Inspection on 13/09/07 for Rook Lodge

This inspection was carried out on 13th September 2007.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rook Lodge 07/06/06

Rook Lodge 27/09/05

Rook Lodge 27/06/05

Rook Lodge 04/02/05

Rook Lodge 19/10/04

Rook Lodge 03/03/04

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

CARE HOME ADULTS 18-65 Rook Lodge 1-6 Wanstead Lane Ilford Essex IG1 3UB Lead Inspector Jackie Date Unannounced Inspection 13 to 24 September 2007 12:30 th th Rook Lodge DS0000025921.V350710.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 Rook Lodge DS0000025921.V350710.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. Rook Lodge DS0000025921.V350710.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rook Lodge Address 1-6 Wanstead Lane Ilford Essex IG1 3UB 020 8518 0740 0208 477 1801 rook.lodge@rchl.org.uk www.rchl.org.uk Redbridge Community Housing Limited [RCHL] 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) Mr Eric Charles Bateman Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Rook Lodge DS0000025921.V350710.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 2006 Brief Description of the Service: Rook Lodge is a home for ten people with mental health problems. It is one of a number of homes run by RCHL, Redbridge Community Housing Ltd. The house is in Ilford in the London Borough of Redbridge. The home is a large detached two-storey building with a garden. There are two TV lounges and a conservatory. Residents’ rooms are located in five bedsits and four self-contained flats, and one self-contained maisonette. The home is near to bus stops and the train station. There are shops close by. Rook Lodge aims to provide rehabilitation to enable service users to move on to less supported accommodation. The basic charge per week for each service user is between £772 & £837. This information was provided shortly after the visit by the finance department of RCHL. Information about the service provided is contained in the service users guide. Rook Lodge DS0000025921.V350710.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 12:30pm. It took place over 5 hours. This was a key inspection and all of the key inspection standards were tested. Staff were asked about the care that residents receive, and were also observed carrying out their duties. Where possible residents were asked to give their views on the service and their experience of living in the home. All of the shared areas and 3 flats were seen. Staff, care and other records were checked. Relatives and healthcare professionals were contacted and asked for their opinions of the service. At the time of writing this report feedback had been received from 4 relatives and 2 healthcare professionals. Written feedback forms were also received from 5 staff. Any feedback subsequently received will be taken into account for future inspections. Keyworkers supported the residents to complete feedback forms or completed them on the residents’ behalf. Feedback forms were received from 7 residents. The last key inspection was in June 2006. Since then a random unannounced inspection has been carried out. This was in November 2006 to assess the progress made by the home and to monitor the actions taken to address the requirements made. Where appropriate references are made about these inspections in relevant sections of this report. Services are now required to complete an AQAA (Annual Quality Assurance Assessment) and the completed form was received on 4th September 2007. Information provided in this document also formed part of the overall inspection. The inspector would like to thank the residents and staff for their input during the inspection. What the service does well: The consultant psychiatrist said, “Rook Lodge provides individualised care and rehabilitation at an appropriate pace. Rook Lodge provides a good service.” The GP said, “patients and service providers seem to have a good rapport. Caring staff”. A relative said, “they take good care of our son”. Another relative said,” they look after her very well and they help her as much as they can in every way. They are a very good team and I have no complaints.” Rook Lodge DS0000025921.V350710.R01.S.doc Version 5.2 Page 6 Residents said: “I can make my own decisions, staff advise me what to do”. “The staff are good, they help and don’t bully or moan”. “The staff are okay and always treat me okay. I am settled and happy here and have no complaints”. A member of staff said, “ the residents get a good level of care. If my brother were ill I would be happy for him to be here.” 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. Rook Lodge DS0000025921.V350710.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 Rook Lodge DS0000025921.V350710.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): 2, 3, 4 & 5. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Information is available to enable the staff team to meet residents’ needs. Residents receive information about what the home provides and the service that they could expect to receive. A lot of good work takes place to support residents to develop their skills and be more independent. The staff team have been active in identifying residents whose needs have changed and who may now need alternative placements. The required information is gathered on prospective residents and they and their relatives can spend time in the home to find out what it would be like to live there and to enable the resident to make a choice about living in the home. EVIDENCE: There has not been any new admissions to the home since the last key inspection. However at that time a new resident had recently moved into the home. An examination of his file showed that an initial referral had been made and an assessment carried out. The manager attended meetings at the hospital before the resident moved into the home, to gather more information Rook Lodge DS0000025921.V350710.R01.S.doc Version 5.2 Page 9 about his needs. This resident had lived in the home previously so was familiar with the home and what happened there. A review of his needs was made a few days after he moved into the home. Therefore the staff team had the necessary information to decide whether they would be able to provide a service to this person. The individual was familiar with the home and what happened there and therefore was able to make a decision about whether he wanted to live there. The accommodation at the home consists of a maisonette, flats and bed-sits. Since the last inspection another resident has moved to more independent accommodation in preparation for living on his own. Residents living in the bed-sits prepare meals with the staff and eat in the communal dining area. They also receive more support than the residents living in the flats and maisonette. Since the last inspection one of the residents has moved from a flat into a bed-sit and he said that he was glad that this had happened. He appeared to be quite relaxed and said that he was okay. Two other residents now need a higher level of support and they have been reassessed with a view to identifying alternative placements that will be more appropriate to their needs. One of these residents has started to visit possible alternative placements with her sister. In the interim the staff team are giving these residents the support that they need. Residents’ needs are being met. Each resident now has a fully costed contract/statement of terms and conditions and therefore residents have detailed information about the service that they are entitled to. Rook Lodge DS0000025921.V350710.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): 6, 7, 8 & 9. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Residents’ plans contain detailed information so that staff can meet their needs. The residents’ plans and risk assessments have been reviewed and therefore contain up to date information about their needs. Residents can and do make their wishes known and make decisions about their lives. EVIDENCE: Each resident has a detailed care plan. Areas covered included health, selfcare, communication, psychological needs, relationships and sexual needs, finance and cultural needs. Where residents are known to have certain specific needs at night, an appropriate care plan is in place and is reported on every night. Daily reports are made and these are linked to the care plans. Therefore there is a record of residents’ care and well-being. A random sample of care plans were checked at the time of the visit and these were all relevant Rook Lodge DS0000025921.V350710.R01.S.doc Version 5.2 Page 11 and up to date. There was evidence that they had been reviewed regularly. Appropriate risk assessments were in place and again those seen had been reviewed and updated when needed. Residents also have six monthly reviews with other professionals as part of the Care Programme Approach (CPA). Copies of notes of the most recent CPA meetings were seen on residents’ files. Residents spoken to confirmed that they were involved in developing their care plan and in reviewing these. Staff spoken to said that they felt that there had been a lot of improvements in the care plans and that they were now kept up to date. Overall sufficient detailed information is available so that staff can meet residents’ needs. Residents also said that they choose what to do and where to go. Residents living in the flats said that they choose what to eat but that staff help them with planning the menu and writing a shopping list. Residents also confirmed that they are having regular meetings. Independent advocacy is available to the residents and one resident said that he did not have any complaints but that he could talk to the hospital, the doctor, the advocate or RCHL if he needed to. Residents and staff talked about the choices that residents made. For example, their menus, what they did, where they went and when they got up and went to bed and one person said that he knew where to contact the independent advocate if needed. Residents can and do make their wishes known and make decisions about their lives. Rook Lodge DS0000025921.V350710.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): 11, 12, 13, 14, 15, 16 & 17. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Residents have opportunities for personal development and are supported to be as independent as possible. They are encouraged to engage in appropriate leisure activities within the local community. Most residents go out when they want to and keep in contact with their friends and families. The residents choose their own food and some of them cook their own meals. All of the residents are encouraged to eat as healthily as possible. EVIDENCE: Residents are encouraged to develop their skills. Those living in the bedsits participate in household tasks on a rota basis. This includes the cooking as well as domestic chores. Residents that live in the flats cook their own meals, do their own washing, ironing and cleaning. The service has been successful in supporting people and enabling them to move on to more independent Rook Lodge DS0000025921.V350710.R01.S.doc Version 5.2 Page 13 accommodation. The consultant psychologist said, “Rook Lodge provides individualised care and rehabilitation at an appropriate pace.” All but one of the residents can go out without support from the staff team. Residents go out when they want to. Residents go to college and to various support groups and clubs. One resident goes to a Jewish club and another to a Caribbean club. Residents were involved in discussions about plans for a holiday and some are going to Butlins in October. One resident organises day trips for herself. Some of the residents have a lot of contact with their families; others do not have any close family that they are in regular touch with. The residents also talked about how staff support them to be as independent as possible. For example supporting them with menu planning, shopping and cooking meals. Minutes of the residents meetings show that residents are encouraged to report any breakages or repairs and also that staff will show them how to safely use some new cleaning products. Residents are going to attend some training courses with staff and this includes health & safety and food hygiene. One resident has been doing some part time temporary work at RCHL head office. When he returned home he said that he had enjoyed doing this but unfortunately the project that he was working on had now finished. One of the areas that the service hopes to develop is more residents being involved in supported workplace schemes. Therefore residents have opportunities for personal development and are supported to be as independent as possible. They are encouraged to engage in appropriate leisure activities within the local community. As stated previously some of the residents cook their own meals and do their own shopping. Staff help them with menu planning and advise on healthy eating. Residents that eat in the communal areas choose the menu, which includes a variety of dishes with healthy and homemade options, and take turns to cook with the staff. None of the residents has any specific dietary requirements. One resident said that different staff have different ‘specialities’ in terms of cooking. He said that one does a good cooked breakfast, another makes a good curry and a third a good Sunday roast. A relative of one of the residents that eat communally was concerned that residents could not have a late supper. This was discussed with the manager and he confirmed that this was not the case but that some areas were locked at night. The manager then spoke to the resident concerned and other residents and they have agreed that a small fridge will be purchased and that food for sandwiches will be left in there at night in case residents want to make an additional snack. Rook Lodge DS0000025921.V350710.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, 20 & 21. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Residents receive personal care that meets their individual needs and preferences and the staff team support them to get the healthcare that they need. Residents are given prescribed medication safely. Information is available to enable staff to identify the needs of residents, as they get older, and also to meet their wishes in the event of their death. EVIDENCE: Most of the residents are very independent in terms of personal care; they just need reminders and prompting. The female staff support the two female residents. One of the female residents wishes to have some treatment for the permanent removal of facial hair and staff are supporting her to do this. Residents are supported, as and when required, by the staff team to access health care. Details are kept of medical appointments and outcomes. Residents receive support from other professionals as necessary. These Rook Lodge DS0000025921.V350710.R01.S.doc Version 5.2 Page 15 include dentist, optician, community psychiatric nurse and psychiatrist. Individual’s mental health needs are reviewed as part of the Care Programme Approach (CPA). Each resident has a “breakdown footprint”. This indicates the symptoms of a possible deterioration in their mental health. There was also evidence that staff listen to residents concerns about their health and act upon these. For example one resident said that he had been having fits and this was followed up. There has been deterioration in the behaviour of one resident and this person has seen a behaviour therapist and there is information in the care plan about staff having a consistent approach to the anti social behaviour. Medication is securely and safely stored in a locked facility in the main office. Medication is administered by staff to those residents who are unable to self medicate. The chemist dispenses most of the medication but some residents collect other medication from the hospital. The medication file contained photographs of each individual. There was also a list of staff that are able to administer medication and their signatures. All of the residents have had medication reviews. This is good practice. Some residents receive PRN (as required) medication and a PRN medication policy and procedure has been developed. This gives general guidance but individual protocols/guidelines are still needed to ensure that all staff know when and why to administer PRN medication to each individual. This requirement remains outstanding from the previous inspection and must be addressed. Examination of the medicines administration record (MAR) chart found that there were handwritten entries but these had been initialled. Any unwanted/unused medication is returned to the pharmacy. Items other than medication have been cleared from the medication cabinet. Previously the medication cabinet contained a lot of first aid items and was very cluttered. A draft policy on ageing has been produced and residents’ files contained information on their, or their families, wishes in the event of death. Rook Lodge DS0000025921.V350710.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): 22 & 23. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. There is a complaints procedure that would be followed in the event of any complaints being made. Residents are given enough information to enable them to know how or who to complain to should the need arise. Staff are aware of, and have received training in, issues of abuse and work to protect residents from abuse. EVIDENCE: There is an organisational complaints procedure and each resident has a copy of this. Residents said that they could talk to the manager if they werent happy about anything. They also meet with the housing officer and discuss problems. In addition all residents have access to an independent advocate. One resident was clear that he had lots of options if he had concerns and that included his doctor at the hospital, the advocate and RCHL. There was one recorded complaint since the last inspection and staff quickly and easily resolved this. The Commission has not received any complaints or allegations about this service. The organisation has produced a detailed adult protection policy that tells staff the actions to take in the event of abuse/suspected abuse being discovered. Staff have attended a course on protecting residents from abuse and are aware of their responsibility to residents. When residents go out the staff usually check where they are going and when they expect to be back. Staff said that Rook Lodge DS0000025921.V350710.R01.S.doc Version 5.2 Page 17 they know the usual pattern that each person has and if anything is different they will follow this up. Most of the residents collect their own money from the building society or bank. They take this to the office and staff record the details and put money into individual wallets, which are kept in the safe. Residents are helped to budget and given money when required. Residents sign to say they have received their money. Some of the residents keep their own money. The records of two residents were examined and cash counted. These were both found to be correct. The manager and senior staff check the records and cash weekly. The organisation carries out annual financial audits and one had taken place shortly before this visit. The report had not yet been received. Therefore systems are in place to protect residents from financial abuse. However it was noted that no record is kept of the transactions with the bank or Building Society and that these accounts are not reconciled or checked. This was discussed with the internal auditor and she confirmed that this should be done and that this will be in her report. Therefore at this stage a requirement has not been made and this will be monitored during the course of future inspections. Rook Lodge DS0000025921.V350710.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, 25, 26, 27, 28, 29 & 30. People using the service experience adequate quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. The residents live in a clean home that is suitable for their needs. Promised refurbishment needs to be completed so that residents will benefit from living in a comfortable, appropriately decorated and maintained home. EVIDENCE: Rook Lodge was a nurse’s home and was converted to a registered care home approximately 17 years ago. Accommodation consists of 5 bed-sits, 4 flats and 1 maisonette. There is a communal lounge, dining area, smoking area, laundry and kitchen. Each resident either has a bed-sit, a flat or a maisonette. The bed-sits consist of a bedroom and en-suite facility. The flats have a combined kitchen/lounge/dining area, a bedroom and a bathroom. The maisonette has a kitchen, a lounge/dining area, a bedroom and a bathroom. Rook Lodge DS0000025921.V350710.R01.S.doc Version 5.2 Page 19 None of the current residents require adaptations or disability equipment. Although one of the residents has very little vision she is able to find her way around the home independently. There is a call alarm system within the home and most of the residents are able to use this. Since the last key inspection a lot of work has been carried out at the home and the environment has improved. The hot water system has been replaced, the communal bathroom refurbished, communal areas have been decorated and the outside of the building has been repainted. Some new net curtains and new blinds have been purchased. At the time of the random inspection in November 2006 the manager said that residents rooms/flats would be decorated in the New Year. Some carpets needed replacing as they are showing signs of wear and had several burns on them. The inspector was informed that this would be addressed as part of the redecoration process. Therefore a requirement was not made as ongoing refurbishment was taking place. At the time of this inspection the deputy manager said that the decorating was due to be done very soon and that 5 flats would be decorated and would get new carpets and beds. In view of the fact that it has been almost a year since that inspection and the work has not yet been carried out it is now necessary to make a requirement in relation to this. All areas of the home must be suitably decorated and worn or damaged carpets and furniture replaced. This will ensure that residents live in a homely, comfortable and safe environment. This requirement refers to standards 24 & 26. Rook Lodge DS0000025921.V350710.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): 31, 32, 33, 34, 35 & 36. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Residents are supported and protected by the organisations recruitment practice, including the recruitment of bank and agency staff. Staffing levels are sufficient, and staff receive the necessary training, supervision and support, in order to meet residents’ current needs and provide an appropriate service for them. Residents are supported by a staff team that know them well and who are committed to providing a service that supports residents to be as independent as possible and where possible to move on to more independent accommodation. In addition to informal support staff now receive formal supervision and regular staff meetings are held. This gives a chance for work practice and the development of the service to the discussed. Rook Lodge DS0000025921.V350710.R01.S.doc Version 5.2 Page 21 EVIDENCE: From examination of the rota and from discussions with staff it was evident that there are usually three staff on duty during the daytime shifts. Since the last key inspection a deputy and a part time support worker have been appointed. This has meant that the need for staff to work long shifts has decreased. The manager is no longer regularly the third person on shift and therefore staffing levels are now sufficient to meet residents’ needs. A member of staff said that they now have more time to concentrate on the residents and that residents are befitting from this. In addition the manager now has designated management time and this means that the home has management support throughout the week. There are also times during the week when the manager “overlaps” with senior staff and this enables discussions, planning and management handover. Staff have job descriptions and in discussion were clear as to their individual role in the home. The organisation operates an appropriate recruitment procedure. Jobs are advertised, application forms completed and interviews held. Staff records are held centrally at the organisations head office in line with an agreement made with the Commission. However copies of the necessary information was available in the file held at the home and two files were examined during the inspection. The files contained copies of the application form, references and identification documents. There was also evidence that the necessary checks had been carried out. Therefore the recruitment procedure offers safeguards to residents. From examination of staff training records and feedback from staff it was apparent that they have been receiving training. One member of staff said that there had been a lot of training relevant to the work that they do. This has included an extended mental health training course. Staff have received adult protection, medication, care planning training and diversity training. In addition to this all staff have personal development folders and have had appraisals. Therefore staff training needs have been identified and appropriate training is being arranged to give the staff team the skills they need to work with the residents. Staff are receiving regular supervision and staff meetings are being held each month. This gives staff the opportunity both collectively and individually to discuss work practice, any concerns and the development of the service. Feedback from staff was that communication has improved and people are keeping up to date. This has given them more insight into residents’ needs and how to improve the service. Rook Lodge DS0000025921.V350710.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, 38, 39 & 42. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. The residents are benefiting from the management and development of the home. The registered provider monitors the service to check the quality of the service provided to residents. The residents are living in a safe environment EVIDENCE: The manager is a qualified psychiatric nurse and has extensive experience of managing services for people with mental health difficulties. Staff spoken to Rook Lodge DS0000025921.V350710.R01.S.doc Version 5.2 Page 23 said that they get good support from the manager and that they can talk to him if there are difficulties or concerns. The quality of the service provided to the residents is monitored by the manager and by the organisation. The service manager carries out monthly monitoring visits to assess how effectively the home is operating to meet its stated aims and objectives, and reports are written. These indicate the action to be taken when deficiencies are identified. Copies of these reports were available in the home and copies are sent to the Commission. In addition to this the organisation carries out a quality audit each year and also a financial audit. All of the necessary health and safety checks are carried out and records are kept of these checks. The home has a comprehensive range of policies and procedures to promote and protect residents’ and staff safety. Staff receive the training that they need to understand and use these. Staff carry out monthly health and safety audits and every three months a ‘housing officer’ from the head office carries out a more in depth audit. Therefore the organisation also monitors health & safety. A safe environment is provided for the residents. Rook Lodge DS0000025921.V350710.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 X 2 3 3 3 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 2 25 3 26 2 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 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 2 3 3 3 3 X X 3 X Rook Lodge DS0000025921.V350710.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? 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 Requirement Specific individual Protocol/guidelines must be in place for each PRN (as required) medication that has been prescribed. (Previous timescale of 3/12/06 not met). All areas of the home must be suitably decorated and worn or damaged carpets and furniture replaced. This requirement also relates to standard 26. Timescale for action 30/11/07 2 OP24 16 31/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Rook Lodge DS0000025921.V350710.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Rook Lodge DS0000025921.V350710.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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