Inspection on 15/02/07 for The Rookery

This inspection was carried out on 15th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 no outstanding requirements from the previous inspection report, but made 27 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Rookery 01/08/07

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 15th February 2007 09:45 The Rookery DS0000001494.V325579.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.V325579.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.V325579.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 268 9598 0113 268 9598 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) www.mencap.org.uk 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.V325579.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th January 2006 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 pre inspection questionnaire stated the fee charged is £329 per week. The Rookery DS0000001494.V325579.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk. The last key inspection was carried out in January 2006. A pre-inspection questionnaire was completed by the home and this information was used as part of the inspection process. Surveys were given to service users and healthcare professionals and responses have been included in the inspection report. The Commission has recently received two complaints and a concern about the home. The issues related to the management of the home, the health and welfare of service users and staffing. These areas were looked at as part of the inspection process. One inspector carried out three site visits. On the first day, the inspector only spent 2 hours at the home because everyone was going out, the second visit lasted 6½ hours. Feedback was given to the manager and a member of the board of trustees four days after the second site visit. During the visits the inspector looked around the home, observed staff and service user relationships, spoke to service users, staff and the registered manager. Care plans, risk assessments, healthcare records, financial records, meeting minutes, and staff recruitment and training records were looked at. What the service does well: The same people have lived at the home for a long time and know each other well. They have weekly meetings and discuss which staff will be on duty and agree the menu for the following week. They also talk about other issues that relate to the home. Everyone said the meetings were good and service users enjoyed receiving information about who would be working at the home for the week ahead. Service users said they were satisfied with the home. The following comments were made, ‘I like it here, I’m happy, if staff are going out they say would you like to come, I have different jobs to do’. The Rookery DS0000001494.V325579.R01.S.doc Version 5.2 Page 6 Service users are encouraged to be involved in daily tasks and this varies on their levels of independence. A cat lives at the home; service users are very fond of her and share the responsibility of looking after her. What has improved since the last inspection? What they could do better: This inspection identified 29 requirements and 2 recommendations. Service users should be provided with information about how much their placement costs. Some information in the care files was out of date and some care needs and risks had not been properly assessed, which could result in care needs and safety being overlooked. More information must be recorded to make sure the health and welfare of service users can be properly monitored. Service users pay for a vehicle but there were no records about how much they have to pay. Some service users do not use the vehicle very often even though they pay towards it and because of the lack of drivers service users sometimes have to use and pay for taxis. This system must be looked at to make sure payments are fair and service users are getting value for money. There have not been enough staff working at the home and this has led to service users not having many opportunities to go out or to spend much quality time with staff in the home. The manager has not had time to carry out many of her management duties. Staff have not been given opportunities to attend training which they need to carry out their duties. The organisation has not had effective systems in place to monitor the running of the home. They have not had clear procedures in place for people to voice concerns. The home is not well maintained or decorated and this has resulted in service users living in unsatisfactory conditions. The Rookery DS0000001494.V325579.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.V325579.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.V325579.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&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Previous inspections and procedures indicate that a thorough admission process would be carried out before service users could move into the home. Service users have not been provided with details of the home’s charges and the amounts paid by or in respect of each service user. This prevents service users or their representatives from having access to information which they are entitled to see. EVIDENCE: No service users have been admitted to the home since 2000, therefore there was very little recent evidence available 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 last inspection identified that service user contracts were not available in the home. Three files were looked at during this visit. Two files had a contract, one did not. The section on the fees charged was left blank. The Care Homes Regulations state service users must be provided with details of the total fee payable in respect of the service they receive. The Rookery DS0000001494.V325579.R01.S.doc Version 5.2 Page 10 The pre inspection questionnaire stated the current charge is £329.53 per week. The contracts have been written with pictures and text to help service users understand the terms and conditions of their stay. There was clear information about terms and conditions including responsibility for payments of haircuts, clothing and toiletries. This is good practice because it gives service users information in an easy read format. One service user was over the age of 65. Staff and the manager said the home was suitable and able to continue to appropriately meet their needs. The Rookery DS0000001494.V325579.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 & 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The care planning and risk assessment process must improve to make sure everyone is safe, receiving the right support and given opportunities to develop. The weekly meetings are very good and they give service users information about what is happening the following week. EVIDENCE: Three service user files were looked at. Each service user had several different documents that provided information about their care needs. Some of the information was good and provided specific guidance on how care needs should be met although the plans did not cover all key areas because some information was missing and other information was out of date. One file had aims and objectives that had been reviewed in September 2006 but the care plan, which accompanies the aims and objectives, was not available. A care plan review referred to the main care plan but there was no other care plan available. The Rookery DS0000001494.V325579.R01.S.doc Version 5.2 Page 12 There was no evidence that service users had been involved in the care planning process. Staff said they do not generally read care plans. Personal information that related to likes and dislikes and medical information was originally written in 2001. Staff had continued to use the same sheets when updating information but this was confusing because it was difficult to establish which information was the most recent. For example one section stated ‘awaiting referral re eating’ although it was not easy to establish the information had been written several years ago. The manager said care plans were evaluated monthly but evaluation records did not reflect this. For example one care plan had only been reviewed in November 2005, April 2006 and January 2007. There was little evidence of individual risk assessments. A file with risk assessments was available but risks that were identified at the inspection, through records and discussions, had not been assessed. This included some daily living tasks and behaviour. There had been a serious incident that had involved a knife. A risk assessment had not been completed and sharp knives were still stored in the kitchen drawers. Each service user has a life storybook and significant events are recorded. This is the document that is most commonly used by staff. Two life storybooks contained details of what the service user had done and this gave a good overall picture. One book only had eight entries over the last fifteen weeks, of which four related to contact with family, one related to being hit by another service user and another related to bruising. The manager said new staff, as part of their induction process would read through six months of the life storybook. Effective care plans would provide more consistent guidance for new staff. In addition to the life story books, staff complete a daily record but this tends to be one or two words, for example if they have been out to day care it will just state the name of their day care service. Therefore this does not provide information about general health and welfare. The manager said she had recently been talking to staff about developing the care planning process. A relatively new member of staff said the manager had said it was important to read service user’s individual care records. Every Saturday service users 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. Everyone said the meetings were good and service users enjoyed receiving information about who was working at the home the week ahead. This is good practice and engages service users in the running of the home. The Rookery DS0000001494.V325579.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Meals at the home are good and service users enjoy being involved in planning menus. Service users are supported to maintain contact with family and friends. Recreational activities on a weekend and evening are not stimulating and must improve. EVIDENCE: Service users said they were satisfied with the home. The following comments were made, ‘I like it here, I’m happy, if staff are going out they say would you like to come, I have different jobs to do’. Service users also talked about the different things they do. Several talked about their day care placements and appeared to enjoy these. One service user said they liked sewing and playing the guitar. Another service user said they had good holidays. The Rookery DS0000001494.V325579.R01.S.doc Version 5.2 Page 14 Service user records contained very little information about activities at the home or outings. One service user said they would like to go out more. Staff were concerned that there were very limited opportunities to go out with service users, and over recent months outings were very few and far between. Staff said sometimes one service user will accompany them shopping but generally service users do not do the main house shopping. There had been occasions when staff had had to go out and buy toiletries for service users because there were no opportunities to take service users out. Staff said they had not had as many opportunities to spend 1-1 time with service users. Service users attend various day centres. Eleven service users attend day centres five days a week. One service user attends different placements including voluntary work. Three service users go to organised activities two nights a week. Service users are encouraged to be involved in daily tasks and this varies on their levels of independence. One service user said she helps change her bedding but staff clean the bedroom and do the washing. Another service user said he tidies his room and talked about doing the house shopping at the supermarket. A cat lives at the home; service users are very fond of her and share the responsibility of looking after her. One relative sent a letter thanking staff and the manager for doing a good job looking after their relative. One relative completed a survey on behalf of the service user. They stated that the service user was happy, there was a happy atmosphere at the home and the manager and staff are excellent and make them welcome when they visit. They also stated some staff don’t stay. One service user talked about ringing their relative every weekend and organising visits. Staff and service users talked about involvement with families and friends. Staff said service users meet every Saturday to decide what they want to eat the following week. A list of preferences is recorded and then meals are decided for each day. Staff and service users said the meals were good. Staff said planning meals the week ahead worked very well. Menus were looked at for the last four weeks. These were varied and nutritionally balanced. The Rookery DS0000001494.V325579.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Routines are generally flexible but bedtime routines should be reviewed to see if anyone would like an opportunity to stay up later. Service users receive support with healthcare but the home does not have systems in place to make sure all healthcare needs are being met. EVIDENCE: When asked about times for getting up, going to bed and bathing, service users said they decide. One service user said ‘I can go out when I want to and get on with my own thing, staff say it’s your home and you can make a cup of tea when ever you want one’. The home does not have waking night staff working and service users have to go to their rooms before 10 o’clock. Staff and service users thought this worked satisfactorily. There is no written record of this and it has not been formally explored to establish if everyone is fully satisfied with the arrangements. The Rookery DS0000001494.V325579.R01.S.doc Version 5.2 Page 16 Healthcare records for three service users were looked at. It was very difficult to track when service users had last attended healthcare appointments because they had only been recorded in the general notes. One service user’s personal information stated that dental appointments were attended every six months but the last appointment was in March 2006. Staff and management have consulted healthcare specialists for advice and guidance. Detailed behaviour plans had been written by the healthcare professionals. One service user was attending a healthcare appointment on the day of the inspection. Another service user said they tell staff if they are unwell. Two surveys from healthcare professionals were returned. They both stated the home seeks advice and acts upon it to improve healthcare needs, and respects individual’s privacy and dignity. One stated individual health care needs are always met, one stated usually. One healthcare professional wrote that the home has a lovely atmosphere and if there was more money the staffing levels could go up. Medication records were looked at and had been completed correctly. Staff only administer medication after they have completed medication training. The Rookery DS0000001494.V325579.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not have an open culture that encourages service users or staff to talk about things if they are unhappy. Staff do not feel confident and are not appropriately trained to deal with aggressive behaviour. Service users’ monies are not safeguarded. EVIDENCE: The complaints procedure was not displayed in the home at the time of the inspection. The manager displayed a copy once this was pointed out but had to hand write the telephone number of the Commission because it was not included. The inspection highlighted areas where the quality of the service has not been satisfactory over recent months and this has included service users not having sufficient opportunities to spend time with staff or go into the community. Leeds Mencap must look at how it can promote service users rights to voice concerns. Staff were not familiar with the whistle blowing policy and generally did not know who they could approach outside the home if they had concerns. The whistle blowing policy was looked at and it did not have details of who staff could contact from Leeds Mencap if they were concerned. The Rookery DS0000001494.V325579.R01.S.doc Version 5.2 Page 18 Complaints received by the Commission raised concerns that there was not a clear management structure in place for staff to use if they wanted to raise concerns. Concerns were raised that staff did not have the knowledge and skills to appropriately deal with aggression. Staff have not attended any relevant training. There had been incidents in the home when staff had to deal with very volatile situations. The manager said violence and aggression training was planned for the near future. Service users finances were looked at. Staff generally obtain receipts for transactions. Service user’ money that was held at the home was separated into three different funds. One that management access, one that staff access and a joint fund. This was confusing because some of the joint funds were being used for individual expenditure. There was not a clear record of monies that were used to pay for daycare activities. Records did not have a separate income and expenditure column, therefore it was difficult to establish what money was credited and which was debited from the account. The home has a car and people at the home make a financial contribution of £12.30 for the cost of the home’s vehicle, which totals £147.60 per week. One service user said they go in the car now and again. Staff said that there were only a few people that could drive the vehicle and therefore there were occasions when it could not be used. Transport records were looked at and although the car was used regularly it was generally to take certain service users to day centres and do the house shopping. The records do not identify which service users have travelled in the vehicle. The cost of the vehicle for service users should be reviewed to make sure it is equitable and they are getting value for money. There were no records at the home that evidenced transport costs. There were financial transactions when service users had paid for taxi fares. The manager said if taxis were used because of staff or driver shortages, the home should fund these. This policy had not been followed and the manager agreed to look at this. The Rookery DS0000001494.V325579.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The home is in a poor condition; it is not well maintained and there are many areas that need decorating. 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 generally odour free. There is an enclosed garden that service users freely access. Service users were keen to show their bedrooms and were very clear this was their personal space. Bedrooms were personalised and each room had a lot of items that reflected individual preferences. This is good practice and demonstrates that everyone is encouraged to make their rooms homely. New kitchen units and flooring have recently been installed. They were waiting for a new cooker to be delivered before they decorate. The Rookery DS0000001494.V325579.R01.S.doc Version 5.2 Page 20 There are four main communal areas, kitchen, dining room, lounge and quiet room. Service users regularly use three of the communal rooms and were seen to walk freely around the home. The decoration in communal areas is generally unsatisfactory. Paintwork had discoloured and looked grubby, woodwork and plaster was damaged and several ceilings had cracks in them. It was evident that certain areas had not been decorated for some considerable time although the main lounge was reasonable. Service users do not use the small lounge very often but it was not very inviting and was used to store various items. Bathrooms were also in need of some attention. Baths have stains and some piping is rusty. Some of these issues must be addressed because the finishes are not readily cleanable, therefore this can cause problems for preventing the spread of infection. The water pressure is low in all bathrooms which results in baths taking a very long time to run. There have been on-going problems with showers and these have recently been attended to however, the temperature of one shower was very hot and it was not possible to hold your hand underneath it. Another shower had to have the hose wrapped around the shower unit for it to work properly. The shower cubicle in a downstairs bathroom was very loose. New fire doors have been fitted but these need attention because they are heavy doors that slam shut. This is a potential risk. Some bedrooms had maintenance problems i.e. handles missing, loose tiles, damaged wallpaper. These problems should be addressed and a system to identify and remedy future maintenance issues must be introduced. One bedroom had a net sellotaped to the window. Staff confirmed it was to keep out flying ants, which is apparently an annual problem and the service user has to move out of their bedroom. The registered provider must demonstrate that it has taken all reasonable steps to address this problem. There was a supply of wipes, gloves and toilet rolls throughout the home. In most bathrooms and the laundry there was antibacterial hand wash. Washable towels are used for hand drying although three areas did not have a towel. The provider must ensure facilities are appropriate to prevent the spread of infection. The registered manager said she has an annual budget for the maintenance of the home. Leeds Mencap have set some money aside to improve the general environment and they are planning how they can develop the home to increase levels of independence for some service users. The Rookery DS0000001494.V325579.R01.S.doc Version 5.2 Page 21 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are not enough staff and this has had a direct impact on the quality of care. Staff are not properly trained, therefore they do not have the knowledge and skills to perform their duties. EVIDENCE: The home has had a high turnover of staff, several staff have left in the last twelve months. Concerns were raised that staff had left because they were unhappy about the general running of the home. There was a problem with staff shortages and only the manager, deputy, two seniors and one care staff were employed to work at the home, although three bank staff that previously work at the home were also covering shifts. A high volume of agency staff had worked over the past few weeks. Staff said all service users basic needs were still being met and they still received a good service but the amount of quality time that staff could spend with service users has diminished. The Rookery DS0000001494.V325579.R01.S.doc Version 5.2 Page 22 Staff are responsible for caring for service users, cleaning, cooking, laundry and shopping. Most weekends and evenings, when service users are at home, only two staff are on shift. As stated in the lifestyle section this has restricted the amount of time that staff can spend with service users and opportunities to go out into the community. The home does not have waking night staff but two staff sleep there. Two staff talked about the recruitment process and confirmed that they had attended an interview. One staff member talked about the induction programme and confirmed they had completed an induction checklist. Recruitment records for two staff were looked at. Both files had an application form, two references and a satisfactory criminal record check. However, one application form had a fifteen year gap in the employment history and one file did not have a reference from the most recent employer and both references were from employment in 2003. Staff training records were looked at. There were major shortfalls in staff training and the majority of staff had not completed mandatory training courses. Two staff had not done any training. Only three staff which included the manager had done fire training, although this was several years ago. The manager said all staff needed to do heath and safety training. Four staff had done adult protection training. Three staff had food hygiene certificates; all staff that cook meals did not have the relevant qualification. Three staff hold National Vocational Qualification (NVQ) level 2 in care or above. Staff have recently started receiving staff supervision although this has not been regularly provided over the past twelve months. Five staff meetings have been held in the past twelve months; these provide opportunities for everyone to talk about things that are relevant to the home. The manager said she tried to make sure all staff had opportunities to talk about different topics and put forward suggestions. The Rookery DS0000001494.V325579.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, 38, 39 & 42 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The manager has not had the right support or time to carry out her duties and the management of the home has suffered. The health and safety of service users and staff is not protected. EVIDENCE: The manager has worked at the home for sixteen years. She has completed NVQ level 4 in management and was doing NVQ level 4 in care. The manager said she has had to spend a lot of time covering shifts because of the shortage of staff and this has resulted in less management time. The Rookery DS0000001494.V325579.R01.S.doc Version 5.2 Page 24 The manager was honest about problems at the home and it was appreciated that a member of the board of trustees attended the verbal feedback session and showed a commitment to put things right. Concerns have been raised about the management of the home and this came from various sources. Issues included a resistance to move the home forward, staff were not appropriately supported, procedures were not followed, equal opportunities were not promoted and effective strategies were not in place that enabled people to voice concerns. 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. The chief executive for Leeds Mencap was responsible for completing these but is no longer working for the organisation. The last regulation 26 report was dated November 2005. The Commission must be notified of any significant events. Some had taken place over a period of two weeks but not all events had been reported to the Commission. Several quality assurance surveys were held in the office but these were not dated. There was no evidence that demonstrated the quality of the service was being properly monitored. As stated in the previous section, staff have not received adequate training in safe working practice areas. Some staff had not received up to date food hygiene, first aid, health and safety and fire safety training. This is unsatisfactory and does not safe guard the health and welfare of service users and staff. The pre inspection questionnaire stated that policies and procedures were available and regular maintenance and health and safety checks by external agencies were completed at the home. Fire equipment was tested in January 2007. An electrical wiring certificate was issued at the beginning of February 2007. The Rookery DS0000001494.V325579.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 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 1 25 X 26 3 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 1 32 2 33 1 34 2 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 1 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 2 1 1 X X 1 X The Rookery DS0000001494.V325579.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 YA5 Regulation 5 Requirement Service users must be given information about the fees that are payable in respect of the service they receive. Each service user must have a care plan that identifies how their social, personal and health care needs should be met. Care plans must be kept under review. 3 YA6 15 Sufficient information must be recorded to make sure service user’s welfare and any changes in needs can be properly monitored and reviewed. Risks to service users must be identified and assessed, and relevant action taken. Service users must be given opportunities to engage in community activities. The routine of service users going to their rooms at 10 0’clock must be reviewed to make sure this is in line with their wishes and preferences. There must be a system in place to make sure service users’ DS0000001494.V325579.R01.S.doc Timescale for action 30/04/07 2 YA6 15 30/09/07 30/04/07 4 5 6 YA9 YA13 YA18 13 16 12 30/09/07 30/04/07 30/06/07 7 YA19 12 30/04/07 The Rookery Version 5.2 Page 27 8 9 YA23 YA23 13 18 10 YA23 17 11 YA23 17 12 16 12 YA24 23 13 13 YA24 23 13 healthcare needs are being properly monitored. There must be a clear whistle blowing procedure in place for staff to report their concerns. Staff must be trained in dealing with violence and aggression to make sure service users are safe and they receive appropriate support. There must be individual financial records that clearly identify all financial transactions that are made on behalf of each service user. The registered provider must review the transport arrangements to make sure charges to service users are recorded, equitable and value for money. The home must be reasonably decorated and properly maintained. This must include the issues identified in the main body of the report. There must be sufficient hot water supply for service users to have a bath. Showers must be safe to use and in good working order. Hand washing and drying facilities must be appropriate to stop the spread of infection. Staff roles and responsibilities must be defined. Catering and domestic tasks must not prevent care staff from carrying out their care responsibilities. There should be more staff that have undertaken a nationally recognised qualification in care. (NVQ level 2 or equivalent) There must be sufficient staff working at the home to meet the needs of the service users. DS0000001494.V325579.R01.S.doc 30/04/07 31/05/07 30/04/07 30/04/07 30/09/07 31/05/07 14 15 YA30 YA31 13 18 30/06/07 31/05/07 16 YA32 18 30/09/07 17 YA33 18 31/05/07 The Rookery Version 5.2 Page 28 18 19 YA34 YA35 19 18 20 21 22 YA36 YA37 YA38 18 10 10 23 YA39 24 24 25 YA42 YA42 23 18 A robust recruitment procedure must be followed. A system must be introduced to identify staff training needs to make sure suitably trained staff are working with service users. Staff must receive supervision on a regular basis. The manager must be given sufficient time to carry out her management duties. The registered provider must provide adequate support to ensure the management of the service is satisfactory. A quality assurance system must be introduced that measures the success in achieving the aims and objectives of the home. Fire training must be provided for all staff. Food hygiene training must be provided to all staff that are involved in food preparation. Health and safety training must be provided for all staff. There must be at least one first aid trained person in the home at all times. Significant events must be reported to the Commission. The registered provider must ensure regulation 26 visits are carried out at least monthly. 30/04/07 30/06/07 31/07/07 30/04/07 30/04/07 30/06/07 30/06/07 30/06/07 26 27 28 29 YA42 YA42 RQN RQN 13 13 37 26 30/06/07 30/06/07 30/04/07 30/04/07 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 Service users should be given more support to engage in recreational activities in the home. DS0000001494.V325579.R01.S.doc Version 5.2 Page 29 The Rookery 2 YA22 Service users should be encouraged to talk about any concerns they have about the home. The Rookery DS0000001494.V325579.R01.S.doc Version 5.2 Page 30 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.V325579.R01.S.doc Version 5.2 Page 31 - 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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