Inspection on 09/04/08 for Roborough House

This inspection was carried out on 9th April 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Roborough House 01/12/09

Roborough House 04/06/09

Roborough House 18/06/07

Roborough House 14/08/06

Roborough House 07/12/05

Roborough House 05/07/05

Roborough House 24/01/05

Roborough House 07/07/04

Similar services:

The Vicarage

7 Hyde Road

5 Seafield Road

Trevaylor Manor

12 Orchard Mews

Stallcombe House

Stepping Stones

Cornerstones

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Roborough House Roborough House Off Tamerton Lane Roborough Plymouth Devon PL6 7BQ Lead Inspector Graham Thomas Unannounced Inspection 9 , 10 and 21st April 2008 9:00 th th Roborough House DS0000061085.V361929.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 Roborough House DS0000061085.V361929.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. Roborough House DS0000061085.V361929.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Roborough House Address 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) Roborough House Off Tamerton Lane Roborough Plymouth Devon PL6 7BQ 01752 700788 01752 721088 Roborough House Ltd Mrs Nicola Grieveson Care Home 51 Category(ies) of Dementia (12), Physical disability (51), Physical registration, with number disability over 65 years of age (51) of places Roborough House DS0000061085.V361929.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. This home is registered as a Care Home with Nursing for a maximum of 51 Service Users in the category of PD 51, PD(E) 51, DE 12 Maximum of 3 service users with mild learning disability needing to convalesce following surgery or other general health care needs - for a maximum of 6 weeks To include a maximum of 12 service users in the DE category One service user named elsewhere under the age of 60 with mild learning difficulties may reside at the home 18th June 2007 Date of last inspection Brief Description of the Service: Roborough House is a 51 bedded home for young physically disabled, terminally ill and elderly people who require nursing care. It can also accommodate a maximum of 3 people who require personal care only. The home is a large older building which has a modern extension. There are extensive grounds suitable for use by wheelchair users, with ample parking for staff, visitors and people living in the home. Accommodation is arranged on two floors with access to most areas via passenger lifts and a step lift. There are two lounges, a dining room and a conservatory on the ground floor. The manager supports a team of Registered Nurses and Health Care Assistants who are able to deliver care to a wide variety of service users. The home has recently changed ownership and extensive refurbishments and building work is taking place to improve the environment. The Statement of Purpose and a copy of the inspection report are available in the reception area of the home. Roborough House DS0000061085.V361929.R01.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 the service experience good quality outcomes. Before visiting the home we reviewed our records including complaints, and correspondence with the home We visited the home on over two days and returned on a third day for discussions with the Registered Manager who was absent when we visited. During the visit we toured the building and looked at all the communal areas, laundry facilities and the kitchen. We also looked at 10 individual bedrooms, bathrooms, a treatment room and an activity room. We spoke with 6 people living in the home, three relatives and five staff. There were also discussions with the Registered Manager and Deputy Manager. A number of records were examined. These included, for example, six individual plans and daily records, four staff files, staff rotas, menus and a sample of health and safety records. What the service does well: • • • • • • • In general, peoples’ changing needs are well reflected in their care plans. There is enough support for people to make choices about how they live their lives. The choices of people who live at Roborough House are encouraged and respected by the staff who care for them. This creates a positive friendly atmosphere. People living at Roborough House generally receive the personal and healthcare they require in the way they prefer. People’s concerns are listened to and addressed. A sufficiently robust system is in place to protect people from abuse. Roborough House provides an environment that is clean, comfortable and well equipped. People living at Roborough House can feel confident that they are supported by competent staff group. Roborough House is a generally well-managed home in which there is an evident pattern of improvement for the benefit of people living there. Roborough House DS0000061085.V361929.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Roborough House DS0000061085.V361929.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Roborough House DS0000061085.V361929.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have the information they need before moving into Roborough House. Assessments of peoples’ needs have improved. EVIDENCE: A “Statement of Purpose” and “Service Users Guide” had been produced to provide information to people considering moving into the home and their relatives. These were displayed in the reception areas of the home during the inspection. The registered Manager described the process for those moving into the home. Following an initial enquiry, a form is sent to the referring agency which requests basic personal and medical information. The person is visited and a detailed assessment is made of their needs. This forms the basis of an individual care plan. The care plan and risk assessment are produced on arrival. Individual files of the people most recently admitted to the home were examined. The detail, organisation and quality of assessment information in these files showed signs of improvement. The files of people more recently admitted contained well-organised, detailed referral information and specialist Roborough House DS0000061085.V361929.R01.S.doc Version 5.2 Page 9 assessments. Risk assessments in all the files contained information about activities of daily living and current needs. There was evidence in the files of ongoing assessments by such professionals as Speech and Language Therapists, Physiotherapists and Occupational Therapists. Some forms were unsigned and undated and some files were awaiting a photograph of the person concerned. Although physical and healthcare needs were detailed in the assessment format, social needs were less well identified. People funded by continuing care health budget have their care monitored by an NHS nurse. Roborough House DS0000061085.V361929.R01.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): Standards 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. In general, peoples’ changing needs are sufficiently well reflected in their care plans. There is generally sufficient support for people to make choices about how they live their lives. EVIDENCE: The individual plans for six people were examined. New formats for elements of the plans were being introduced so plans varied in their format and content and organisation. Care plans included information on such topics as mobilisation, continence, personal hygiene and diabetes control. Some plans also contained a section on “my social story” which provided details of family relationships, hobbies, work and food preferences. Although some reviews were seen to be overdue, there was evidence that these needs were being monitored regularly. Roborough House DS0000061085.V361929.R01.S.doc Version 5.2 Page 11 Where the records were well-organised and complete, there was evidence of a clear cycle of assessment, action, planning and review. For example, elements of the risk assessment were numbered and carried through to the daily records. In keeping with a previous recommendation, restrictions on personal freedoms and reasons for them were recorded in the individual plans. Each person has a named member of staff who is responsible for ensuring the goals for them are regularly reviewed. People living in the home with whom we spoke were satisfied that they were able to make choices about how they spent their time and the activities in which they might participate. This was confirmed by our observations of the routines of the home. Individual plans showed evidence of speech and language therapy involvement to help people communicate their wishes and needs. A Residents’ Forum has been set up for people to express their views and ideas. Records showed that recent staff shortages had affected the opportunities available for people such as, for example, attending a communion service. Roborough House DS0000061085.V361929.R01.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): Standards 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at Roborough House have their personal choices encouraged and respected by the staff that care for them. This creates a positive friendly atmosphere. EVIDENCE: Roborough house has its own qualified Occupational Therapist and, at the time of our visit, was advertising for a Physiotherapist. Two rooms have been allocated to support progress to a more independent life style within the home. These contained a bathroom and a large sitting room with a bed and kitchenette space. The home has an equipped activities room and an activities co-ordinator. During our visit, groups of people were seen enjoying table-top activities. People with whom we spoke talked of swimming, shopping trips, trips to the cinema and theatre as well as church attendance. One person was looking Roborough House DS0000061085.V361929.R01.S.doc Version 5.2 Page 13 forward to going out for a meal with a friend who also lived in the home. There were also said to be barbeques in the summer. Some people had also attended college courses. The activities co-ordinator also stated that there were exercise and relaxation sessions, as well as outings such as horse riding for people with disabilities. People said that their relatives were usually made welcome in the home. This was confirmed by the relatives with whom we spoke. One person spoke about difficulties experienced by his relatives in accessing the home at weekends. The Registered Manager was aware of this difficulty. An electronic key fob lock system has been introduced in the home. People that had been assessed as able to use these had been given a fob. The nurse in charge advised that these gave access to areas with in the home, which had been agreed with the person. A programme of modifications was in progress to provide more private locking arrangements to individual rooms. During our visit staff were seen knocking on people’s doors before entering. A small domestic style kitchen was provided for people who are able to use it. One person spoke with us about using this facility. A drinks preparation area was provided in the dining area of the lounge. This gives people who are able access to drinks and biscuits during the day. The lunchtime meal observed was unhurried with people eating their meals at their own pace. Some people were eating their meals in the dining room others had chosen to eat their meals in their own rooms. Staff was giving those people who required assistance to cut up or eat their food in a sensitive supportive way. Menus were varied and were displayed in the dining room. On the first day of our visit, the main meal consisted of chicken in a wine sauce with roast potatoes and vegetables followed by trifle. Menus showed that alternatives were available on a daily basis. People said that they enjoyed the food and there was always plenty. One person said that they felt that the food had improved recently. Pureed food had been prepared to allow people to experience the different tastes of the food. Arrangements were also in place to cater for diabetic and gluten-free diets. Roborough House DS0000061085.V361929.R01.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Roborough House can feel confident that they will receive the personal and healthcare they require in the way they prefer. EVIDENCE: During the inspection, we observed staff providing care and support with patience and skill. Personal care took place in privacy with staff taking care to ensure that doors were closed to preserve people’s dignity and privacy. Our observations of people’s routines during our visit demonstrated that there was sufficient flexibility to accommodate individual needs and preferences. One person stated that the home’s reliance on agency staff limited their choices and preferences regarding the person providing support and care. This was being addressed at the time of our visit. Advertisements had been issued for new staff and four were recruited as a result of interviews taking place at the time of our visit. Arrangements were in place to provide individuals with the equipment and facilities they required to meet their needs. For example, this included mobility aids such as wheelchairs and frames. Some rooms had been specially fitted Roborough House DS0000061085.V361929.R01.S.doc Version 5.2 Page 15 with soft surfaces throughout for people with Huntingdon’s disease. This was designed to lessen the risk of injury as a result of falls and maximise their independence. The people with whom we spoke all said that they had access to any medical attention they needed. One person had recently returned from hospital having undergone specialist treatment. Registered Nurses are on duty over a seven day, 24 hour period to monitor and assess people’s health and personal care needs. Individual plans showed records of health monitoring and liaison with specialists where this was required. For example, this included liaison with Community Psychiatric Nurses and specialists in diabetes. The home employs its own Occupational Therapist and at the time of our visit was advertising for a Physiotherapist. The system for administering medication was examined. Medicines were stored securely in dedicated rooms on each floor. These contained secure cabinets, extra security for the storage of controlled drugs and refrigerators for medicines requiring cool storage. The refrigerator examined was cool inside but appeared to have a faulty temperature gauge which was reading 25.50c. It would therefore not be possible to establish whether medicines were being stored at the correct temperature. Secure medication trolleys were in use on both floors. Recording of the administration of medicines was generally accurate. However in one instance there were gaps in recording and two tablets were apparently missing that had not been accounted for. This presents the risk that medicines have been incorrectly administered or misappropriated. A controlled drugs register was available for inspection and this had been signed by two staff for each dose administered. A sample of these medicines was examined which showed that the stock held agreed with the records. Roborough House DS0000061085.V361929.R01.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): Standards 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Roborough House can feel confident that their concerns will be listened to and addressed. A sufficiently robust system is in place to protect people from abuse. EVIDENCE: There was a clear complaints procedure that includes timescales. Most people with whom we spoke said they felt confident that their concerns would be listened to and acted upon. We spoke with one person who raised a number of concerns. This person stated that they had raised these issues with the Registered Manager who had replied in writing and undertaken to address them within a timescale. This was confirmed in discussion with the Registered Manager. Some of the concerns related to issues of staffing which were being addressed at the time of our visit. A record was available of all complaints and issues raised. The Registered Manager had reviewed the complaints procedure and was proposing to put in place a more robust procedure and recording system. Since the last key inspection a number of anonymous complaints have been received by the Commission. These have been investigated though the local adult safeguarding team. Where action has been needed, the Registered Manager has been fully co-operative with this process. Some of the allegations made are believed to have been malicious and have been investigated by the Police. Roborough House DS0000061085.V361929.R01.S.doc Version 5.2 Page 17 The staff files seen during the inspection showed the training they had received included managing challenging behaviour and adult protection. The Commission has been informed that the staff at Roborough House have accessed the training for adult protection provided by Plymouth City Council. Interviews with individual staff showed that they were all clear as to the action needed if abuse was witnessed or suspected. A business manager completes billing accounts for individual people at the home. A system for providing individuals with information about their finances is in place. Roborough House DS0000061085.V361929.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Roborough House benefit from an environment which is clean, comfortable and well-equipped. EVIDENCE: During our visit we examined all communal areas and ten individual rooms. Overall, the environment provides a good standard of accommodation for people who live there. There are a variety of communal spaces including an activities room and treatment room. In addition to a spacious open plan lounge and dining room people have access to a quiet lounge on the first floor and a smaller lounge created between the old and new parts of the building on the first floor. Wheelchair access has been provided to the patio and large grounds around the home. An electronic key fob system controlling access around the home has been introduced. People who have been assessed as able have been given their own key fob to access agreed areas in the home. These were seen in use Roborough House DS0000061085.V361929.R01.S.doc Version 5.2 Page 19 during the inspection. At the time of our visit locks to individual rooms were being upgraded to improve privacy and security. Staff confirmed that air conditioning had been provided for all the internal spaces without natural ventilation used by staff and people living at the home. Rooms in the extension to the building were decorated and equipped to a high standard. The older part of the building has been upgraded and redecorated to improve the standard of accommodation. Evidence of ongoing upgrading was seen including new en-suite facilities in some rooms. Two rooms have been equipped as bed-sitting rooms to enable people to progress towards independent living in the community. Some rooms had been fitted with soft surfaces throughout to accommodate the particular needs of people with Huntingdon’s disease. During the inspection visit the home was fresh and clean in all areas. Cleaning is carried out by an independent contractor whose staff were seen at work during our visit. A waste disposal system for clinical and domestic waste was in place. Staff were observed using gloves and aprons when attending to personal care for individuals. One person had acquired an infection and required scrupulous infection control measures. The antibacterial hand gel outside this person’s room was found to be empty. However there was ample supply nearby and the container was replaced immediately the shortfall was noted. Laundry trolleys were in use for transporting soiled laundry and separate containers were used for clean laundry. Sluicing facilities were available and the laundry was equipped with industrial standard washers and dryers. Hand washing facilities and antibacterial gel was available for use in the laundry. The training records confirmed that training had been provided for staff in infection control and information about infection control practices were available for staff in the office. Roborough House DS0000061085.V361929.R01.S.doc Version 5.2 Page 20 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): Standards 32, 34, 35 and 36 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People living at Roborough House can feel confident that they are supported by a generally competent staff group. However there needs to be better evidence of the supervision of new staff awaiting criminal records checks. EVIDENCE: Roborough House has recently undergone changes in its management. This has been accompanied by a significant turnover in staff. At the time of our visit, recruitment was taking place and four new staff were appointed. The staff group included seven Registered General Nurses, three Registered Mental Health Nurses and an Enrolled Nurse. Three care supervisors were in post and a further post was to be confirmed. There were also sixteen senior carers. The home employs its own Occupational Therapist and was in the process of advertising for a Physiotherapist. Registered Nurses are on duty at all times. People with whom we spoke during the inspection said that staff were friendly and supportive. Staff were observed talking with the people who live at the Roborough House DS0000061085.V361929.R01.S.doc Version 5.2 Page 21 home, encouraging them to take part in activities and offering assistance with individual assistance such as help with eating. All the staff observed were respectful and polite when speaking to individuals for whom they were caring. A sample of four staff files was examined. These showed evidence of checks such as references and Criminal Records checks. Some of the CRB checks were obtained after an individual had started work at the home. This was due to the urgency of staff replacement. Other checks had been carried out to ensure as far as possible, that the individuals were safe to work with people living in the home. Although supervision arrangements for these staff were said to be in place prior to the arrival of their criminal records checks, this was not recorded. A staff training programme was in place. Evidence was seen in staff files of a structured induction for new staff. Discussion with staff and examination of the files confirmed that they had attended short courses in relevant subjects such as food hygiene, manual handling, and Huntingdon’s disease. Staff were also undertaking National vocational qualifications at levels 2 and 3 in care. Staff with whom we spoke stated that they had received management supervision. The Registered Manager stated that there was additionally peer supervision. At the time of our visit the new system introduced by Ms Grieveson had not been fully implemented and the supervision of some staff was overdue. Records of the supervision which had taken place demonstrated that a sound process was being implemented. Roborough House DS0000061085.V361929.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Roborough House is a generally well-managed home in which there is an evident pattern of improvement for the benefit of people living there. EVIDENCE: Since the last inspection, Nicola Grieveson has been Registered by the Commission as the manager of the home. She had worked as a manager for the service for a year before registration. Ms. Grieveson is a qualified Nurse and has previous management experience within the NHS with whom she had worked since 1981. She has attended many courses relevant to her current role. Our previous inspections have revealed that she has overseen a pattern of overall improvements in the home since her appointment. This includes matters such as improvements in care planning. Roborough House DS0000061085.V361929.R01.S.doc Version 5.2 Page 23 Discussion with the Registered Manager, and examination of records demonstrated that the quality of the service provided was being monitored and subject to continuous improvement. This was evident in improvements to the home’s environment and recording systems. The Registered Manager was also able to identify clearly areas where development was still needed and improvements could be made. A system for surveying the views of staff and residents was being developed and implemented at the time of our visit. There was also evidence of staff and residents’ meetings which provided a forum for ideas about potential improvements and maintaining standards. For example staff meeting minutes recorded a reminder to staff about the reporting of incidents. Discussion with staff and examination of their files provided evidence of training in health and safety topics such as food hygiene, infection control and manual handling. One member of staff is a qualified manual handling trainer. Systems were in place for the control of infection in the home. Cleaners were seen wearing protective clothing. Staff wore disposable aprons and gloves for personal care tasks. Antibacterial hand gel was available for staff use. One container was found to be empty and this was replaced immediately. There was also an ample alternative supply in the vicinity. A current legionella safety certificate was seen with a risk assessment. During our tour of the home two fire doors were found wedged open, one with a piece of cardboard and the other with an ornament. These issues were the subject of an immediate requirement but were dealt with before the inspection had ended. All hazardous substances were found to be securely stored or under the supervision of cleaning staff. There were records of the routine maintenance and repair of items such as shaft lifts and washing machines. An ongoing maintenance log was seen. During the visit refurbishment and maintenance was taking place. Accidents were recorded and the Commission has been notified of incidents affecting the welfare of people living in the home as required by regulation. Roborough House DS0000061085.V361929.R01.S.doc Version 5.2 Page 24 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 3 X X 2 X Roborough House DS0000061085.V361929.R01.S.doc Version 5.2 Page 25 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 The Registered Person must ensure that there is a clear and accurate record of all medicines administered in the home. The Registered Person must ensure that there are clear records relating to the supervision of staff who have commenced working prior to the completion of criminal records checks Fire doors must be held open only with approved hold-open devices. Immediate Requirement notice issued. Complied with before inspection visit ended Timescale for action 01/06/08 2. YA34 19(11) 01/06/08 3. YA42 23(4)(a) 10/04/08 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. Refer to Standard YA36 Good Practice Recommendations The Registered Person should ensure that the new system of supervision is made available to all staff to assist them DS0000061085.V361929.R01.S.doc Version 5.2 Page 26 Roborough House in carrying out their jobs. Roborough House DS0000061085.V361929.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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