Inspection on 07/07/04 for Roborough House

Care Homes For Adults (18 ­ 65)Roborough HouseOff Tamerton Lane Roborough Plymouth Devon PL6 7BQAnnounced Inspection7th July 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Roborough House Address Roborough House, Off Tamerton Lane, Roborough, Plymouth, Devon, PL6 7BQ Email address nina@bartonplace.com Name of registered provider(s)/company (if applicable) Goldmax Resources Limited Name of registered manager (if applicable) Type of registration Care Home with nursing No. of places registered (if applicable) 35 Tel No: 01752 700788 Fax No: 01752 721088Category(ies) of registration, with (number of places) Physical Disability - (35), Physical Disability ­ Over 65 years of age (35), Terminally ill (4) Registration number D540002018 Date first registered 23rd April 2004 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ?Date of latest registration certificate 4th June 2004 YES NO 19.08.03 29.08.03 04.09.03 13.09.04 10.12.04 If Yes refer to Part CDate of last inspectionRoborough HousePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 37th July 2004 10:00 am Mandy NortonID Code075562Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMr Nigel Morris ­ manager (not yet registered with Commission for Social Care Inspection)Roborough HousePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementRoborough HousePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Roborough House. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Roborough HousePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Roborough House is owned by Goldmax Resources, trading as Roborough House Ltd. It is a 35 bedded home for young physically disabled ,terminally ill and elderly who require nursing care. It can also accommodate a maximum of 3 Service Users requiring personal care only. It is an old building that has a modern extension. It is arranged on 2 floors with access to most areas via 2 passenger lifts and a step lift. There are 2 lounges , a dining room and conservatory on the ground floor. The manager supports a team of trained nurses and carers who are able to deliver care to a wide variety of Service Users. The home has recently changed ownership and extensive refurbishment and building work is taking place to improve the environment. The grounds are extensive and suitable for use by wheelchair users with ample parking for Service Users vehicles and staff and visitors.Roborough HousePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This inspection was announced and took place on 7th July 2004. It found that many of the National Minimum Standards had been met and partially met and that the overall quality of care provided was good A number of service users were spoken to on the visit who were pleased that the home has changed ownership (9th June 2004) and pleased that work is underway to make improvements to the environment. Some commented on the fact that the activities had improved recently. There were 23 Service Users living in the home on the day of the inspection. This inspection was the first inspection since Goldmax resources bought the home in June 2004. The inspection was an opportunity to discuss the future plans, see changes that have already been implemented and to talk to Service Users about the current situation. Although some recommendations from the last report have been bought forward to this report as not being met, the new owners demonstrated that work is ongoing to ensure the standards will all be met. Choice of Home (Standards 1- 5) 3 of the 3 standards assessed were met. An interim Statement of Purpose and Service Users guide been produced. It includes relevant information about the home and staff group. It explains about the current refurbishment and type of Service User the home hopes to offer care for. The manager described the assessment process he had just gone through with 2 prospective Service Users in order to assess their suitability for admission to Roborough House. Over the next few months the categories of care are going to be changed to reflect the current Service User group which is predominately younger adults with physical disabilities. The staff group have appropriate skills to provide general nursing care and some staff are being appointed with specialist therapy skills. Some are undergoing training relevant to the social and other complex needs of the Service Users. Individual Needs and Choices (Standards 6 - 10) 3 of the 3 standards assessed were met. Work is underway to improve the plans of care to include a lot of information about the Service Users interests, past experiences in life and future development potential. They will be drawn up with the Service Users or their representative where possible and if appropriate. Some of the current Service Users were able to raise their concerns about the home before it was bought by the current owner. During the inspection some of these Service Users were spoken with, they said they had been informed of all the changes taking place and felt generally more included in the development of the home. The staff always forward untoward/regulation 37 notices to the Commission for Social Care Roborough House Page 6 Inspection for information. A recent situation has confirmed that the home responds promptly and appropriately to unexplained absences by Service Users. Lifestyle (Standards 11- 17) 2 of the 4 standards assessed were met and 2 were almost met. The manager explained the ways in which the staff are beginning to enable Service Users the opportunities to maintain and develop social, emotional, communication and independent living skills. A multidisciplinary approach to the Service Users has now been adopted by the home and more emphasis is being placed on the need for appropriate leisure activities. Activities have improved over recent months with the introduction of activity organisers The manager explained that the daily routines for Service Users are being reviewed on an individual basis in order to promote independence and more freedom of movement. Service Users spoken to and completed comment cards received said that the food had improved considerably over the last couple of months. The manager said that the catering team have been developing suitable and nutritious menus appropriate to the Service User group. Personal and Healthcare Support (Standards 18 - 21) The 1 standard assessed was met. Key workers and `specials have been allocated to Service Users to ensure consistent and in depth care is achieved. Specialist practitioners are being used in order to provide additional support to the Service Users. Completed comment cards received from relatives said that the staff are to be praised for their dedication and nothing has been to much trouble for them. Concerns, Complaints and Protection (Standards 22 - 23) The 1 standard assessed was met. The complaint procedure is available within the home but needs to be also presented in a format more suitable to the Service User group. During the inspection Service User s were observed commenting to staff about their views and concerns. Environment (Standards 24 - 30) 2 of the 4 standards assessed were met and 2 were almost met. The environment is currently being refurbished and upgraded in order to meet the assessed needs of the Service User s in a more appropriate setting. Many of the rooms are being redecorated. Some Service User spoken to in their rooms had them decorated and furnished as they wished. A tour of the home confirmed that specialist equipment is in use throughout the home The tour of the home also confirmed that it was clean and free from offensive odours. The laundry facilities are appropriate for the needs of the home. Staffing (Standards 31 - 36) None of these standards were assessed during this inspection. Conduct and Management of the Home (Standards 37- 43) The 2 standards assessed were met. The manager has undergone a successful `fit person interview and will be registered with the Commission for Social Care Inspection as soon as a Criminal Records Bureau check Roborough House Page 7 has been received. He is a qualified RGN and RMN. The manager has proved popular with staff and Service Users who have seen many positive changes since he took over the role. The style of management is one of inclusion and all staff are being informed of changes with their input welcomed.Roborough HousePage 8 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 2 YA3 Demonstrate continued improvement in the homes capacity to meet the needs of the current Service Users. The plans of care should show evidence that they are completed with the Service User or their representative. The current system should be reviewed in order to identify the most effective way of ensuring inclusion of the Service Users. Information about decisions made on behalf of Service Users needs to be clearly documented stating reasons why the decision was made. A more secure way of storing Service Users individual records should be explored. The current review of Service Users should identify areas of unmet needs in the area of opportunities to learn practical life or other skills. Once areas of need have been identified the relevant training should be accessed. The annual holiday for Service Users who are on long term placement needs to be fully discussed and arrangements made. Page 93YA64 5 6 7YA7 YA10 YA11 YA14Roborough House 8 9 12YA16 YA22 YA34Service Users should offered a key to the front door and a suitable locking device for their own rooms or a statement made in the Statement of Purpose as to possible reasons why these should not be provided. The complaints procedure should be readily available within the home and in formats to suit the variety of needs if the Service Users, Staff should be employed in accordance with the General Social Care Council code of conduct and practice. MET (YES/NO)CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Roborough HousePage 10 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for actionRECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * YA16YA11 The staff should continue to develop the opportunities for Service User to maintain and develop social, emotional, communication and independent living skills where possible. Continued refurbishment and development should be maintained to upgrade the environment to being more suitable for the Service User group.12YA26YA24* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.Roborough HousePage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO YES NO YES 7 0 0 YES NO YES NO 25 10 07/07/04 09.50 6.20Roborough HousePage 12 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Roborough HousePage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. X X Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are 3 Key findings/Evidence Standard met? An interim Statement of Purpose and Service Users guide been produced. It includes relevant information about the home and staff group. It explains about the current refurbishment and type of Service User the home hopes to offer care for. Also included is the complaints procedure.Roborough HousePage 14 Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? The manager described the assessment process he had just gone through with 2 prospective Service Users in order to assess their suitability for admission to Roborough House. If a Service Users cannot be visited in their current circumstances a full care manager assessment is required and conversation with relevant health care professional about the needs of the Service User. The manager has said he is telling the prospective Service Users about the development and refurbishment that is currently taking place within the home and what they hope to achieve once it is completed. Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? Over the next few months the categories of care are going to be changed to reflect the current Service User group which is predominately younger adults with physical disabilities. The staff group have appropriate skills to provide general nursing care and some staff are being appointed with specialist therapy skills. Some are undergoing training relevant to the social and other complex needs of the Service Users. This standard will be explored more fully once the manager has implemented changes over the next few months. Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met? This standard was not discussed during this inspection.Roborough HousePage 15 Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 0 Key findings/Evidence Standard met? This standard was not discussed during this inspection, as the process has not yet been completed. It will be fully explored during the next inspection.Roborough HousePage 16 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? Work is underway to improve the plans of care to include a lot of information about the Service Users interests, past experiences in life and future development potential. They will be drawn up with the Service Users or their representative where possible and if appropriate. A primary nursing system is being introduced and a key worker(either RGN or RMN) has been allocated to each Service User in order to gain a full knowledge of the individual. A `special (carer) will also be allocated 1-2 Service Users in order to take a special interest in them and find out their likes and dislikes for example. Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 0 Key findings/Evidence Standard met? This standard was not discussed during this inspection.Roborough HousePage 17 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? Some of the current Service Users were able to raise their concerns about the home before it was bought by the current owner. During the inspection some of these Service Users were spoken with, they felt that they had been informed of all the changes taking place and felt generally more included in the development of the home. New policies and procedures are being developed and it is hoped that the Service Users who are able will contribute to these where appropriate.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? The staff always forward untoward incident (as per regulation 37) notices to the Commission for Social Care Inspection for information. A recent situation has confirmed that the home responds promptly and appropriately to unexplained absences by Service Users. Risk assessment is an ongoing joint effort by staff working in the home. MENTOR are carrying out a Health and Safety assessment of the whole home on 14th July 2004 and are expected to make recommendations for the company to follow. Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 0 Key findings/Evidence Standard met? This standard was not discussed during this inspection.Roborough HousePage 18 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 2 Key findings/Evidence Standard met? The manager explained the ways in which the staff are beginning to enable Service Users the opportunities to maintain and develop social, emotional, communication and independent living skills. The staff group as well as caring for the nursing needs are developing skills required for looking after Service Users with complex multiple disabilities.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 0 Key findings/Evidence Standard met? This standard was not discussed during this inspection.Roborough HousePage 19 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 0 Key findings/Evidence Standard met? This standard was not discussed during this inspection. Development is taking place in this area and the standard will be fully explored at the next inspection.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? A multidisciplinary approach to the Service Users has now been adopted by the home and more emphasis is being placed on the need for appropriate leisure activities. Activities have improved over recent months with the introduction of activity organisers. They have organised quizzes, DVD film nights and trips to local shops on an individual basis. Service Users spoken to said that the activities had improved recently. One Service User was unhappy at having to wait for the new mini bus to have a tail gate fitted so it can be used by wheelchair users, but had been reassured that this will be completed in the near future. The home hopes to employ a sports therapist and already has aromatherapy sessions. Annual holidays were discussed and although some Service Users go on holiday every year anyway, provision is to be made for the rest of the clients to have a suitable holiday if they wish and their health permits. Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? This standard was not discussed during this inspection.Roborough HousePage 20 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 2 Key findings/Evidence Standard met? The manager explained that the daily routines for Service Users are being reviewed on an individual basis in order to promote independence and more freedom of movement. Staff were heard knocking on Service Users doors before entering the room. Service Users have unrestricted access to the home and gardens. In the next few months there may be some restrictions placed on where Service Users can go in the house and gardens due to building work and refurbishment taking place.Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Service Users spoken to and completed comment cards received said that the food had improved considerably over the last couple of months. The manager said that the catering team have been developing suitable and nutritious menus appropriate to the Service User group. The meal time was not observed during the inspection. Service Users spoken to said they have their main meal at a time suitable to them and can have their meal where they wish.Roborough HousePage 21 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? As described in previous standards the manager is introducing a multidisciplinary approach to the care of the Service Users with a view to enhancing and developing their lives as much as possible. Key workers and `specials have been allocated to Service Users to ensure consistent and in depth care is achieved. Specialist practitioners are being used in order to provide additional support to the Service Users. Completed comment cards received from relatives said that the staff are to be praised for their dedication and nothing has been to much trouble for them. Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) Key findings/Evidence This standard was not discussed during this inspection. Standard met? 60 0Roborough HousePage 22 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 0 Key findings/Evidence Standard met? This standard was not discussed during this inspection.Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? This standard was not discussed during this inspection.Roborough HousePage 23 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home since November 2003 No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 2 2 0 0 0 1 100 3 Key findings/Evidence Standard met? The complaint procedure is available within the home but needs to be also presented in a format more suitable to the Service User group. During the inspection Service User s were observed commenting to staff about their views and concerns. A record is kept of concerns and complaints. The procedure is due to be updated to the used within the company.Roborough HousePage 24 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YESX Standard met? 0Key findings/Evidence This standard was not discussed during this inspection.Roborough HousePage 25 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? The environment is currently being refurbished and upgraded in order to meet the assessed needs of the Service User s in a more appropriate setting.Roborough HousePage 26 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence This standard was not discussed during this inspection. NO NO YES X X X X Standard met? 0 X XX X X XRoborough HousePage 27 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 2 Key findings/Evidence Standard met? Many of the rooms are being redecorated. Some Service User spoken to in their rooms had them decorated and furnished as they wished. Not all of the Service User rooms are lockable.Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 0 Key findings/Evidence Standard met? This standard was not discussed during this inspection.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 0 Key findings/Evidence Standard met? This standard was not discussed during this inspection. Additional communal space is going to be provided in the proposed extension.Roborough HousePage 28 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? A tour of the home confirmed that specialist equipment is in use throughout the home. The home has 2 passenger lifts and a step lift. There is a call bell system fitted throughout the home. The home is undergoing refurbishment at the time of the inspection. At the next inspection arrangements for repair and maintenance of equipment will be discussed.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? A tour of the home confirmed that it was clean and free from offensive odours. The laundry facilities are appropriate for the needs of the home. Policies and procedures for the control of infection are to be introduced by the company.Roborough HousePage 29 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? This standard was not discussed during this inspection.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 0 Key findings/Evidence Standard met? This standard was not fully discussed during this inspection. Work is underway to ensure the staff group are trained to meet the needs of the Service User group. The training file was seen during the inspection Three staff are currently undergoing level 3 NVQ training.Roborough HousePage 30 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXXKey findings/Evidence Standard met? This standard was not discussed fully during this inspection.0The inspector was provided with information about how the staff group will achieve the `high standards of total care outlined by the manager. Duty rotas were provided with the pre inspection questionnaire and indicate nursing and care staffing levels are as recommended by the previous registering authority. However the type of care offered is highly intense hence the multidisciplinary team approach and the variety of staff employed. Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This standard was not discussed during this inspection. An administrator is due to start in the near future and will help ensure the correct documentation is held in relation to each staff member.Roborough HousePage 31 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This standard was not discussed during this inspection.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. Key findings/Evidence Standard met? This standard was not discussed during this inspection.0Roborough HousePage 32 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. X3 Key findings/Evidence Standard met? The manager has undergone a successful `fit person interview and will be registered with the Commission for Social Care Inspection as soon as a Criminal Records Bureau check has been received. He has not yet registered for a level 4 NVQ in management course. He is a qualified RGN and RMN. Mr Morris has successfully run homes in the past and has been at Roborough House for some months, staying with the current owners on change of ownership. He has some clear ideas about the provision of care at Roborough ad how it can be achieved.Roborough HousePage 33 Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The manager has proved popular with staff and Service Users who have seen many positive changes since he took over the role. The style of management is one of inclusion and all staff are being informed of changes with their input welcomed.Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? This standard was not discussed during this inspection.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? This standard was not discussed during this inspection. The home is to adapt the current policies and procedures used by the company. They will be introduced in the near future.Roborough HousePage 34 Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met ? This standard was not discussed during this inspection.Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 0 Key findings/Evidence Standard met? This standard was not discussed during this inspection. MENTOR is carrying out a Health and Safety assessment of the home on the 14th July 2004. The manager provided as much information as he could about safe working practices such as dates of maintenance and other associated records in the pre inspection questionnaire Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? This standard was not discussed during this inspection. Financial information and a business plan were submitted with the recent application for registration by Mrs Griffiths. .Roborough HousePage 35 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Regulation Manager DateMandy Norton Lesley BrownSignature Signature SignatureRoborough HousePage 36 Public reports It should be noted that all CSCI inspection reports are public documents.Roborough HousePage 37 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 7th July 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible On behalf of all the Service Users and the team at Roborough House I would like to thank Mandy for a very positive approach to the Inspection. The team are very proud of the way that Roborough is being transformed into the centre of excellence which we believe it can be. We look forward to working in partnership with the Commission for Social Care Inspection to create the best environment for our Service Users. Mrs C GriffithAction taken by the CSCI in response to provider comments: Roborough House Page 38 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESYESNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 23rd August 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here Roborough HousePage 39 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of Roborough House confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of Roborough House am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Roborough HousePage 40 - 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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