Inspection on 10/07/08 for Rocklee

This inspection was carried out on 10th July 2008.

CSCI found this care home to be providing an Adequate 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

Rocklee 08/07/09

Rocklee 18/11/08

Rocklee 06/11/07

Rocklee 09/05/06

Rocklee 09/10/05

Rocklee 18/04/05

Rocklee 08/10/04

Rocklee 12/05/04

Rocklee 13/02/04

Rocklee 19/09/03

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Rocklee 341 & 343 Stone Road Stafford Staffordshire ST16 1LB Lead Inspector Linda Clowes Unannounced Inspection 10th July 2008 10:00 Rocklee DS0000004995.V368136.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 Rocklee DS0000004995.V368136.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. Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rocklee Address 341 & 343 Stone Road Stafford Staffordshire ST16 1LB 01785 602347 F/P baugha1@aol.com 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) Ms Jacqueline Downes Ms Jacqueline Downes Care Home 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11) of places Rocklee DS0000004995.V368136.R01.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 categories: Mental Disorder MD 11 The maximum number of service users to be accommodated is 11. 2. Date of last inspection 6th November 2007 Brief Description of the Service: Rocklee is a residential care home that provides a service for adults who on admission have mental health needs. The home is located on the outskirts of Stafford town centre, having easy access to a wide range of local transport and amenities. The property consists of two semi-detached houses, the interior structure of which has been altered to allow access throughout. The exterior of the property has been maintained as two semi-detached houses in keeping with the local community. Rocklee provides accommodation for eleven people and has seven single and two shared bedrooms. En suite facilities are not provided. However, bathrooms and toilet facilities are conveniently situated throughout the home and are in close proximity to bedrooms and communal areas. Two lounge areas that are comfortably furnished and equipped are provided for communal use. The kitchen consists of two areas with one containing the cooking and dining area and another used as a utility area. There is also a compact laundry area at the rear of the property that is currently being revamped. The property stands in its own grounds with a lawned area and shrubs to the front, a private hard-landscaped area to the rear, together with car parking Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 5 facilities. The Statement of Purpose was not available on the day of this inspection visit. It was not possible, therefore to establish the scale of fees and current charges. Service users and their stakeholders should, therefore, request this information from the service prior to admission. Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. One inspector carried out this unannounced key inspection and inspected against the National Minimum Standards for Care Homes for Adults and the Care Homes Regulations. The inspection took place over a period of 7 hours and included an examination of records, service user plans, personnel files and associated recruitment procedures, complaints files, health and safety records and a feedback session. Various methods were used to obtain information regarding the services provided by the care home. Questionnaires (surveys) were forwarded to people who were presently receiving a service and six responses were received. On the day of this inspection we spoke with all the people who lived at Rocklee. Surveys were also received from five staff members. It was found that service provision was satisfactory and there was a high satisfaction rate amongst the people who lived in the home who felt valued and respected by the management and staff. Following the last inspection visit in November 2007 an Improvement Plan had been put in place to address the issues identified in the Inspection Report of 6th November 2007. The home has been working with us to improve areas of concern. This inspection has monitored those issues in order to confirm compliance with the requirements in the last inspection report. There had been concerns regarding recruitment procedures at the time of the last inspection. However, these issues had been addressed at the time of this visit. There were concerns, however, that the renovation and redecoration work had not been completed and a commitment was received from the proprietor/manager for this to be completed by 30th October 2008 and this will be monitored. There had been damage externally to drains that had been affected by tree roots. This work has been completed, however, this area had still not been tidied and made safe. The proprietor/manager agreed that this would be completed by 31st July 2008. There has been a change to the Certificate of Registration and the service is now provided for people who have mental health needs at point of admission. There had been no review and update to the Statement of Purpose to reflect this change at the time of this visit. The proprietor has subsequently Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 7 submitted updated documents and the requirement has been removed from this report regarding this issue. Recommendations have also been made to update and implement staff training to ensure that they are competent to provide services to people with mental health needs. What the service does well: What has improved since the last inspection? Recruitment procedures have improved and there is evidence that police checks and references are in place. The home have made application to change its Certificate of Registration for the provision of service to people who have mental health needs at point of admission to reflect current service provision. The Fire Safety Officer has visited the home and expressed satisfaction with fire safety issues and the improvement in equipment and fittings that has resulted from the renovation of the home. The Environmental Health Officer has visited the home and was satisfied that when refurbishment and redecoration was completed there would be a ‘satisfactory end result. Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 8 Uneven paving in the garden had been removed. A new central heating boiler has been fitted. 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. Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 9 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 Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 10 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): 1,2,4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who currently live at Rocklee had received sufficient information to enable them to make an informed choice that the home would be able to meet their needs, although this needs to be kept up to date to reflect any changes so that people know what they can expect from the home. EVIDENCE: No requirements were made in this outcome area in the last inspection report. There has been a change of focus to provision of service to adults with mental health needs however, the Statement of Purpose and Service User Guide had not been reviewed and amended to inform people who wished to use the care home, what services they might expect. The proprietor discussed plans to limit the age ranges of people being admitted to the home and was asked to include this information in the Statement and Service User Guide. (Recommendation 1). The Statement of Purpose and Service User Guide sets out the aims, objectives and philosophy of the service. All six people who responded to questionnaires confirmed that they had sufficient information at the time of admission about the home to enable them to decide it if was the right place for them. Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 11 All people who use the service are publicly funded. The files of the last two admissions to the home were inspected. A full needs assessment had been undertaken by the Assessment and Care Management Team (Social Services) and the home had insisted on receiving the documentation prior to admission. There was evidence to confirm that new service users had been encouraged to visit the home in order establish whether their needs could be met and in order that the manager could ensure compatibility with others living there. Each person has a contract covering the terms and conditions of their residency in the home. It is recommended that details regarding the room to be occupied are included in the contract. (Recommendation 2) People spoken with confirmed that they liked their rooms and that they were admitted to the rooms promised to them when they were viewing. They also confirmed that they had visited the home on a number of occasions prior to admission. Everyone who returned surveys confirmed that they had information about the home. One person stated “yes, that’s another reason I chose this house”. Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 12 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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An individual plan of care is in place to reflect the changing needs and aspirations of the people using the service and forms the basis of service delivery. The people using the service are encouraged to take part in this process to promote a person-focussed service. EVIDENCE: No requirements were made in this outcome area in the last inspection report. The service involves individuals in the process of drawing up care plans in order that they can be encouraged to make their own decisions and choices based upon the aims and objectives provided in the Care Management Assessment (Care Plan). The Plans of Care for the last two people admitted to the home were inspected. The plans covered all aspects of personal, social and healthcare support. We spoke with both people in detail about their lives in the home. One individual had been resident for over eighteen months and the other had recently moved Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 13 into the home. It was apparent that each had different lifestyles and aspirations and the home managed this well. Both were relaxed and comfortable in their surroundings and confirmed that they enjoyed living at Rocklee. Each confirmed that they had visited the home prior to admission and that they were included in decisions regarding all aspects of their lives. The home works in collaboration with other professionals (community psychiatric nurses, consultants, social workers) to ensure that the service promotes independence and autonomy for service users within a comprehensive risk assessment framework. There is evidence to confirm that the home appropriately seeks professional advice for individuals where they identify possible risks. The home has a confidentiality policy. Personal information is appropriately stored in lockable cabinets to comply with Data Protection. Staff spoken with were aware when information given to them in confidence must be shared with their manager and others. All people spoken with on the day confirmed that they played an active role in planning the support they received and that the home worked hard to ensure that they maintained community links. Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a strong commitment to enabling residents to develop and maintain their skills. People who use the service are supported to identify their goals and work to achieve them. EVIDENCE: No requirements were made in this outcome area in the last inspection report. Family links are given high priority by the home and the two people who were being case tracked confirmed that they maintain regular links with family and friends. Neither of those being case tracked undertook external education or occupational activities due to their personal circumstances but they are encouraged to take part in the daily activities in the home. They are responsible for keeping their rooms tidy and one person has the task of showing the daily menu to everyone, recording their choices and returning this to the proprietor in good time. They thoroughly enjoyed this ‘job’. Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 15 Relationships between service users appeared good. We sat chatting to one group, just before teatime, who were discussing what they had done during the day. It was clear that they enjoyed one another’s company and were relaxed and confident. Several people spoken with confirmed that they attend educational activities and their case files showed many educational achievements and skills gained whilst living in the home. Several spoke about attending the library, visiting local cafes, pubs and clubs. One had independently arranged to undertake some voluntary work on the day of the inspection and received encouragement from the manager who also agreed with the service user to look at all the arrangements together with the individual to monitor any possible health and safety issues. There was a record of trips and holidays attended and service users spoke to us about a recent holiday and confirmed that several would be going on holiday later in the summer. Those people who choose to spend time alone have their wishes respected but care staff were observed monitoring them during the day. It was apparent that meal times are a pleasurable activity and we observed people chatting and laughing whilst they were eating. Everyone confirmed that they enjoyed the food served in the home. One person was delighted that they had been assisted to lose weight and commented how much better they felt. There was evidence in care plans that sensible eating is encouraged and that this is an important issue to all of them. One person has some difficulty swallowing but the home caters for their needs. Feedback received in surveys confirmed that people are satisfied with their lifestyle in the home. The following comments were added:“We have cards, dominoes, bingo. Sometimes I go to college. We have games, holidays – sometimes for a whole week. We have plenty of activities, like going to town, shopping, residents meetings, washing up, chores round the house and many more”. “I enjoy the activities” “I join in when I can”. “I mainly go to college”. Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 16 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. The health and personal care that people receive is based on the principles of respect, dignity and privacy and the medication management in the home keeps them safe. EVIDENCE: The records that we inspected showed that service users are supported to attend health appointments and to have regular check ups. Specific health issues are monitored regularly and, where appropriate, specialist health professional support is asked for. On the day of this inspection visit a consultant and a community psychiatric nurse visited people in the home. Several people had attended recent dental appointments with one ‘recovering’ on the day. The service has a medication policy and procedure and operates a monitored dosage system. Medication is securely stored and the medication administration record was complete and up to date. Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 17 It was apparent that people’s physical health needs are met. People spoken with and those who returned surveys confirmed this. The following comments were added to surveys:“CPN comes to the house or I go for an appointment. For the doctor I walk there, he comes to the house or the nurse will take me by car. Other people I am under for my illness also help when they have time”. “Yes, I have support to go to the doctor”. “I go to the doctor when I need”. Staff make sure that those who are fit and well enough are encouraged to be independent, have regular appointments and visit local health care services. Professional advice and support is arranged for those who may need advice in relation to a range of healthcare issues, including intimate relationships. Staff work hard to ensure that people receive the medical care they need. Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 18 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and have access to a robust complaints procedure. Policies and procedures are in place to protect people from abuse. This assures people that the service will listen to them and their supporters and keep them safe. EVIDENCE: No requirements were made in this outcome area in the last inspection report. A complaints procedure is available in a user-friendly format and is on display in the home. Service users said in their surveys and during the site visit that they know how to make a complaint. The service maintains a record of any complaints it receives. The record shows there had been one complaint since the last inspection that had been investigated by the home and satisfactorily resolved. The Commission has not received any complaints about this service since the last inspection. We spoke with all service users on the day and they confirmed that they felt safe in the home. They confirmed that they would have no hesitation in raising any concerns with the manager and other staff members knowing that they would be listened to. Staff spoken with were aware of whistle blowing and safeguarding procedures. Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 19 It is recommended as part of this report that training on Protection of Vulnerable Adults for all staff is updated. (Recommendation 3). The policies and procedures for safeguarding adults are available and give guidance to staff. Staff working at the service know when incidents need external input and who to refer the incident to. Our records since the last inspection show the service keeps us informed of events at the home. Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 20 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, 25, 26, 28 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe and comfortable environment. However the long awaited renovations and refurbishments should now be completed to ensure complete comfort and safety. EVIDENCE: Three requirements were made in this outcome area in the last inspection report – a) for bedroom doors to fit properly, b) for uneven paving in the garden to be made safe, and c) for measures to be introduced to ensure the safety of a person (window restrictor had been removed). There are two bedrooms that are not being used and which are due for renovation and refurbishment. The doors of those bedrooms that are occupied and which were a concern in the last report were inspected and found to fit snugly. The Fire Safety Officer had visited the premises on 18th April 2008 and found that a satisfactory standard of fire safety was evident. The Fire Safety Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 21 Officer took account of the current renovations but was satisfied that there would be an upgrading of the fire alarm system and a replacement of all fire doors by completion. The proprietor is aware of her responsibilities to review risk assessments throughout the process to take account of changes that may affect the people who use the service. A commitment was obtained from the proprietor on the day of this inspection for the renovations to the two bedrooms presently out of use, to be completed. Delay to this work is having an adverse knock-on effect to the completion of work in the other areas of the home (internally). (Requirement 1) The fitting of suitable locks (approved by the Fire Safety Officer) to all bedroom doors to protect privacy and security was also agreed by the manager for completion by 30th October 2008. (Requirement 2) A commitment to complete the external work at the rear of the property including a satisfactory access to the back door by 31st July 2008 was also given. (Requirement3). In the interim the proprietor has reviewed her risk assessments to promote the safety of people who use the service, staff.members and other visitors to the property. There had been concerns about lack of heating. A new boiler was fitted in November 2007 and the certificate of completion was seen during this visit. There was an issue regarding the removal of a window restrictor in one bedroom. This was viewed at this inspection and was in place. However, the restrictor from the other window in the same room had been removed. This was addressed on the day of this inspection. Window restrictors are an integral part of the replacement windows that are being fitted throughout and this should address the issue. The home will benefit greatly from the present upgrading of furnishings and equipment and will provide a pleasant and comfortable environment for the people who live there. New laundry facilities are planned in the rear porch to enable individuals to do their own laundry as required. Everyone spoken with was happy with their own bedroom. Every room reflected the personality and style of its occupant. There are sufficient toilet and bathing facilities located throughout the home. Communal areas are clean, bright and comfortable. There was a good standard of hygiene throughout. A pay phone is located in the hallway, however, those people spoken with stated that they used the home’s phone. Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 22 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): 32,34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are generally well trained, skilled and in sufficient numbers. However, updating in staff training for mental health and other specialist areas relevant to the needs of people who use the service would improve the quality of the service provided. EVIDENCE: Two requirements were made in this outcome area in the last inspection report. The home was required to obtain Criminal Record Bureau Enhanced Disclosures (Police checks) and two references on a specific member of staff and to ensure there was sufficient night staff on duty whilst renovations were taking place. We looked at the file of the staff member identified in the last report and found a CRB in place. This person also worked at another local care home. There were not, however, any references on file. The proprietor stated that these were mislaid and agreed to obtain new references as quickly as possible. Copies of the references from a current employer where the employee had Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 23 worked for many years, were forwarded to us. This requirement has, therefore, now been complied with. We looked at two other staff files which showed that all relevant preemployment checks have been carried out that included CRB checks, two written references from previous employer and application forms showing the individual’s work history. Night staffing arrangements are satisfactory bearing in mind the needs of current service users. The home has recently been notified that it has retained its Investors in People status until 2010 when it must next be reviewed. The Deputy stated that she has completed the National Vocational Qualification (NVQ) level 4 in Management. Certificate not seen. The Deputy provided information to confirm that she has attended medication training in 2004. However, updated external medication training for all those responsible for the administration of medication would be most beneficial. (Recommendation 4) Of the seven permanent care staff employed, five have attained NVQ level 2 and one is working towards this award. Staff training records stated that the following training has been provided dementia and dealing with challenging behaviours, medication training, health and safety. From the information provided, it was not possible to confirm that all staff had received updates of their moving and handling training (Recommendation 5) and it would benefit all staff to have good, external training in mental health awareness and other specialised training that is relevant to the needs of its service users and the stated areas of service provision for which the home is registered. (Recommendation 6) Five staff responded to surveys and confirmed that they received good induction training, had regular supervision and were well supported by management. The following comments were added to surveys: “I have a lot of knowledge but I am always willing to learn more”. “We discuss the needs of clients every day. I receive further training and knowledge from my management. The manager has always supported me in my endeavours”. “Every day we update the care plans. I have obtained lots of training in this job but I am always willing to learn more skills. We have staff appraisals and meetings. I have the knowledge and experience due to all my training. Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 24 “Induction was very good. Training is always available and many leaflets are handed out for me to read. I have regular supervisions. I feel very competent in my job role and feel I have the experience to help as best I can and always willing to have advice off other people”. Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 25 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 adequate. This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that the management and administration of the home is based on openness and respect although management of the recent refurbishment of the environment has had a negative impact on the people using the service. EVIDENCE: One requirement was made in this outcome area in the last inspection report that an application is made to the commission for renewal of the Certificate of Registration to reflect current services provided in the home. This has been carried out and a new Certificate was issued on 5th June 2008 and was seen displayed in the home. The Care Homes Regulations state that it is an offence not to have a current Statement of Purpose and Service User Guide. These documents outline the Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 26 aims and objectives of the care home and the facilities and services which are to be provided and should be readily available to the commission, every service user and any representative of a service user. The proprietor/manager confirmed that she was updating the Statement of Purpose. However, it was not available on the day of this inspection. This document has been subsequently been sent to us and therefore this is no longer a requirement as part of this report. The AQAA was completed in detail and sent to us in time, however the manager acknowledges that improvements need to be made to the service. It is regrettable that the renovations to this property have taken so long. The proprietor has made a commitment that the works will be completed by 31st October 2008. This will be monitored to ensure that the people who live in the home are provided with the well-maintained and suitable environment to which they are entitled. The Registered Manager has many years experience within social care and demonstrated a thorough knowledge of the care needs of the people living at the home. Staff training needs to be reviewed to ensure that all staff receive mandatory and specialist training to meet the needs of the people using the service, this particularly applies to mental health training. The manager has acknowledged this shortfall in the AQAA. Service users are responsible for their own finances or have their finances managed by social services. Information in the Annual Quality Assurance Assessment indicates that all necessary checks of equipment, servicing and maintenance are carried out regularly. Staff and service users are involved in fire drills and fire safety risk assessments have been carried out. The manager indicated that the views of service users are sought on a regular basis and individuals spoken with confirmed this. No information was provided to confirm that a formal Quality Assurance process (Satisfaction Survey) had been carried out in the last twelve months. A recommendation has been made for this to be undertaken. This will provide the people who use the service with a formal means of expressing their views about their lives in the home. (Recommendation 7) Appropriate and current insurance is in place for the purposes of the business. Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 27 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 3 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 1 25 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 x 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 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 X 3 x x 3 x Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 28 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 YA24 Regulation 13(4)(a) Requirement Bedroom doors should be fitted with appropriate locks (approved by the Fire Safety Officer) in order to promote privacy and security for the people who use the service. Risk assessments for the use of such locks should be in place for each person living in the home. Work must be completed to upgrade the two bedrooms currently out of service so that they are suitable for habitation. Delay to completion of these rooms has caused knock-on delays in completion of other work in the home. E.g. the fitting of privacy locks to bedroom doors. Work must be completed to the external rear access to the back door and rear driveway to the home in order to protect the health and safety of the people who use the service and visitors to the home. Timescale for action 30/10/08 2 YA24 13(4)(a) 30/10/08 3 YA24 13(4)(a) 31/07/08 Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 29 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 YA1 Good Practice Recommendations It is recommended that explicit information regarding the lower and higher age ranges for admission to the care home are included in the Statement of Purpose and Service User’s Guide. This will better inform prospective and current service users. It is recommended that each individual’s contract of terms and conditions of residency specifies the room(s) to be occupied. This will reassure people about their accommodation in the home. It is recommended Safeguarding (Protection of Vulnerable Adults from Abuse) training be updated for all staff in the home. This will ensure that staff are able to respond appropriately to any issues of abuse. It is recommended that all staff who are involved in the administration of medication receive updated good quality, professional medication training. This will ensure that medication is administered by competent people who are fully aware of current approved practice and procedures. It is recommended that all staff receive updates for moving and handling training. This will protect the health and safety of people who use the service and staff. It is recommended that all staff receive specialist training to ensure that they have the skills and experience to provide for the needs of all service users, e.g. mental health. This will assure people that the home is able to meet the needs of people with mental health needs for which it is registered. It is recommended that annual formal Quality Audits (Satisfaction Surveys) are carried out in order to provide people who use the service with a formal means of expressing their views about their lives in the home. 2 YA5 3 YA23 4 YA32 5 6 YA32 YA32 7 YA39 Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Rocklee DS0000004995.V368136.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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