Inspection on 22/11/05 for Romans

This inspection was carried out on 22nd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Romans 17/08/06

Romans 08/07/05

Romans 15/09/04

Romans 10/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Romans 1 Roman Road Southwick Shoreham-By-Sea West Sussex BN42 4TP Lead Inspector Mrs H Church Unannounced Inspection 22nd November 2005 07:30 X10015.doc Version 1.40 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 Romans DS0000014682.V266968.R01.S.doc Version 5.0 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 Older People. 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. Romans DS0000014682.V266968.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Romans Address 1 Roman Road Southwick Shoreham-By-Sea West Sussex BN42 4TP 01273 270100 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) West Sussex Housing Society Limited Mrs Linda Francis Leach Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Romans DS0000014682.V266968.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th July 2005 Brief Description of the Service: Romans is registered with the Commission for Social Care Inspection to provide personal care for up to thirty people over the age of sixty-five in the category of Older People. The establishment is a three storey detached building situated in the town of Southwick in West Sussex. A plaque in the hall shows that Romans has been operating as a care home since 1956. Romans is situated approximately quarter of a mile from Southwick Green, the main shopping centre of Southwick and all its amenities and half a mile from the sea front. Accommodation is provided in thirty single rooms. The rooms are arranged over three floors with a lift giving access to all but four of the rooms. A lounge, sun lounge and separate dining room provide the communal space. The responsible person is Mr Tony Matthews who represents West Sussex Housing Society Limited, a voluntary organisation who owns the service. The registered manager responsible for the day-to-day running of the care home is Mrs Linda Leach. Romans DS0000014682.V266968.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection, one of two required under the Commission for Social Care Inspection was planned to join the night staff and the handover to the day staff. The inspector was also able to observe the early morning care and activities provided for the residents. The manager was not present at this inspection but her deputy was able to assist the inspector with her enquiries. The inspector spoke to three members of staff, including an agency worker, two visitors and ten residents. A number of residents chose to have their breakfast in the dining room. The residents seemed generally happy and relaxed. One resident told the inspector that she considered this to be her home now. The Statement of Purpose and Service Users Guides have been updated and include information on how the home is run and how changes can be made to improve residents lives there. As well as discussing their views with residents, the inspector examined four care plans and other related records to see if the care provided was the care required. All residents were able to give a clear account of their life at Romans and generally, all comments were enthusiastic and residents seem contented and happy to be there. It was clear from the residents that they are encouraged to say what they like or don’t like about the home. The members of staff were supportive of the management structure and were able to access all records to refer to and add to the records of care provided. There were no requirements made at this inspection but a recommendation was made regarding records. What the service does well: Romans provides a warm, homely and friendly environment where the resident’s collective and individual needs are central to all its activities. Staff listen to residents comments and the suggestion box in the hall is a clear indication that the staff are keen to make any changes that would improve their lives there. From residents and visitor’s comments and observing staff at work, it was clear that the outcomes for residents are good with staff committed to treat residents with respect and dignity. Romans DS0000014682.V266968.R01.S.doc Version 5.0 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. Romans DS0000014682.V266968.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Romans DS0000014682.V266968.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. All residents had been assessed before moving into the home. The staff at the home are meeting the residents identified needs. Relatives were given enough information to help them decide the home would be suitable. EVIDENCE: The Statement of Purpose and Service Users Guide has been continuously reviewed for all their residents, representatives and prospective residents. Four care plans were examined and it was clear residents are being assessed prior to admittance to ensure the home would be able to meet their needs. One resident told the inspector of a trial visit. Risk assessments were in place but the inspector informally recommended that these could be more informative. Night staff are well informed about the care needed and had access to records to update these accordingly. Romans DS0000014682.V266968.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 All residents had an individual care plan set out for staff to follow. Some residents have elected to manage part of their medication. Staff are meeting the health care needs of the residents in an appropriate and respectful manner. EVIDENCE: Four care plans gave clear information of the care needed with risk assessments to inform staff how to minimise risks. However, the inspector recommended that the areas of risk identified be widened to include individual pursuits. Accident records have improved and new forms are being devised to give more information. Care plans were comprehensive in the care provided, demonstrating a good understanding of holistic needs. Medication sheets were completed accurately and it was clear that appropriate referrals are made and care followed up as directed by the Primary Health Care Team. Romans DS0000014682.V266968.R01.S.doc Version 5.0 Page 10 Staff were observed speaking to and caring for the residents and treating them with respect. Staff knocked on doors before entering and spoke to residents in a caring manner. Resident’s comments included “there’s nothing wrong with the staff”, “staff are really lovely”, “staff are very good” and “we couldn’t do any better”. Romans DS0000014682.V266968.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Activities are suited to the conditions and dependency levels of each of the current residents. Visiting is positively encouraged. Residents are served meals that are nutritious and appetising. EVIDENCE: Activities are based on ability with staff assisting with these. The number and choice of activities has continued since the last inspection according to the views of the residents. Music and bingo sessions are popular. There are twenty-eight residents currently in residence with staff spending individual time with them. The two visitors told the inspector they have always been made welcome and it was clear from the visitor’s book that visitors come every day at all times of the day and evening. The residents told the inspector that they really enjoyed their food. The change of cook has been a success and it was clear that the meals are steadily improving again. At the time of the inspection the residents had been offered a variety of dishes for breakfast but as one resident commented “You can always ask for something else”. The dining room was very welcoming and tables prepared with all necessary items. Romans DS0000014682.V266968.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Residents are confident that any complaints they may have are taken seriously and acted upon appropriately. Staff training in adult protection procedures is up-to-date so staff are equipped to protect residents from abuse. EVIDENCE: The home has a complaints procedure displayed and included in the Statement of Purpose and Service Users Guide. One resident said she knew who to complain to, but had had no occasion to do so. The West Sussex Multi Agency guideline was available in the home and staff, when questioned appeared to know the procedures for protecting residents from abuse. Updated training has been provided and is also included in the National Vocational Qualification training. Romans DS0000014682.V266968.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26. The indoor areas used by residents are clean, safe and homely with good access to the rear garden. The resident’s rooms are suitable for their needs and are homely. EVIDENCE: During a tour of the home the inspector noted that a maintenance programme is in place but one radiator in the stairwell needed some attention to meet the safe levels required. According to the deputy manager, the heating system was due to be improved but an agreement was made for staff to continuously check the area. At the time of the inspection, an empty room was being decorated with the other empty room prepared for decorating. There are two ground floor communal rooms and a separate dining room furnished to provide a homely atmosphere. There is a passenger lift, inspected regularly, for access to first and second floors. Romans DS0000014682.V266968.R01.S.doc Version 5.0 Page 14 All rooms are equipped according to the National Minimum Standards with thermostatic valves in place to restrict water temperatures to safe levels and all room radiators guarded. The home was clean and hygienic. Resident’s rooms were visited and were homely and comfortably furnished with personal possessions around them. The latest Fire Officer’s inspection showed some outstanding items from the previous inspection visit. The home have been given a further period of time to complete these. Romans DS0000014682.V266968.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,30 The duty rotas did indicate that enough staff were on duty over the 24 hours period to meet needs. Recruitment processes are robust and ensure residents are protected. EVIDENCE: The inspector noted that an additional member of staff had been appointed to give staff more time during the early morning and more time to socialise with residents after breakfast. Two members of staff said they had received updated mandatory training and felt well supported by the management system. An agency staff said she had received all the training required to provide the care needed. The inspector did not examine training records on this occasion. Romans DS0000014682.V266968.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36,38. The registered manager is Mrs Linda Leach. Mrs Leach has the qualifications and experience to manage the home. EVIDENCE: Mrs Leach has completed the National Vocational Qualification level 4 in Management and the Registered Managers Award. The staff said that they felt well supported by the management structure. The inspector examined the supervision records required under the Care Homes Regulations from the last inspection. It was clear that these were now in place with a supervision agreement to inform staff of their use. However, the inspector made a recommendation to implement these according to all the areas stated in the National Minimum Standards. The inspector did not examine the financial records on this occasion and noted from management Romans DS0000014682.V266968.R01.S.doc Version 5.0 Page 17 comments that the quality assurance questionnaire is being upgraded. Apart from the one radiator in the stairwell, all areas were seen to be safe giving resident’s sufficient space for them to have personal possessions or necessary equipment to support their care needs and move around their rooms and communal areas safely. Romans DS0000014682.V266968.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Romans DS0000014682.V266968.R01.S.doc Version 5.0 Page 19 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. Standard Regulation Requirement Timescale for action 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 OP36 Good Practice Recommendations Supervision must cover all aspects of the standard. Romans DS0000014682.V266968.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 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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