Specific staff training has not been kept up to date, for example, in first aid, food hygiene or moving and handling. Staff are also expected to deal with people who have specific problems and for which they have had little or no training (for example dealing with challenging behaviour, dementia, diabetes and autism). Records need to show that staff have proper supervision so that they can discuss their training needs more frequently as well as the way they are working with people. Some people need one staff member to support and supervise them at all times. This means that there are less staff to work safely with the remaining residents and support them with the things they need and want to do. Staff do not always have up to date information about people’s needs to follow. Sometimes the information is not specifically about the needs of each single person, but is general guidance. Some staff do not follow the instructions the information contains about how to make sure things are as safe as possible when they are working with people or taking them out. This means that they, a member of the public and the people they are working with, could get hurt. Although the home has improved some of the things about the way they recruit staff, there had been a slip at this visit, which meant a staff member had been taken on to start work before the checks the law says are needed had been properly made. This could place people living at the home at risk. The manager has the full report and can give people more information about these things, as well as the suggestions we have made that could help to improve things, but are not required by law. 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 DS0000027307.V352241.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 DS0000027307.V352241.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): 1 and 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 this service. Prospective residents could be confident that their needs would be assessed. There must be improvement in the content of the Service User Guide so that people, or their representatives, have access to the full information, however they choose to gather it. EVIDENCE: The Service User Guide is published on the Internet or can be made available in paper copy in an information pack. The self-assessment completed by the manager states that this is made available. Fees, methods of payment and charges are covered in terms and conditions of residence. However, the Service User Guide as published on the Internet does not provide the information about fees that amendments to regulations in September 2006 require. A requirement has been made. The manager says there are plans to improve the information available to prospective service users by developing a DVD of life at the home within the next 12 months. He has identified that the service could improve, (and would exceed this standard), if an introduction package was developed in alternative formats. This would better suit differing abilities and communication needs. The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 10 The information for one person admitted recently was checked. An assessment of the person’s needs was recorded and completed. Information had been gathered about the person’s needs from a previous placement. Risk assessments had been carried out promptly addressing areas of known difficulty – for example road safety, travelling in cars and severe allergic reaction. There was an initial personal profile completed on the day of admission involving interests, dislikes and dietary needs. There was evidence that other professionals were involved in providing guidance such as in relation to challenging behaviour. The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 11 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, 8 and 9 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 this service. Although care plans identify where people can develop independence, taking risks into account, they are not consistently maintained as up to date, recording practices are not always of the best and guidance could be clearer and more specific. Where clear guidelines are in place regarding identified risks, everyone must follow them until such time as the risk is identified as minimal. There is room to improve the way people feel they participate and make decisions about aspects of life at the home. EVIDENCE: There are care plan files and keyworker files accessible in the office so that staff can be up to date with what needs people have and how they are to be met. Generally care plans focus on what people “can do”, adopting a positive approach to encouraging people to maintain or develop skills. Comments from four staff show that they feel they are kept up to date with people’s needs.
The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 12 The Guide to Challenging Behaviour is a standard document contained in the case files that we checked rather than being person centred. However, there are separate management sheets showing behaviour for individuals and known triggers that might cause agitation. The Guide itself refers to not using punishment, but that “some privileges may be withdrawn after calm discussion and agreement.” None of the guidance makes clear what is considered a privilege or who the withdrawal of these should be agreed with, (for example purchasers or behavioural specialists), as part of a valid treatment plan. As some service users have difficulties communicating they may not understand any “agreed” removal of privileges after the event or what this was intended to achieve. A requirement has been made. The standard Guide also says that it may be necessary to move the person to a quiet area away from others. It does not record how or what action to take should the person not be agreeable to this and potentially need to be moved against their will in the interests of the person’s safety of that of others. We spoke to people about their keyworkers and people could tell us who they were and said they got on well with them. One person said that they did not want a keyworker and we saw that this choice was respected and recorded. This is good practice. There is a good range of risk assessments that reflect people’s individual difficulties and activities and how risk may be minimised. They also reflect where it may not be safe for people to do particular things they might like to, such as going out unaccompanied or being vulnerable financially. However, the manager does not consistently sign any of these despite retaining accountability for monitoring the accuracy and reasonableness of the assessments. A recommendation has been made. People living at the home sign some of them if they are able to do so. We discussed one risk assessment with staff, dated July 2007, relating to travelling in cars. It is clear that there have been problems from information confirmed by the deputy and that also came to us in a complaint. Recorded incidents show a risk that the person will try to open doors, pull people around and undo their safety belt. From discussion it is clear that some staff contravene the assessment by taking the person out alone, (substantiating concerns raised with us by a complainant). Staff must follow it in order to protect the safety of the person, their own safety, and that of others who may be affected. If this is not so insurances may not be valid and an accident may be more likely. A requirement has been made. If the risk is considered to be historic the risk assessment updated in July 07 is not an accurate reflection of the situation. The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 13 Although much of the information is reviewed on a regular basis, there are out of date items on files, including the keyworker files to which staff make regular access. On one of these we found instructions to staff to follow a toileting programme. The manager says the information about this that was on the file was not up to date. Another file contained a report called “residents review information” dated 9/11/04. A requirement has been made. People told us that they did things like helping to keep their rooms clean and that they had chosen décor and furniture. There is a catering committee, set up before the last inspection and still operating. Service users are not yet involved in recruiting and selecting staff, although the manager says that there are plans to try and introduce this to the recruitment process. Of the 20 people completing comment cards for us, 15 (75 ) felt that they were involved in making decisions in their home. One felt that they were not involved and four felt they were sometimes. This area could be developed further. The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 14 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, 15, 16 and 17 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 this service. People are able to engage in activities that meet their needs and preferences, and efforts are made to use the local community. The way that mealtime routines and menu preferences are developed could be improved to increase satisfaction in this area and also to combat institutional practices. EVIDENCE: Two thirds of the staff team have had some training in signing to help them understand and communicate with people they care for and the manager has plans to try to increase this by training some staff in more depth. This would be a welcome development. People have some educational opportunities in the community and also through the day care facilities offered by the organisation. During our visit a keep fit session took place and we heard, (from the sounds of laughter and singing), that the people involved clearly enjoyed this. We saw other people were engaged in activities in the Art Barn and there are
The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 15 regular exhibitions of people’s work together with lots of things around the home that people have produced. 95 of people completing comment cards say that they always have lots of things to do. One person (5 ) says they do sometimes. All of the people we spoke to say they have lots of things to do and told us what these were. Two people told us what they had done on their outing that day. Records support that people have opportunities to go out on shopping trips for example, to the sensory room, and on holidays. One relative commented specifically in a written comment card that the staff worked well as a team and supported not only the person living at the home, but the family as well. Four out of six relatives responding say that the home always supports the person to keep in touch with them. Two people feel this could be improved. One person’s care plan sets out that they are to be prompted/encouraged to send cards and letters home, but records do not show that this happens (i.e. that the care delivered in this area reflects that set out as necessary or desirable). A recommendation has been made. One relative was not confident that they were told about appointments or doctor’s visits until after the event and said that sometimes staff were rude on the telephone. All of the people we spoke to told us they were able to keep in touch with their families and one person said that they had been able to visit their brother while they were on holiday in the area during the summer. People’s sexual needs are recognised in care records together with how this may be expressed and guidance for staff in managing this. This is good practice. As at the last inspection, we did not see that people were supported with meal preparation in their cottages and potentially staffing continues to affect the ability to do this and so encourage some independent living skills on a regular basis. Some people do their own breakfasts. In the evening, there is still the practice of people collecting their meals from the kitchen hatchway to take to their table if they eat in the dining room, or back to their own cottages. However, we did not hear raised voices in the dining room as we had on the last fieldwork visit to the home. The mealtime seemed more relaxed. There is a catering committee involving some service users, and two thirds of the people completing comment cards (with staff support) say that they “always” like the food. A third of people completing comment cards say they like the food “sometimes” rather than always. A recommendation has been made. The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 16 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 and 20 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Predominantly this is due to a lack of consistent training to provide staff with the underpinning knowledge they need to understand people’s health conditions properly. There are also poor practices concerning the way various medicines are handled and recorded and the way staff are trained to do this. These mean the health care needs of people are not being met appropriately, consistently and safely and complications may not be recognised. EVIDENCE: The staff group is mixed and so service users have some choice about the gender of people who support them. One person is provided with one-to-one support from people of the same sex. The manager says in the service’s selfassessment that someone of the same sex provides personal care to people living at the home. Care records show what people can manage for themselves and how they should be encouraged even in small tasks such as putting on their own shoes. One person told us they managed their own personal care, but appearance suggests that additional prompting may be necessary to maintain dental health and oral hygiene. The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 17 Records show that people have appointments made for them where their health condition presents concern. The people we spoke to told us that staff would help them to go and see their doctors when they needed to. One person confirmed they had been recently because they had not been well. We heard staff reassuring them about the temporary medication needed for the condition and about their recovery. This is good practice. We were told that staff support people who need to go to hospital, including if they have to stay there. This means people have a familiar face with them in what could be a distressing environment. This is good practice. However, we are concerned about how well staff are trained to understand the complex needs of those with autism. They need to know how to manage routines and structures so as to minimise risks from difficult behaviour associated with this. Just under half of the staff have had training specific to autism recently (in July). Two others have had other training linked to autism (one in 2005, and one not since 2003). A complaint raised with the Commission recently suggests that this area of training is underdeveloped and training records support this. See also comments under staff training. One person has need of a hoist and wheelchair. Moving and handling training is not up to date for some staff. For example, training dates show 7 people (over a quarter of staff) have had no moving and handling training since 2005. One person has complained to the Commission about a lack of training in this area, and another complaint in July concerned what was felt to be inappropriate moving and handling practices. The manager has identified that this training is needed and we have been informed that it has now been arranged. However, given a lack of up to date training for staff and two consistent and separate sources of information expressing concern in this area, we cannot conclude practices have been wholly safe. None of the staff, based on training records supplied, have had specific training in epilepsy. This is despite records showing that several people have seizures and that some are sufficiently severe to require the occasional use of rectal diazepam. Training records confirm that two people have had training in diabetes awareness and another may have had as the record is marked with a question mark and no date. Only four staff have had any training in understanding and dealing with dementia, which is also present in the home. Requirements have been made. People’s emotional health is considered when their needs are set out. We saw on one file that issues of depression and possible complications of the
The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 18 menopause were also taken into account. Records show appointments with consultants or other specialists as necessary. This is good practice. There are letters on files showing that where people have glasses, for example, they are supported with appointments with the optician as needed. Our specialist pharmacy inspector looked at the way medication is handled in the home. Detailed findings are included in a separate pharmacy report sent to the home. A summary of the evidence follows and requirements and recommendations are included at the end of this report. Some medicine had been removed from its original packaging and so was not appropriately labelled. Although we were told this action was taken to restrict the numbers of such medicines available it is poor practice. The filing cabinet and kitchen storage cabinet do not meet the current standard for medicine storage. There is institutional practice in relation to the administration of medicines, with this being collected at the serving hatch with the person’s meal. The person accepting responsibility for preparing medicines into the pots and for signing the records, may not be in a position to see when they have finally been taken. The involvement of two persons in the procedure for the administration of medicines is set out in the medicine policy, but this does not retain accountability and is unsafe practice. We saw during the process that the record of administration was often completed before the person had actually taken their medication. There were also omissions from the record where it had not been signed. Staff meeting minutes show that the manager raised this concern at a meeting on 29th August. The management team have clearly not adequately addressed and monitored the issue since raising it at the meeting. A cabinet in one of the cottages was inspected. One resident has a locked cabinet within their room where penfil insulin currently in use is stored. Back up supplies of insulin are kept in a refrigerator within the unit in a locked metal tin. However, the temperature of the refrigerator is not monitored or recorded to ensure the insulin is appropriately stored. The medication administration record (MAR) charts are printed by the pharmacy. The deputy manager confirmed there has been confusion when the pharmacy has both printed inaccurate quantities of medicines supplied on the charts and continued to print medicine entries for medicines that have been discontinued. This has mostly been resolved. However, during inspection there were at least two medicines available for administration to residents for which there were no corresponding MAR chart medicine entries. For these medicines The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 19 there were no means by which the medicines could be safely checked and prepared for administration. Where doses of medicines have been altered during the period to which MAR charts relate, this had been recorded in case notes, but was not clearly shown on the MAR chart. For some medicine not supplied in monitored dosage packs there was no audit trail in place because there was no means of reconciling records of medicine receipt and administration against quantities of medicines available. This is despite the manager being advised to ensure proper audit trails were in place following a recent investigation (in August), and agreeing that standards had slipped in this regard. For example, one resident had received 56 tablets at the start of the current MAR chart period. There were a total of 31 tablets since administered so there should have been 25 remaining, but there were 52 tablets indicating a surplus of 27 tablets. This means records do not show that all medicines are being given as prescribed. There are also concerns about the service keeping training in the administration of rectal diazepam up to date for people who have severe epilepsy. There was a list of people authorised to administer this in one person’s case notes, because outings should be undertaken with such trained staff accompanying. However, the list included people whose training was not up to date. For another resident administered insulin by care staff there was no such list of those trained and authorised. The inspection attempted to establish that all members of care staff currently authorised to access, handle and administer medicines had received appropriate levels of training to undertake medication-related tasks. There was no list of authorised staff with specimen signatures/initials to audit MAR chart records. There were 7 members of care staff who had received training on the administration of insulin by injection. Each most recently attended a training event in January 2006. The deputy manager confirmed that a specialist nurse at the Diabetic Centre provided this. It was also confirmed that since then, the deputy manager has provided training on site. One member of staff currently said by the deputy to be authorised to administer insulin by injection had not attended the specialist training event. The deputy manager on duty confirmed that community registered nurses attending the home had had no input in ensuring that members of care staff were competent in insulin administration. This is despite this being considered to be a delegated task. The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 20 See six requirements and five associated recommendations made under standard 20. The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 21 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 and 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 this service. We cannot conclude that measures, including training and monitoring, contribute wholly to upholding people’s rights, the protection of people living at the home and to a positive approach to the management of complaints. However, there are issues that have been recently raised as of concern and which are not yet concluded that may provide more supporting information regarding the home’s performance in this area. EVIDENCE: The manager has responded to one complaint made to the home within appropriate timescales. He indicates positive response to part of the complaint in terms of needing to organise more moving and handling training. There is a complaints procedure and information in the Service User Guide also gives details of how people can contact the Commission. One of the people we spoke to told us that they could speak to the manager if they were concerned about anything. Other people spoken to identified their keyworkers as being who they would go to. Of the 20 comment cards we received from service users, 17 people knew who to speak to. (85 ) Five out of six relatives completing comment cards say they know who to go to if they have concerns, but only four people feel the service has always responded appropriately when they have raised these. The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 22 We have had three complaints between May and September. Where we have found concerns that correspond to these we have included information in the report. We noted at our last inspection that inappropriate sanctions had been imposed, although we did not see records on this occasion suggesting that the process continued. There are concerns, however, about any withdrawal of privileges which might be imposed following an episode of challenging behaviour, (see section on individual needs and choices). We had a complaint from someone who perceived that staff responded with physical contact that may have been more than was necessary, although the manager records in his investigation that this was not handled inappropriately, but was misconstrued. However, training details supplied show that only a quarter of staff have had any form of training in dealing with challenging behaviour. This would cover managing aggression and de-escalation techniques, and safe holding practices if they were needed. Without such training staff may inadvertently respond inappropriately because the home has not equipped them with the training they need to ensure a consistent, well planned approach to managing such situations. A requirement has been made. We have had additional information from two separate sources that practices for attempting to promote continence have not been appropriate in the past. The manager says that a programme we found on a file in current use was never put into practice. One document we saw was recorded with a start date of September 2005 and reviewed in October 2005. This was followed with another document dated November 2005. We consider it inconsistent that a programme the manager says was never introduced was reviewed and had a start date recorded and another document with additional interventions superseded it. It is also ill advised that the programme, if not intended to be used, and other inappropriate guidance was left accessible to staff rather than being removed. The information contained in the guidance was broadly consistent with the two complaints. See requirements made under other sections about the need for up to date information at all times. The service has notified the Commission of an allegation of financial abuse. It was identified that staff had not been following the appropriate procedure and this had not been identified in time to prevent the abuse from developing. The manager says he has taken action to recompense people. The police are investigating this matter. Records show that people have spent sums of money on furnishing their rooms including carpets and curtains. These are not transparent in showing the decision making process and the level of subsidy that the home should provide given that furniture would normally be provided by the service under the terms and conditions of residence. The general manager says that people would only fund this sort of expenditure if they wanted something over and
The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 23 above what was generally provided or chose to furnish and re-carpet before existing furnishings had reached the end of their useful life. A recommendation has been made. The manager says he has completed a training course and is able to deliver training to his staff about awareness of vulnerable adults at risk. Training records show the majority of established staff have received this. Staff who have not, now need to complete it. The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 24 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 and 30 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 this service. People benefit from living in an environment that is homely and suited to their needs, as well as providing for some of the benefits of living in small groups. EVIDENCE: We did not make a detailed inspection of all areas of the service. However, we did see four separate cottages/bedsits where people can live in smaller groups, the classroom area, hallway of the main home and part of the grounds. The areas we saw were homely and people’s rooms reflected their interests, hobbies and preferences. People told us that they helped to keep their rooms clean and that they had chosen how they were furnished. Fire detection systems are tested regularly and serviced, based on records seen. Maintenance issues and decoration problems are clearly identified by the person who visits on behalf of the registered providers as well as by routine reporting and a schedule is kept of when these are attended to. Improvements have been made to areas immediately around the cottages
The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 25 including improved lighting and an area with potted plants of different smells and textures. In some cases people have been assessed as able to have their own keys, although one person had lost this and told us they would like a replacement. However, they did say that they locked themselves in the room when they wanted privacy, even though they could not lock it when they went out. Another person had a key and used it. The laundry is situated externally and so washing does not have to be taken through areas where food is prepared or stored. Some people take their own washing to the laundry. The manager’s own assessment of the service shows that 16 out of 27 staff have training in infection control. Training matrices do not record this separately. However, we noted that staff have access to appropriate protective equipment where they need this. There is policy guidance and some reminders are posted in the laundry. The kitchen would be difficult to clean thoroughly given the items left laying on the windowsill and the top of the medication cupboard situated in the main kitchen was very dusty. A recommendation has been made. Areas of the home that we saw on this visit, were generally clean, (with the minor exception notified above). The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 26 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): 32, 33, 34, 35 and 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 this service. Care staff are often working hard in very difficult and stressful situations without necessarily receiving support to develop skills that will help them meet people’s needs safely and consistently. Not all newly recruited staff had sufficient checks and so people were placed at potential risk. (This is in contrast to the normal practice of the home.) There are good opportunities for people to work towards external qualifications. EVIDENCE: There is some overlap between the shifts allowing for extra staff in the daytime to help with activities. The deputy manager confirmed to us that there were five staff on duty for the late afternoon and evening of our visit. However, two people need 1:1 support to manage risk or behaviour. This means only three staff were available to support the remaining 27 people living at the home. This compromises the ability of staff to support people in smaller groups and in their cottages, compromising any benefit they may get
The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 27 from small group living. There is also potential risk given epilepsy, challenging behaviour, continence and mobility difficulties noted in care plans. None of the staff feel there are always sufficient staff on duty to meet individual needs. Two commented that on some shifts, levels are very low and we have had concerns expressed to us that staffing at weekends can be a particular problem. A requirement has been made. Eleven full time and two part time staff have left the home in the last twelve months. A complainant indicates that some of this is due to the way things are managed at the home, (for example continence as set out in the complaint). Another complainant told us they had left because they found it too distressing to return after their first shift due to the concerns they had about the way staff responded to people living at the home. We have no additional evidence for this, but a turnover of approaching 50 will have an impact upon people living at the home, particularly for example, those people with autism who need very settled structures and routines to support them. Staff training records do not support that staff are adequately trained in the skills they need to deal with challenging behaviour. Although the home deals with people whose behaviour can present significant challenge, less than 25 of the care staff have any training at all in relation to behaviour that challenges. One of four staff commenting to us say that they could do with training in this area, and this is supported by supervision notes we saw. See requirement linked with standard 23. Comment has been made elsewhere regarding training in autism or autistic spectrum disorders. The training matrices confirm the information given on the self-assessment about the numbers of people with NVQ qualifications and those working towards it. The 50 ratio of care staff with the qualification is not yet achieved, although if the numbers of staff working towards this complete the qualification and are retained in the service it will be met. Completed induction workbooks were seen and show that these cover the required standards. They are completed in a timely manner and signed off by the manager. This is good practice. Three staff comments show they feel induction is good. One considers it mostly covered what they needed to know to be able to do the job. Recruitment records show a more robust effort to gather full employment histories and explanations of gaps. This represents an improvement since our last visit. However, one staff member started work without the necessary references and clearance against the register for the Protection of Vulnerable Adults, (POVA). The POVA First, (the initial disclosure), was not received until 9 days after the person started work at the home. See requirements. Four staff say the manager meets with them regularly to give them support and discuss how they are working. However, records do not support that this
The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 28 is a formal process. At present one person is responsible for supervision where two did this previously and staff do not receive adequate formal supervision regularly. See requirements. Food hygiene training was said to be offered regularly, although training matrices do not seem to be being monitored to see when this training is due to be updated. For example we saw that the record for one person showed it was due for renewal in September 2005. Sometimes care staff need to carry out catering tasks and should be involved as part of encouraging and supporting service users to develop these skills. A requirement has been made. We were informed that some training had already been booked to address some of the shortfalls identified when we visited, while the report was being written. We anticipate significant improvements in this area at our next visit. The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 29 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 and 42 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 this service. The manager is appropriately experienced, but we do not consider he has been able, (possibly due to his span of control and shortfalls in other management support), to robustly monitor the home’s performance under the key standards and regulations on a day-to-day basis. There are shortfalls in ensuring that systems are implemented fully to adequately promote the health, safety and welfare of people living at the home. The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 30 EVIDENCE: The manager is appropriately qualified, experienced and registered in respect of the service. Training records show that he undertakes periodic training to make sure he is up to date. Information in the service’s self assessment says that Mr Finlay has completed training in the awareness of abuse of vulnerable adults that enables him to train his staff team. This is good practice. It is apparent that, in some cases, procedures have not been consistently followed (e.g. management, recording and checking of finances) and that this has not been promptly picked up. Identified problems, (e.g. failure to sign medication administration records), have not been adequately followed up to ensure they are adhered to and shortfalls rectified. Quality assurance surveys are carried out regularly, but the general manager could not show that the feedback from those obtained earlier in the year had yet been analysed and incorporated into any specific plan for improvement. See requirement. There are regular monthly monitoring visits on behalf of the registered providers. There are shortfalls in ensuring that all staff have up to date training in health & safety, moving & handling and first aid. The home has arranged some of this training since we visited. There are concerns that “appointed persons” first aid training, (which needs renewing every three years), has lapsed in some cases. For example one person last did this in February 2004, one in December 2000, and one in September 2004. Similarly, basic first aid, which should be repeated annually has not been undertaken by some staff since 2005. A requirement has been made. There was no evidence that the hoist acquired in March 2006 has been serviced and checked every 6 months as required by Lifting Operations and Lifting Equipment Regulations. This means it has not been certified as being safe in usage. A requirement has been made. We saw that electrical systems were tested to ensure safety. A report says that the wiring in the main home is poorly installed and needs to be replaced in the “next few years”. This information comes from the servicing undertaken in 2004. The remedial action has not yet been taken. A recommendation has been made. The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 31 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 2 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 2 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 1 x 2 x 2 x x 2 x The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 32 Are there any outstanding requirements from the last inspection? Yes – only in part 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 YA1 Regulation 5 Requirement Timescale for action 31/12/07 2. YA6 12.1, 15.1 People who live at the home or who are thinking about moving there, must have the information the law says they need. This is so they or their representatives can make an informed choice about moving into the home. It is also so they can be sure of the arrangements for charges or increases in these. Partially outstanding 30/11/07 requirement. Where people have behaviour that is difficult to manage, guidance must be clear and specific for each person. This is so that each person receives intervention that is properly tailored to their own needs, abilities and understanding. (This relates to the requirement made at the last inspection that care plans set out clearly how people’s needs are to be met) The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 33 3. YA6 12.1, 13.1, 13.6 4. YA6 YA23 5. YA9 6. YA18 7. YA18 8. YA19 Where intervention is considered necessary to modify behaviour, clear guidance must be set out and validated by other professionals as being acceptable, reasonable and workable. This is so that things do not happen to people that will not be in their best interests. 15,17.3 Guidance for staff about how to meet people’s needs and support them properly, must be up to date so that staff do not inadvertently place people at risk by supporting them in the wrong way. 13.4 Staff must follow guidance considered necessary to reduce risks. Failure to do so increases the likelihood of accident and risk to both staff themselves and people living at the home. 18.1 Staff who have not completed recent training in understanding and working with people with autism, must have this. This is so they better understand how people should have their needs met and can work in a way that minimises the risk of difficulties, distress and anxieties for people with the condition. 13.5 Staff must have training in techniques for safely moving and handling people, so that neither staff nor residents are at risk from poor or inappropriate techniques. 12.1,18.1.c Staff must have training in understanding the health conditions (e.g. diabetes, dementia and epilepsy). This is so they can properly support people in managing their conditions and recognising potential effects and complications.
DS0000027307.V352241.R01.S.doc 30/11/07 30/11/07 31/10/07 28/02/08 31/12/07 28/02/08 The Rookery Version 5.2 Page 34 9. YA20 13.2, 13.4 10. YA20 13.2, 13.4 People who use the service must have their medicines administered directly from original pharmacy-prepared containers. Medicines must remain appropriately packaged and labelled at all times. This is so practice and procedures help protect people from error or misuse. People who use the service must have their medicines administered by staff who follow safe procedures for their administration. Records for the administration of medicines must be completed immediately following their administration. This is so practice and procedures help protect people from error and make sure that they get the treatment they need. People who use the service must have their medicines requiring refrigeration stored within the correct temperature range. Daily records must evidence this. This is so people receive the medicines they need and these are still effective and safe to use. People who use the service must have records of prescribed medicines with indicated prescribed doses at all times. Changes to prescribed doses must be safely and accurately documented. This is to help make sure people receive the right dose of medicines and help to protect them from error. 31/10/07 31/10/07 11. YA20 13.2, 13.4 31/10/07 12. YA20 13.2, 13.4 31/10/07 The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 35 13. YA20 13.2, 13.4, 17 People who use the service must have their medicines administered in line with prescribed instructions. This must be evidenced by recordkeeping practices. This is so people receive the medicines they need at the time and dose is considered necessary to keep them well. People who use the service must have their medicines administered by staff who have received recent and appropriate training and have been designated competent. 31/10/07 14. YA20 18.1.c 31/10/07 15. YA23 YA32 18.1.c, 13.5&6 16. YA33 12.1, 18.1 17. YA34 13.6,19 This is to help protect people from errors and to make sure they receive the treatment they need safely. 31/03/08 Staff must have training in managing and responding to challenging behaviour, and in safe holding techniques where this may be necessary. This is to avoid people or staff being placed at unnecessary risk of harm and so that staff are supported to understand the behaviour and are confident in their responses. Staffing levels must be reviewed 31/12/07 to ensure that the need to provide 1:1 support for people does not compromise the care available to other people living at the home. There must be adequate checks 30/11/07 completed on staff in line with Department of Health guidance, before staff start work at the home. This is so the manager can ensure people are not put at risk from unsuitable staff. The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 36 18. YA35 18.1, 16.2.i 19. YA36 18.2.a 20. YA39 24 21. YA42 13.4 22. YA42 13.5, 23.2.c Staff need to have training to make sure their food hygiene knowledge and practice is up to date. This is they are sure they understand how to minimise risk of harm to people from food contamination. Staff must be supervised with the agenda and frequency set out in national minimum standards. This is so staff receive adequate supervision and support to ensure they understand their roles fully, can support people in line with the home’s philosophy and so that any initial problems with staff performance can be addressed. The views of stakeholders must be incorporated into an audit of service quality so that their views inform development and improvement of the home. This is so people living at the home and significant others can be confident their views are taken into account in service development. Staff must receive the necessary updates in first aid training to ensure that all shifts are appropriately covered and prompt action can be taken in the event of accident. This is so the health, safety and welfare of people is adequately promoted and protected. The manager must contract to have moving and handling equipment serviced regularly. This is to ensure unnecessary risks to the health and safety of staff and people living at the home are avoided. 31/12/07 31/12/07 31/01/08 31/12/07 30/11/07 The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 37 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 YA9 Good Practice Recommendations Assessments, risk assessments and other case records should be signed by the person responsible for completing them and also by the manager. This is to show accountability for accuracy and that the manager is properly monitoring content to make sure they reflect people’s needs. Records of care delivered should be monitored to show that they match what the care plan has set out as necessary or desirable. This is so the home can show the support given is directly related to people’s needs. Opportunities should be increased for people in the smaller units to make better use of their facilities for the preparation of meals, to encourage development/practice of skills and better fulfil the stated aims and objectives for the home. There should be wider consultation on choices of food to increase the satisfaction people have with this area of the service. It is recommended that cabinets meeting the standard be obtained for the storage of medicines. Consideration should also be given to obtaining a medicine trolley to administer medicines to residents in the main building This is so medicines are safely stored and administered. 6. YA20 It is recommended that regular audit trailing and reconciling of medicines against records is undertaken to promptly identify and resolve discrepancies arising This is so the manager can be sure people are receiving medicines as they are prescribed, that there is no misuse, and people are protected by the way medicines are handled. 2. YA15 3. YA17 4. 5. YA17 YA20 The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 38 7. YA20 It is recommended that adjustments are made to care plans for the management of psychological behaviour and agitation as identified during the inspection This is so staff have clear and up to date guidance for when medication may be needed. It is recommended that a specimen signature/initial list is put in place for all members of care staff authorised to manage medicines This is as an aid to monitoring processes and so accountability for giving people their medicines as prescribed is better demonstrated. It is recommended that once training has been provided the competence of members of care staff authorised to manage medicines is assessed on a regular basis via supervision events This is so the manager can be confident that staff remain competent to administer and record people’s medicines safely and accurately. The manager should devise clear guidance and policy on the usage of clients’ monies where significant amounts of money are being spent. The guidance should identify the limit beyond which consultation with service users representatives should begin and evidence that this takes place. This is so the home is protected from allegations of abuse, and so that people living at the home are protected from actual abuse. The kitchen cleaning schedule should include the exterior of the cupboard used for medicines, and “clutter” should be kept to a minimum to make cleaning easier. This is to people are protected from risk of any infection or contamination of their food. The rewiring of the main house should be scheduled as recommended the last time it was tested. This is to ensure concerns are addressed before the system presents a risk to staff or people living at the home. 8. YA20 9. YA20 10. YA23 11. YA30 12. YA42 The Rookery DS0000027307.V352241.R01.S.doc Version 5.2 Page 39 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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
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