Inspection on 27/06/05 for Rook Lodge

This inspection was carried out on 27th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 23 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rook Lodge 13/09/07

Rook Lodge 07/06/06

Rook Lodge 27/09/05

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 27 June 2005 10:00 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 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 Stationary 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 G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Rook Lodge Address 1-6 Wanstead Lane, Ilford, Essex IG1 3UB Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8518 0740 020 8477 1801 Redbridge Community Housing Ltd Eric Charles Bateman CRH Care Home 10 Category(ies) of MD Mental Disorder (10) registration, with number of places Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 04 February 2005 Brief Description of the Service: Rook Lodge is situated in a residential area of Ilford in the London Borough of Redbridge and 10 adults within enduring mental health support needs live there. It is one of a number of homes operated by Redbridge Community Housing Ltd (RCHL) within the borough. The home is a large detached twostorey building with a rear garden. The communal areas are spacious with two TV lounges and a conservatory. The accommodation consists of five bedsits and four self-contained flats, and one self-contained maisonette. The home is located close to Redbridge tube station and local bus services. There are shops and other local amenities close to the home. Rook Lodge aims to provide rehabilitation to enable service users to move on to less supported accommodation Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection lasted for about six and a half hours and took place during the late morning and afternoon. It was the first of the two inspections that each home must have during the inspection year. The manager, four staff, and six of the ten residents were spoken to. All of the communal areas and four of the residents rooms were seen. Staff, care and other records were checked. The main focus of the inspection was to check the progress of the 24 requirements and four recommendations from the previous inspection. In addition to this the inspector had previously visited the organisations head office to view staff records. What the service does well: What has improved since the last inspection? What they could do better: Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 Page 6 There are 23 requirements and one recommendation made in this report. Many of these requirements have been made on three previous occasions and have still not been addressed by the registered persons. The Commission are in consultation with their legal department with regard to the future action that will be taken about this. The organisation must ensure that all the outstanding requirements are addressed within the timescales set to ensure that the welfare of residents is safeguarded and promoted and that the registered persons operate the service in accordance with legal requirements and National Minimum Standards. 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. Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 and 5 Information is obtained to enable the staff team to decide whether or not the home can meet prospective residents needs. Prospective residents can spend time in the home to find out what it would be like to live there. Residents do not receive information about what the home provides or the service that they could expect to receive. Whilst a lot of good work takes place to support residents to develop their skills and be more independent the needs of all of the residents are still not being fully met. EVIDENCE: The previous three inspections have all required that the registered manager must produce an up-to-date service user guide. This piece of work has still not been completed. Therefore there is no written information available about the home for prospective residents. The manager said that he was still halfway through this but that the work was lost due to a problem with the computer. He hoped that this would be retrieved. The first date to complete this piece of work was 31 March 2004, more than a year ago and it is unacceptable that action has not been taken to address this. A prospective resident was staying at the home for a week to enable staff to carry out assessments and for him to get to know the home. This was part of Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 Page 9 a slow carefully planned admission. Initial information was available and staff had kept notes of his visits. Therefore information was being gathered before a decision was made as to whether this person moved into the home or not. The accommodation at the home consists of a maisonette, flats and bedsits. One resident has recently moved out to more independent accommodation. Residents living in the bedsits prepare meals with the staff and eat in the communal dining area. They also received more support than the residents living in the flats and maisonette. At the previous inspection the manager said that one of the residents of the flats needed more supervision and support than usually given and that this person appeared happy when in the communal areas and functioned better with less responsibility. However this person would not give up the flat and could not have their meals or more support provided whilst living there. Rook Lodge is a registered care home and appropriate support must be provided irrespective of the specific accommodation. Residents should not have to move rooms to receive the support that they need. The previous two inspections required that the registered person must ensure that the assessed needs of all services are being met and it still remains outstanding. The previous two inspections have required that the organisation must provide each resident with a fully costed contract/statement of terms and conditions. The manager said that he has raised this issue with the quality assurance section of the organisation but this was still not available. Therefore residents still do not have detailed information about the service that they are entitled to. As one of the registered persons, the manager has a legal responsibility to ensure that the regulatory requirement is complied with. Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 7 Residents’ plans contain detailed information so that staff can meet their needs but the plans are not reviewed often enough and therefore may not contain up-to-date information. If current needs are not clearly specified they may not be addressed. EVIDENCE: Each resident has a detailed care plan. These take into consideration personal, healthcare and social support needs. Staff spoken to say the care plans are done with the residents and this was confirmed by some of the residents. The previous two inspections required that the plans must be reviewed with the resident and significant others at least every six months and updated to reflect changing needs. One of the care plans seen had not been reviewed for more than one year and the other one had not been reviewed for nine months. The requirements from previous inspections have therefore still not been met. Each resident has a six monthly review with other professionals as part of the Care Programme Approach (CPA) but agreed changes are not recorded and care plans were not updated to reflect changing needs. Daily recordings are now made and therefore there is a record of residents’ care and well-being. Prior to the Care Programme Approach (CPA) meeting the manager writes a report containing all the relevant information. Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 Page 11 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. Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16 and 17 Residents have opportunities for personal development and 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. On the day of the inspection one resident was ironing, another was washing their clothes and a third said that it was their turn to help with the cooking. Residents that live in the flats cook their own meals and had a variety of different meals that day. The menu is varied and nutritious. All but one of the residents can go out without support from the staff team. They said they go to various activities and support groups and one person said Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 Page 13 that they still keep in contact with a resident that used to live at the home. During the inspection residents were observed to come and go as they chose. Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 and 21 Residents received personal care that meets their individual needs and preferences. The staff team administer medication appropriately and support the residents to get the health care that they need. There are not any policies or guidance in place to guide staff in dealing with the aging of residents. EVIDENCE: Most of the residents are very independent in terms of personal care, they just need reminders and prompting. The two female residents are supported by the female staff. 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 include dentist, optician, community psychiatric nurse and psychiatrist. The two previous inspections have required that the medication procedure must be updated to give detailed action to be taken in the event of a medication error occurring. On the day of the visit when the inspector first checked this requirement it had not been actioned, but during the course of Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 Page 15 the visit the manager typed up some guidelines and put them on the medication cabinet. The manager said that he was not clear as to what had been required. However this had been explained at both the previous inspections. The previous three inspections required an ageing policy to be developed. The manager said that the organisations quality assurance section had been asked for this but it was still not available. Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Residents are not given enough information to enable them to know how or who to complain too should the need arise. Staff have not received sufficient training to enable them to protect residents from harm or abuse. EVIDENCE: The previous three inspections have required that the home must ensure that the Commissions details are included in the complaints procedure. This had not been done. However during the course of the inspection the manager typed a brief note to say that the Commission could be contacted at any time. A copy of this was put into each residents message box. There were not any copies of the organisational complaints procedure or forms available at the home. Residents are able to express their dissatisfaction and say that they would tell the manager if they werent happy. The organisation does have a complaints procedure and form for residents and copies of this must be given to all residents in the home to ensure that they or their relatives are clear about how they can complain and what will happen if they do. Staff spoken to were aware of adult protection issues and do work with residents to keep them safe in the community. However staff have not received any specific adult protection training. All staff must receive adult protection training so that they are clear as to what constitutes abuse and are able to prevent service uses from suffering abuse or being placed at risk of harm or abuse. Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 27 and 30 The communal areas are generally clean and satisfactorily decorated and furnished but this is not always extended to residents living in the flats whose accommodation is not always maintained to an appropriate standard. EVIDENCE: The standards were tested in relation to the requirements of the previous inspection. At that time one of the flats was in a poor condition and the bathroom and kitchen needed attention to meet an acceptable standard. The new kitchen has been fitted and the lounge and bedroom have been repainted. However no improvements have been made to the bathroom. New flooring and a new bath panel are required. This requirement has been made in the two previous inspection reports. The resident living in this flat said that they liked the new kitchen but would like their bathroom to be done as well. In one of the other flats the sofa was broken. The resident said this was okay as they could sit on the other half of the sofa. The sofa must be replaced and systems must be put into place to ensure that all areas of the home are in a good state of repair. There is a communal lounge, dining area, smoking area, laundry and kitchen and these were clean and appropriately decorated and furnished. Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 Page 18 The previous inspections required that a deep clean must be carried out throughout the home with particular attention to the bathrooms and toilets. The manager said that every four to five months the carpet in the corridors is steam cleaned and that the rooms are steam cleaned every six months. At the time of the visit all areas at the home appeared to be clean and free from unpleasant odours and all extractor vents had been cleaned, both as required by the previous inspections. The previous inspection also recommended that the bath in the communal bathroom be replaced and this has not happened. Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 and 36 The Commission for Social Care Inspection cannot be confident that residents are supported and protected by the organisations recruitment practice, including the recruitment of bank and agency staff. Staff do not receive the necessary training or support to enable them to fulfil their duties or to fully meet residents needs. EVIDENCE: The previous three inspections required that the current staffing levels be reviewed using the residential forum staffing tool to ensure that sufficient numbers of staff were available to meet the rehabilitation goals of each service user. This calculation was received with a letter saying that the calculation allowed two staff to be on duty during the daytime shift and one waking and one sleeping in staff at night. However there are no details of how the staffing levels were matched to individual residents needs, in particular those preparing for independent living. The manager said that he felt that there should be one of the management team and two support staff per daytime shift and one waking and one sleeping in staff at night. From examination of staff rotas and discussion with staff on duty it was apparent that there are a minimum of two staff on duty during the day but there were occasions when staff had not been available to sleep in. Overall there was no evidence to confirm that sufficient Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 Page 20 staff are on duty to meet the residents assessed needs or to provide a safe service and this must be addressed by the organisation. A comprehensive review must be carried out that identifies residents’ needs and matches these to staffing levels and the aims and objectives of the service. Agreed staffing levels must then be adhered to. This will ensure that all residents receive sufficient support. Staff had job descriptions and in discussion were clear as to their individual role in the home. An inspection, at the organisations head office, of a sample of personnel files showed that not all of the required checks on staff could be demonstrated to have taken place. This was of particular concern, as many of the files inspected related to staff who have joined the organisation in the past year, and for whom the recruitment process should have been robust, as matters regarding recruitment had been discussed previously with the organisation. Staff spoken to indicated that training is limited and that they had not received specific training in areas such as mental health, dual diagnosis and drug and alcohol problems. All of these are relevant to the current residents. Staff must receive the necessary training to enable them to meet the needs of the residents. The requirement from the three previous inspections that there must be a training and development plan for each member of staff and that staff receive five days paid training each year still remains outstanding. Further discussions with staff highlighted that supervision is not consistently provided. Some staff receive regular supervision, some less frequent, and in one case a member of staff said they had never received supervision. Therefore staff do not necessarily have the opportunity to discuss problems and work practice. However the staff did say that they do have staff meetings and handovers are detailed. All staff must have regular, recorded supervision meetings at least six times a year with a senior/manager in addition to regular contact on day-to-day practice. The previous three inspections have also required that an appraisal system is in place and that all staff receive a yearly appraisal. The deputy has started this process but only three staff have received appraisal so far. This requirement has therefore still not been fully met. Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 41, 42 and 43 The organisation has not been robust in monitoring the service, maintaining staff records or maintaining a safe environment. These potentially place residents at risk. The service is not being robustly managed or monitored, resulting in failure to ensure that residents receive consistent quality care. This has resulted in some practices that may jeopardise the safety and well-being of people using the service. EVIDENCE: Regulation 26 of the Care Home Regulations 2001 requires that a representative of the organisation visit the home unannounced at least once each month to check on the standard of care provided. A written report must be made and a copy of this lodged with the home and a copy sent to the Commission. At the last inspection the manager said that he would forward copies of these reports to the Commission but this has not happened. The manager confirmed that these visits do take place but was unable to provide Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 Page 22 copies of all of the reports. Therefore it is not possible to confirm that the home is being appropriately monitored in accordance with the legislative responsibilities placed on the registered persons. As stated previously an inspection of staff records held at the head office found that staff records as required by Schedule 2 of the Care Homes Regulations 2001 were not available in all staff files. The registered persons are required to maintain records for the protection of service uses in line with Schedule 2 of the Care Homes Regulations 2001, both for new staff before appointment and for existing staff. Fire call points are checked each week and two fire drills have been held so far this year. Staff are also checking water temperatures on a weekly basis. Health and safety checks are carried out by the staff and a housing officer visits quarterly to carry out a health and safety check. These checks show that issues are picked up and that they are reported for action. However the previous two inspections made four health and safety requirements that have not yet been met. The first is that a satisfactory landlords gas safety certificate must be obtained and a copy sent to the Commission. The manager said that the work had been carried out but there was no certificate. The second was that at a satisfactory electrical intake report must be obtained and a copy sent to the Commission. The organisation has said that a new check is due this year but have not provide the copy of the previous certificate. The third is that the problems with the hot water system must be investigated and remedied. The manager said that “some new valves have been fitted and some tinkering has been done with the system” and that “this seems to have evened things out a bit”. However the problem has not been fully resolved. The final requirement was that advice must be sought from the fire service with regard to the fire exit from the kitchen and any requirement actioned. If the current situation is acceptable then written confirmation must be supplied to this effect. The manager said that they are still waiting for the fire service to visit. Therefore the residents cannot be sure they live in a home that is safe. The previous three inspections have required that the registered manager must ensure that there is a business and financial plan for the home and that a copy of this is sent to the Commission. The manager said that he was still waiting for a format to come from head office and then he would do this. Therefore residents cannot be sure that they live in a home that is effectively managed and financially viable. Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 2 3 2 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x 2 x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x 2 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Rook Lodge Score 3 3 3 2 Standard No 37 38 39 40 41 42 43 Score x x 2 x 2 2 2 G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 Page 24 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 YA1 Regulation 5 Requirement The registered manager must produce an up-to-date service user guide. (Previous timescales of 31 March 2004, 31 January 2005 on 30 April 2005 not met). The registered person must ensure that the assessed needs of all service users are being met. (Previous timescales of 31 March 2004, 31 January 2005, and 30 April 2005 not met). The organisation must provide the service user with a fully costed contract/statement of terms and conditions as detailed in standard 5.2. (Previous timescales of 31 January 2005 on 30 April 2005 not met). Care plans must be reviewed with the service user and significant others at least every six months and updated to reflect changing needs. (Previous timescales of 31 January 2005 and 30 April 2005 not met). The home must ensure an ageing policy is produced. (Previous timescales of 31 March 2004, 31 January 2005 and 30 April 2005 not met). Timescale for action 31 August 2005 2. YA3 12,14 31 August 2005 3. YA5 4,5 31 August 2005 4. YA6 15 31 August 2005 5. YA21 12 31 August 2005 Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 Page 25 6. YA22 22 7. 8. YA23 YA24 13 23 9. 10. YA24 YA24 23 23 11. YA27 23 12. YA33 18 13. YA34 19 14. YA35 18 15. YA36 18 16. YA36 18 A copy of the organisations client complaints procedure and form must be given to all residents All staff must receive adult protection training. All areas of the home must be kept in a good state of repair. (Previous timescales of 31 January 2005 on 30 April 2004 not met). The broken sofa must be replaced. A system must be in place to ensure that all areas of the home are checked regularly for damage or wearing care The bathroom in flat three must be renovated to an acceptable standard. (Previous timescales of 31 January 2005 and 30 April 2005 not met). A comprehensive review must be carried out that identifies residents needs and matches these to staffing levels. Agreed staffing levels must then be adhered to. The registered persons are required to ensure that their recruitment procedure is robust and in line with regulation. The registered manager must ensure that there is a training development plan for each member of staff and that staff receive five days paid training a year. (Previous timescales of 1 June 2004, 31 December 2004 and 30 April 2005 not met). All staff must have regular recorded supervision meetings at least six times a year with a senior/manager, in addition to regular contact on day-to-day practice The registered provider must ensure that an appraisal system G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc 31 August 2005 31 October 2005 31 August 2005 31 August 2005 31 August 2005 31 August 2005 30 September 2005 Ongoing 31 August 2005 30 September 2005 31 August 2005 Page 26 Rook Lodge Version 1.40 17. YA39 26 18. YA41 17 19. YA42 13 20. YA42 13 21. YA42 13 22. YA42 13 23. YA43 25 is in place and that all staff receive an appraisal annually. (Previous timescales of 1 June 2004, 31 January 2005 and 30 April 2005 not met). A representative of the organisation must visit the home unannounced at least once each month to check on the standard of care provided. A written report must be made and a copy of this lodged with the home and a copy sent to the Commission. The registered persons are required to maintain records for the protection of service users in line with Schedule 2 of the Care Homes Regulations 2001. For new staff before appointment and for existing staff. A satisfactory landlords gas safety check must be obtained and a copy sent to the Commission. (Previous timescales of 31 December 2004 and 30 April 2005 not met). A satisfactory electrical intake report must be obtained and a copy sent to the Commission. (Previous timescales of 31 December 2004 and 30 April 2005 not met). The problems with the hot water system must be investigated and remedied. (Previous timescales of 31 December 2004 and 30 April 2005 not met). Advice must be sought from the fire service with regard to the fire exit from the kitchen and any requirements actioned. If the current situation is acceptable then written confirmation must be obtained to this effect. (Previous timescales of 31 December 2004 and 30 April 2005 not met The registered manager must G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc 30 September 2005 30 September 2005 31 August 2005 31 August 2005 31 August 2005 31 August 2005 31 August Page 27 Rook Lodge Version 1.40 ensure that there is a business and financial plan for the home that a copy of this is sent to the Commission 2005 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 YA27 Good Practice Recommendations It is recommended that the bath in the communal bathroom be replaced. Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection Ferguson House 113 Cranbrook Road Ilford Essex IG1 4PU 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. Extracts may not be used or reproduced without the express permission of CSCI Rook Lodge G55_S0000025921_Rook Lodge_V235755_270605_Stage 4.doc Version 1.40 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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