Inspection on 11/01/06 for The Rookery

This inspection was carried out on 11th January 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Rookery 01/08/07

The Rookery 15/02/07

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 Kathleen Firth Unannounced Inspection 11/01/06 11:30a The Rookery DS0000001494.V262596.R01.S.doc Version 5.0 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.V262596.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V262596.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Rookery Address Woodland Lane Chapel Allerton Leeds West Yorkshire LS7 4PD 0113 2689598 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) Royal Mencap (Housing & Support Services) 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.V262596.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th July 2005 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. Accommodation is provided over two floors with the less mobile residents having rooms on the ground floor. Local amenities including shops, banks, library, pubs and the post office are all within easy walking distance. The home is surrounded by large gardens where the residents enjoy barbeques in the better weather. There is also a recreational area providing a pool table, art equipment and musical instruments. Other games and a kitchen are also available in this area. The Rookery DS0000001494.V262596.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over three hours by one inspector on Wednesday 11th January 2006. The inspector looked around the building and examined residents’ records including care plans, finances, menus and risk assessments. Staff and residents were very helpful during the inspection and were happy to speak to the inspector. Four staff members and four residents were spoken to on the day. What the service does well: What has improved since the last inspection? The Rookery DS0000001494.V262596.R01.S.doc Version 5.0 Page 6 The files have been rearranged to allow easier access to information although there is still room for improvement. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Rookery DS0000001494.V262596.R01.S.doc Version 5.0 Page 7 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.V262596.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 Prospective residents can be sure that the home will meet their needs and aspirations following their assessment for admission. EVIDENCE: There have been no admissions to the home since the last inspection meaning that the last admission was five years ago. The home has an admission policy and process in place that will be used whenever a vacancy does arise. An assessment of need was done on all the present residents prior to their admission plus a social or healthcare worker was also involved. All of the residents can be sure that their needs and aspirations are met at the home. The staff are trained to work with people who have a learning disability and show a good understanding of their needs. They encourage the residents to live as independently as possible and offer the appropriate support to allow them to fulfil their ambitions. The Service User Guide is presented in a way that the residents can read and understand. All of the residents have an individual contract but at present these are at the Mencap head office being printed in a more appropriate format. The Rookery DS0000001494.V262596.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 8, 10 Records accurately reflect the needs of the residents and highlight any areas of risk. Residents are involved in the drawing up and review of their care plans. They are involved in all aspects of life within the home. EVIDENCE: All of the residents are involved in writing their care plans in some way and are made aware of any changes made following a review of care. Residents, families and social/healthcare worker are all involved in any review of care meeting. The manager is trying to make sure that reviews are done on an annual basis. The key workers review the care plans on a monthly basis and discuss any changes that are needed with the individual residents. Regular meetings with the residents are held and they are able to discuss anything they wish at these. Staff changes have been discussed recently as new people have started working at the home. Residents are given the chance to meet prospective staff members before they are appointed. Staff and residents eat their evening meal together and this offers a further opportunity for discussion between them. Summer holidays are a topic for much discussion at the present time. The Rookery DS0000001494.V262596.R01.S.doc Version 5.0 Page 10 Residents are aware that information is kept about them and that they can see this if they choose to. All information is stored in the office that is kept locked when no one is in. The files are in a lockable filing cabinet and confidentiality takes a high priority at the home. The Rookery DS0000001494.V262596.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 14, 15,16,17 The home offers a wide range of activities based on the residents’ choices and abilities. They are given opportunities for their own development and encouraged to take advantage of these. A good, healthy and varied diet is served at the home. EVIDENCE: Some of the residents attend college and study a variety of subjects including, horticulture, life skills and drama. One gentleman has achieved an NVQ level one in horticulture and has been involved in doing paid work in this area. He has recently resigned from his place of work due to transport problems and is being helped to find work closer to home. One lady does paid work one day per week and volunteers two days at an enterprise centre. Others attend centres of varying kinds where they take part in activities that suit their abilities and interests. The home offers a wide range of activities including group and one to one sessions. Going bowling, out for meals and to the cinema or theatre are just some of the things the residents do. Activities within the home are also popular. The residents are encouraged to make friends with people outside of The Rookery DS0000001494.V262596.R01.S.doc Version 5.0 Page 12 the home and are able to invite them to visit. They are given space and privacy when they do this. Staff and residents often spend the evenings discussing the events of the day and everyone is included in this. Family are able to visit the residents at any time and if agreed in their care plan can take them out. Residents are expected to take some responsibility for cleaning their rooms and there is a rota for helping in the kitchen/dining room at teatime. They set the table, wash up, empty the rubbish etc. If a resident needs a packed lunch they take responsibility for preparing this. The main meal is eaten at teatime with the home working from a five weekly menu. Two choices are always offered with an alternative if neither of these are suitable. The manager is looking at the menus at present with the idea of updating them. Looking at the menus during the inspection the meals appear to be good, varied and nutritious. If a resident has a visitor at mealtime they can either ask their guest to join everyone in the dining room or can choose to eat in a separate room. None of the present residents has a particular dietary need and the manager makes sure that everyone’s likes and dislikes are taken into account whilst serving a sensible diet. The Rookery DS0000001494.V262596.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 The physical and mental health needs of the residents are monitored and appropriate action taken to meet these. A medication policy and procedure is in place at the home. EVIDENCE: Personal care is offered in the privacy of the residents’ own room or in the bathroom and their dignity is maintained at all times. The type and amount of help offered to the residents is decided on an individual basis. The residents are given as much control over their lives as they are able to accept. All of the residents are registered with a local GP practice and the local healthcare team offers good support to them and the staff at the home. If required the resident is able to access good psychiatric support. Arrangements are in place to make sure that the residents receive chiropody, optical and dental care. The local dentist is used where possible but some of the residents have been referred for specialist care. None of the present residents are able to manage their own medication but the home has a policy and procedure in place to take care of this. They use the Boots system and the staff have been trained in this. Boots supply specific labels where the resident has to take medication out with them for the day. All of the medication records seen were correctly maintained. The Rookery DS0000001494.V262596.R01.S.doc Version 5.0 Page 14 The home has a dying and death policy in place. The manager stated that although she tries to raise people’s wishes following their death some residents do not want to talk about this. It was explained that this discussion should be recorded on the individual’s file. The present residents all have someone who would arrange a funeral for them. The Rookery DS0000001494.V262596.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Residents and their families have their views listened to and any complaints are acted on. Their rights are respected and residents are protected from abuse. EVIDENCE: The home has a complaints procedure and policy in place that meets the required standard. No complaints have been received since the last inspection. Residents are able to talk to the manager and staff team if they have any concerns and good interactions between them were seen during the inspection. There are policies in place to deal with physical and verbal aggression and staff know what to do if one particular resident becomes volatile. Psychologists and Psychiatrists are involved with individual residents where a need has been identified. None of the staff have had Adult Protection training although these modules will have been completed on the NVQ level 2 and the manager is looking into arranging specific training for everyone. The home has adopted the Leeds Multi Agency Adult Protection policy and all staff are made aware of this. If staff have concerns about particular residents they are able to talk to the people working in the day care centres that they attend. Observing the residents and their reactions to things is important to the manager and staff team. The residents are registered to vote although the manager said that only one person had done so at the last election. The Rookery DS0000001494.V262596.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 29, 30 The home offers a safe, well-maintained, comfortable environment for the residents and provides appropriate toilet and bathing facilities. EVIDENCE: The home is decorated and furnished to a good standard and the manager stated that she has easy access to workmen if required to maintain the house in good order. The communal rooms offer plenty of space for residents to take part in individual or group activities. Residents choose the decor for their bedrooms and have personalised these with their own possessions. The bedrooms are very much their own space and the residents’ privacy is respected and maintained. Rooms looked at during the inspection were done so in the company of the individual residents. There are sufficient baths and showers in the home to meet the needs of the residents. Toilets are available in different areas of the home. The home is clean and tidy throughout and there were no unpleasant odours present. None of the present residents require any specialist equipment to retain their independence. The manager is able to access this if the situation changes. The Rookery DS0000001494.V262596.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 36 Staffing numbers and skill mix make sure that the residents’ needs can be met. Residents are protected by the recruitment policies in place. EVIDENCE: The home is fully staffed at present with two members of staff recently joining the team. Written references, CRB and POVA checks were obtained before the new staff members were allowed to start working at the home. They both had an induction period where they shadowed another staff member and they will be undergoing statutory training in the near future. There were sufficient staff on duty at the time of the inspection and staff spoken to confirmed that this is normal practice. Staff appear to have a good understanding of each other’s role and responsibility. Staff meetings are held on a monthly basis and supervision sessions are in place. An agenda is available for all staff meetings and everyone can contribute to this. Minutes are made available for everyone. Staff spoken to said that they were happy working at the home and that the manager offers them good support. The new staff stated that they had found the shadowing period very useful. Staff have easy access to appropriate training and are working on LDAF (Learning Disabilities Award Framework) courses and NVQ. The staff group work well together and support each other. The Rookery DS0000001494.V262596.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38, 40, 41, 42, 43 The home has an effective communication system and the interests of the residents are seen as important at all times. EVIDENCE: The manager has a level 4 NVQ in management and is working on level 4 in care. Once this is completed she will start working on the Registered Manager’s Award. Staff said that she offers good support to them and good interactions were seen between her, staff and residents during the inspection. Residents came to the office on several occasions and she dealt with their questions in an appropriate way. Health and safety is the manager’s responsibility although she has delegated some tasks to other staff members. One person has been trained in PAT testing and takes responsibility for this. All staff are trained in Health and Safety and take it in turn to be involved in the monthly safety checks at the home. Fire bells are tested and evacuations done every week and the fire service visit on an annual basis to carry out the necessary checks. The Rookery DS0000001494.V262596.R01.S.doc Version 5.0 Page 19 All records seen about the residents were correctly maintained and up to date. Everything was seen to be stored in a correct manner. People are able to raise any issues they may have with the manager and staff and are encouraged to attend the regular residents’ meetings. The Mencap Management team visit the home and meet with the residents as often as possible. The main accounts are done at the head office and records concerning spending monies for the residents were seen to be correctly maintained. Each resident has an individual record and a box for their money and these are stored in the safe. The Rookery DS0000001494.V262596.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X 3 X 2 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 3 3 N/A 3 LIFESTYLES Standard No Score 11 3 12 3 13 X 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 X 3 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Rookery Score 3 3 3 2 Standard No 37 38 39 40 41 42 43 Score X 3 X 3 3 3 3 DS0000001494.V262596.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA 32 Regulation 18(1) Requirement 50 of staff must be qualified to NVQ level 2 or equivalent. Timescale for action 31/12/06 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 YA 43 Good Practice Recommendations A clear key should be provided either on the risk assessment form or at the front of the file. Files still need to be organised in a better way to make it easy to access specific information. Staff need to discuss with residents their wishes following death and record these. If residents or family do not wish to discuss this matter this should be recorded. Resident’s contracts should me kept on their file at the home. 2 3 YA 21 YA 5 The Rookery DS0000001494.V262596.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Rookery DS0000001494.V262596.R01.S.doc Version 5.0 Page 23 - 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. 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