Care Home: The Rookery

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What the care home does well The service is very good at assessing the risk to people involved in a variety of day-to-day activities, and putting measures in place to minimise those risks without removing people`s independence. Each person has a specific member of staff who acts as their key worker coordinating their support and ensuring that all staff know how their key person wants to be supported. The staff spoken to were very positive and knowledgeable about this role.The service is good at promoting choice, from what someone wants to eat each day, to how they want their home decorating and furnishing. The service is good at including people`s families in their care and support. Relatives expressed their confidence in the staff team and said they felt comfortable about raising any aspect of care that they were concerned about. People who live there said that they enjoy being involved in the day-to-day life of the home; they like the food that is provided, and enjoy being able to be in the kitchen, helping with various tasks. From what people said about the activities they do outside the home, the staff support them to lead fulfilling lives. Staff are well trained, supervised and supported in their role. What has improved since the last inspection? Action had been taken to address all of the requirements identified at the last inspection. A new system of care planning has been put into place, which is providing much better outcomes for people. The alteration and refurbishment works that have been carried out mean that people now live in a safer, more comfortable and pleasant environment. Staffing levels continue to improve, due to some successful recruitment. The home is now supported by a part-time domestic assistant, which has reduced the burden on care staff to provide domestic support for the house. Staff training continues to improve. Structured induction and a basic training programme is provided. This leads on to National Vocational Qualifications (NVQ). Efforts have been made by the management body (the board of trustees) to make sure that they monitor the day-to-day running of the home, by way of regular monthly visits. What the care home could do better: Staff must use the system provided by the pharmacist to administer medication safely, rather than taking the tablets out of the pre-filled containers and transferring them into medicine pots. All staff must be trained in handling and administering medication safely. There are still some areas of the home where attention is needed to the fabric of the building, or to carpets that are badly worn. The manager has already identified these areas and requested that the organisation take action about them.Efforts have been made by the service to gain the views of people living there and their families, by way of surveys, the most recent being carried out in December 2007. However, there was no analysis of, or response to, the surveys, which has made it difficult to assess whether the surveying process has been able to influence any change in the service. CARE HOME ADULTS 18-65 The Rookery Woodland Lane Chapel Allerton Leeds West Yorkshire LS7 4PD Lead Inspector Stevie Allerton Key Unannounced Inspection 31st July 2008 2:30pm The Rookery DS0000001494.V371801.R02.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.V371801.R02.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.V371801.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Rookery Address Woodland Lane Chapel Allerton Leeds West Yorkshire LS7 4PD 0113 2689598 F/P 0113 2689598 michelle@wilks.orangehome.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Leeds MENCAP Mrs Michelle Wilks Care Home 12 Category(ies) of Learning disability (12) registration, with number of places The Rookery DS0000001494.V371801.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Learning disability - Code LD, maximum number of places: 12 The maximum number of service users who can be accommodated is: 12 1st August 2007 Date of last inspection 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 those people who are less mobile 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 on a regular basis. The standard fee charged by the home is £371.11 per week. This information was provided on 31st July 2008, during the inspection. The Rookery DS0000001494.V371801.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection was carried out without prior notification and was conducted by one inspector over the course of two visits. The first, on 31st July, was from 2.30 pm until 6.00 pm and the second visit, on 5th August, was from 10.00 am until 6.00 pm. Before the visit, accumulated information about the home was reviewed. This included looking at any notified incidents or accidents and other information passed to CSCI since the last inspection. This information was used to plan this inspection visit. The home completed their Annual Quality Assurance Assessment (AQAA) fully. We did not send surveys out to people living at the home on this occasion. Staff surveys were left at the home and three were returned. Four people were case tracked, and other files were looked at. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. Using this method, all twenty-one key standards from the Care Homes for Younger Adults National Minimum Standards, plus other standards relevant to the visit, were able to be assessed. We spent time with people living at the service and spoke to relatives and relevant members of the staff team who provide support to them. What the service does well: The service is very good at assessing the risk to people involved in a variety of day-to-day activities, and putting measures in place to minimise those risks without removing peoples independence. Each person has a specific member of staff who acts as their key worker coordinating their support and ensuring that all staff know how their key person wants to be supported. The staff spoken to were very positive and knowledgeable about this role. The Rookery DS0000001494.V371801.R02.S.doc Version 5.2 Page 6 The service is good at promoting choice, from what someone wants to eat each day, to how they want their home decorating and furnishing. The service is good at including peoples families in their care and support. Relatives expressed their confidence in the staff team and said they felt comfortable about raising any aspect of care that they were concerned about. People who live there said that they enjoy being involved in the day-to-day life of the home; they like the food that is provided, and enjoy being able to be in the kitchen, helping with various tasks. From what people said about the activities they do outside the home, the staff support them to lead fulfilling lives. Staff are well trained, supervised and supported in their role. What has improved since the last inspection? What they could do better: Staff must use the system provided by the pharmacist to administer medication safely, rather than taking the tablets out of the pre-filled containers and transferring them into medicine pots. All staff must be trained in handling and administering medication safely. There are still some areas of the home where attention is needed to the fabric of the building, or to carpets that are badly worn. The manager has already identified these areas and requested that the organisation take action about them. The Rookery DS0000001494.V371801.R02.S.doc Version 5.2 Page 7 Efforts have been made by the service to gain the views of people living there and their families, by way of surveys, the most recent being carried out in December 2007. However, there was no analysis of, or response to, the surveys, which has made it difficult to assess whether the surveying process has been able to influence any change in the service. 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.V371801.R02.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.V371801.R02.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 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Staff are aware of the need to ensure good pre-admission assessment, and the gradual introduction of the person to the service. This ensures a smooth transition and a good experience for the person. EVIDENCE: One person recently admitted to the home was case tracked. The care file contained copies of the full care assessment, contract, service user plan, evidence that this had been reviewed and daily records. We spoke to a relative of this person, who described the admission process. They came to look round beforehand and felt the staff had worked well with the family in order to provide the right support to help the person to settle in. The manager said that new care plan review forms are to be introduced, with the intention that this will be carried out monthly with the person or their family. The Rookery DS0000001494.V371801.R02.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Person centred planning ensures that support is tailored to the individual. The staff manage risk well, promoting independence and freedom of choice. People enjoy being able to take part in decisions about what happens in their home. EVIDENCE: Four people were case tracked. All have person centred plans in place. This method of care planning highlights peoples abilities, rights and wishes, promoting their individuality, human rights, self-help skills, domestic skills and leisure opportunities. Risk assessments are in place. These are also person specific, so some people may only have one or two and others have a lot; for example, fire safety, mobility, finance, outings, being in crowds, bathing/showering, and food and The Rookery DS0000001494.V371801.R02.S.doc Version 5.2 Page 11 drink preparation. There were some really good examples of risk assessments seen, including a temporary one for the bathroom during refurbishment, followed by a new one for the new shower that was installed. This is very good practice. We spoke to a member of staff who is a key worker, about the main areas of support for one of their key clients, who was case tracked. They displayed a good level of knowledge about people’s needs and abilities, including the form of communication used (Makaton) if people are not able to converse. The key workers do evaluations monthly and feed back to the rest of the staff team at the staff meetings. This means that everyone is notified of changes and adjustments to the person centred plan. Where appropriate, there are behaviour/intervention plans with records of progress in this area. Action plans linked with the person centred plans show a record of the achievement of goals. People have the opportunity to participate in all aspects of life in the home, by way of the residents meetings. As a way of developing this further, the service is looking at involving people other than paid staff, to encourage more ideas on how people would like to see their home run. Risk assessments are carried out to determine whether people are able to manage their own finances, either in full or in part. Robust procedures are in place to manage peoples money on their behalf. One of the people case tracked showed me his room, which had recently been redecorated to the colour of his choice. Everyone is able to exercise choice about the food. The Rookery DS0000001494.V371801.R02.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People have opportunities to do different things, and there is now more staff support available to assist this. The food is of good quality, although unfortunately there are now less opportunities for residents to assist with buying this locally. EVIDENCE: There was evidence in people’s support plans that their individual interests had been identified and were being supported, along with outside activities. People spoken to also said that they enjoyed various opportunities, to do voluntary work, visit local shops, go on holiday, take part in dance classes, college courses, etc. The Rookery DS0000001494.V371801.R02.S.doc Version 5.2 Page 13 The notice board in the hall provided a good level of information about the various clubs and groups in the local area. Person centred plans included the details of how people keep in contact with their families and friends. Some people have their own bedroom door keys. Key workers plan a one-to-one with their client once a month, going out and doing an activity of their choice. A relative spoken to said she felt her sister had developed tremendously in confidence and could now do things on her own e.g. travelling. The evening meal was seen during the inspection, which consisted of a choice of jacket potatoes, cheese, baked beans, spaghetti, and quiche. The quantities were good, and residents appeared to be enjoying the meal. After tea, everyone made up their lunch boxes for the next day, with their choice of sandwich, crisps, fruit and cereal bars. The home has recently gone back to buying dry goods in bulk, rather than shopping at supermarkets, due to constraints on finances and staff time. Fruit and vegetables are still bought locally, and one of the residents in particular likes to help with this. One person washed up and was cleaning the cooker down very thoroughly. Staff said that she likes to do this every evening, while others take turns at drying up and putting the crockery away. Some people have attained food hygiene certificates (evidence was seen in peoples rooms). The staff plan to take photographs of plates of food and make them into flash cards, to help communication and the promotion of choice. This would be very good practice. The Rookery DS0000001494.V371801.R02.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Person centred planning ensures that health issues are monitored and needs continue to be met, with appropriate support from other healthcare professionals. The medication system and procedure in use are not being fully followed by some staff members, however, which could lead to error. EVIDENCE: Staff said there was no one with any particular health issues at the moment. There are four male and eight female residents, and one male member of staff. The staff team are aware of potential problems regarding personal care and gender preference, but feel that this is not proving to be an issue for people at present. Medication is provided by Boots the chemist on their Monitored Dosage System. One member of staff was doing medication at teatime, so the practice was observed. She was seen “potting up” medication; however, this was only The Rookery DS0000001494.V371801.R02.S.doc Version 5.2 Page 15 for two people, and therefore not a serious issue at that time. It was not clear, however, what would happen on a morning, when there were more people receiving medication. One member of staff was undergoing medication training and another two who had already received training were currently updating theirs. The service encourages the use of such things as the Medic-alert bracelet, which is discreet, but enables someone with epilepsy to remain independent outside of the home without staff. The Rookery DS0000001494.V371801.R02.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Staff have received training that makes sure that they understand how to protect potentially vulnerable people. There is an open approach to communication and discussion of any concerns or complaints that people have, which means that people feel confident that they will be listened to. EVIDENCE: The complaints procedure was on display and is in a fully accessible format, supported with pictorial symbols. The new procedure has been sent out to relatives. This just needed to be updated by including CSCIs current address. There is a written policy for safeguarding adults, and all staff have now had training in safeguarding vulnerable adults procedures. Staff have also had training in challenging behaviour. Mental Capacity Act training was being started during the week of inspection. A relative spoke to us. She said she felt very comfortable communicating with all of the staff and felt she could discuss any concerns openly. The Rookery DS0000001494.V371801.R02.S.doc Version 5.2 Page 17 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 & 30 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The alteration and refurbishment works that have been carried out mean that people now live in a safer, more comfortable and pleasant environment. Further attention is needed, however, in some areas, to ensure people’s safety and wellbeing. There is a plan to address this, which demonstrates that the provider continues to look at ways to improve life for the people who live there. EVIDENCE: Various parts of the premises were seen over the two visits. The first visit took place in torrential rain, and there were buckets out on the stairs and in the office to deal with the leaks in the ceilings. Action to rectify this had already been started. The Rookery DS0000001494.V371801.R02.S.doc Version 5.2 Page 18 One bedroom was seen by invitation of the occupant, who was very proud of his room, which was very large. It had been recently decorated, in the colour and style of his choosing. Works to refurbish the bathrooms have been completed. Staff have identified the need to purchase a new washing machine with a sluice setting, which will improve infection control in the future. Currently there is not a great demand for moving and handling equipment, as people are quite independently mobile, apart from a handling belt in use for one person. General fire safety appear to be good. Extinguishers were in place and fire exits kept clear. The sitting room and dining room were both well furnished, and the dining room has had a new floor fitted. However, the carpet in the corridor outside the dining room was potentially hazardous (it had been repaired with tape). The manager had already taken action towards replacing this, had obtained quotes and was ready to proceed with ordering a new one. The kitchen is well organised and has good storage space and pantries. A new cooker has been installed. An old office upstairs is hopefully going to be converted into a small kitchen and meeting room. The home stands in excellent grounds, with lots of lawn space. The Rookery DS0000001494.V371801.R02.S.doc Version 5.2 Page 19 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, 34 & 35 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The recruitment process in place protects people from those who may be unsuitable to work with them. Key workers make sure that they can spend some one-to-one time with their clients, although recent staffing levels have prevented this from happening during an evening. Staff are well trained and supervised, which ensures that people are supported well. EVIDENCE: A recent round of recruitment had secured 2 new staff members, who were awaiting start dates. The two posts are for 24 hours and 33 hours per week. The rotas showed that there are currently still only 2 staff on late shifts, therefore no opportunity to go out with people, but this should be relieved when the new staff start. There is now a domestic assistant for 12.5 hours a week which the staff say has made a huge difference. This means that they can spend more time supporting the people who live there. The Rookery DS0000001494.V371801.R02.S.doc Version 5.2 Page 20 The home has a bank of staff that are used to fill in gaps on the rota. An example of this is workers that have been with the home for some time and are now at university studying, but remain on the books. One was on duty on the first day of the site visit. Staff files contained all of the relevant documents, showing that the home’s recruitment procedures are robust. One file showed that the person was registered for the Learning Disability Induction Award (LDQIA), had completed their food hygiene certificate, were doing a health and safety course this month and had a record that fire instruction had been given. Further fire training, first aid, moving and handling, and POVA training were due to be done within the next three months. The other file that was looked at showed the person was currently doing a distance learning course in infection control. The manager said that three staff have completed the LDQIA, two are in the process and another two are to start. We spoke to staff on both visits. A discussion was held about the role of the key worker with one member of staff: they described how they are responsible for keeping track of appointments, trying to arrange them when they would be on duty and able to escort the person; helping the person in remembering family birthdays, etc; looking after their clothes, their room, etc; reviewing support plans and risk assessments, and carrying out the monthly evaluations, which are discussed at staff meetings. Staff said there had been “tons of training”. Information provided by the manager said that 80 of the staff have now achieved National Vocational Qualifications (NVQ) level 3 in Health and Social Care. Training in the Mental Capacity Act was to take place the following day. People confirmed that their training was up-to-date in areas including fire, first aid, food hygiene, etc., and that they received supervision, generally every six weeks. Discussion was held with one of the seniors regarding the new person centred support plans and their feeling is that there is a lot of duplication of information, creating more paperwork for the staff. Staff comments on surveys: “There are always enough staff to meet individuals needs on shift every day”. “I sometimes find it difficult when providing personal care for one service user, although there is always someone to support me when I am working with that person”. The Rookery DS0000001494.V371801.R02.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41 & 42 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The home is run in the best interests of the people living there and they feel they can contribute towards this. There are clear lines of accountability, which ensure the efficiency of the service. The records that are kept protect people and support the smooth running of the service. EVIDENCE: The manager has now completed her NVQ level 4. There is a new chief executive, Frank Plumbridge, who has been promoted from his former post of general manager. He is currently looking at strategies to take the service forward. The Rookery DS0000001494.V371801.R02.S.doc Version 5.2 Page 22 The service charges low fees in comparison to other similar services. Some people receive only basic personal allowance and this limits their spending power. The Manager is currently investigating whether people are able to claim additional benefits. The Treasurer is currently revising financial procedures: samples seen include “my budget” and “handling service users’ money”. The manager ensures that staff keep up-to-date with the written policies and procedures of service. She has a “policy of the month” strategy, a different policy displayed on the staff notice board each month for staff to read & sign. There are regular residents meetings. One of the people who was case tracked has a support plan that includes a goal to be more involved in the running of his home and there was evidence to show how this is being supported. People living in the home and stakeholders were surveyed in December 2007 and the responses to these were available for inspection, but the results have not been analysed and publicised. This would provide information to everyone involved with the service about what people think about it, what could improve, and what action the organisation intends to take to make improvements. Monthly visits are now carried out by individuals from the board of trustees that manages the home, in line with Regulation 26 requirements. Regulatory and operational records were sampled, including: • fire safety records • person centred plans and daily records • accident records • menus • medication records • staff records • training records • staff rotas • people’s financial records All were readily available and appeared to be accurate and up-to-date, with advice given about how to make sure that accident records were kept in accordance with regulations (individually numbered). Health and safety risk assessments were seen and assessed as very good documents that were easy to complete. The Rookery DS0000001494.V371801.R02.S.doc Version 5.2 Page 23 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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 3 3 3 X The Rookery DS0000001494.V371801.R02.S.doc Version 5.2 Page 24 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 YA20 Regulation 13(2) Requirement Staff must be trained, and follow the practice guidance issued by the Royal Pharmaceutical Society, for administering medication safely. This is so that mistakes do not occur. Worn carpets must be replaced, as planned, so as to minimise any trip hazards. Timescale for action 30/11/08 2 YA24 13(4)(a) 30/11/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA30 YA39 Good Practice Recommendations The provider should consider installing a washing machine with sluice facility, to achieve better infection control for laundry. The results of satisfaction surveys should be analysed and published, so that they can let everyone involved with the service about know about what people think, what could improve, and what action the organisation intends to take to make improvements. Accident records should be kept in accordance with the DS0000001494.V371801.R02.S.doc Version 5.2 Page 25 3 YA41 The Rookery Data Protection Act (individually numbered). The Rookery DS0000001494.V371801.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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.V371801.R02.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!