Inspection on 27/09/05 for Rook Lodge

This inspection was carried out on 27th September 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 28 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 27/06/05

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 27 September 2005 14:00 Rook Lodge DS0000025921.V254131.R01.S.doc Version 5.0 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.V254131.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 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.V254131.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Rook Lodge Address 1-6 Wanstead Lane Ilford Essex IG1 3UB 020 8518 0740 0208 477 1801 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) Redbridge Community Housing Limited [RCHL] 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.V254131.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2005 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. Rook Lodge DS0000025921.V254131.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by two inspectors. The visit lasted for about four and a half hours and took place during the mid afternoon and early evening, at a time when it would be possible to discuss the outstanding requirements with staff on duty, as well as having the opportunity to speak to residents about the service that they receive. It was the second of the two inspections that each home must have during the inspection year. The focus of this visit was to check on the progress of the requirements from the previous inspection, and which had a timescale for compliance of 31st August 2005. Many of the requirements made at the time of the previous inspection had been made several times before and enforcement action was being considered should the organisation fail to comply with requirements by the timescales stated. All of the communal areas and some of the residents’ rooms were seen. One inspector spoke to 10 service users, as part of a group discussion about their views of the care and support that they received. Care and other records were checked. In addition to this one of the inspectors had previously visited the organisation’s head office to view staff records. Any requirements from the previous inspection whose date for compliance had not been reached at the time of the inspection have been re-stated in the statutory requirements of this report and compliance will be tested at the next inspection. Full information about these is available in the inspection report of the 27th of June 2005. What the service does well: Residents stated that they were happy with the way in which staff supported them. The majority were satisfied with the arrangements for meals and mealtimes, and the support from staff to undertake social activities. Those who required assistance with personal care stated that this was undertaken in a way that they were satisfied with. The staff on duty felt that they helped to develop service users’ confidence and skills, and helped them to maintain or develop skills for independent living, and this was confirmed by some of the service users. Rook Lodge DS0000025921.V254131.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: We were informed about significant decisions being made about some service users, and it was not clear how service users were being involved in these decisions, or what action the staff were taking to advocate on service users’ behalf. The registered persons must ensure that the interests of service users are actively promoted by the staff who know them best, or by independent advocates, where decisions are being made which impact on their lives and which they may not be in a position to comment on or contribute to. Hazardous chemicals were not stored securely, and broken furniture and potentially dangerous appliances had not been removed/repaired. All staff must undertake more robust checking of the home to identify issues which represent safety hazards to service users and for hazards to be removed whilst awaiting repair or replacement. We were informed that staff were informed in advance when the monthly monitoring visits would take place. The organisation must ensure that it undertakes its statutory monthly monitoring visits in accordance with the legal requirement for these visits to be unannounced. Some people felt that the home could be more focused to assist residents to move on to more appropriate accommodation, such as independent flats in the community. More could be done by the management team to encourage innovation and creativity in the way service users are supported and to enable service users and staff to influence the way in which the service is delivered and developed. Rook Lodge DS0000025921.V254131.R01.S.doc Version 5.0 Page 7 Following the inspection of June 2005, a review of the service was undertaken by the local office of the Commission, to consider enforcement action concerning failure by RCHL to demonstrate compliance with previous requirements. A decision was made to carry out one further visit to the home, to monitor compliance, as well as meeting with senior officers of RCHL to make clear our concerns. It is disappointing that so few of the requirements have been fully met since that discussion, and also that it has been necessary to make new requirements. The Commission will now be reviewing the decision to progress enforcement action, and a further meeting has been arranged with the manager of the home and a senior representative of the organisation, to discuss the findings of this inspection. 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 DS0000025921.V254131.R01.S.doc Version 5.0 Page 8 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.V254131.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 1, 3 and 5 A service user guide has been developed and although it needs some amendments will provide prospective residents with information about the service that the home is able to offer. However residents still do not yet have an individual contract or statement of terms and conditions with the home. The needs of all the residents are still not being fully met. EVIDENCE: This standard was specifically tested in relation to the outstanding requirement for there to be an up to date service user guide and for service users to have a fully costed contract or statement of terms and conditions. The manager has now produced a service user guide, as required by the previous three inspections, and a copy of this has been sent to the Commission. Some amendments are needed, as the guide does not cover all of the areas that are specified in the national minimum standards. Feedback on the service user guide was given to the senior person on duty. The comments in section 6 and section 19 of this report give details of some of the needs of the residents. These refer mainly to the health care of residents. In addition to this section 6 also shows that care plans are not always up-todate, correct or followed. There are no details available about discussions on residents’ needs. Therefore there is insufficient evidence to demonstrate that Rook Lodge DS0000025921.V254131.R01.S.doc Version 5.0 Page 10 the manager and staff team are appropriately meeting residents’ assessed needs. The requirement from the four previous inspections therefore still remains outstanding. The sections in this report on Individual Needs and Choices and Personal and Health Care Support set out in more detail the serious concerns about individualised care planning, identified by the inspectors as a result of this visit. The previous three inspections have required that the organisation must provide each resident with a fully costed contract/statement of terms and conditions. At a meeting with representatives of the organisation on the 12th of September the Commission was informed that RCHL is in the process of sending out the new statement of terms and conditions, but none of the service users said that they had yet received it This requirement still remains outstanding and therefore residents still do not have detailed information about the service that they are entitled to. However as this work is in progress, the timescale for compliance has been extended to allow for the information to be made available to all residents. Rook Lodge DS0000025921.V254131.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 6 Whilst service users are consulted on day to day events, the Commission cannot be confident that service users are consulted on, and participate in, important decisions which affect their lives. EVIDENCE: This standard was tested in relation to the requirements for there to be a review of care plans, with the resident and significant others, every 6 months, and that care plans are updated to reflect changing needs. This requirement has been made on two previous occasions. Each resident has a detailed care plan. These take into consideration personal, healthcare and social support needs. One of the care plans included good information about how a specific resident expressed signs of anxiety. The care plans inspected had notes on them to indicate that they had been updated, however there were no details of any meetings or discussions with the resident about this. The requirements from previous inspections have therefore still not been met. Rook Lodge DS0000025921.V254131.R01.S.doc Version 5.0 Page 12 According to their care plans two of the residents should be weighed on a weekly basis. For one resident the daily notes show that they were weighed twice in May and once in June but have not been weighed since then. There is a note on file saying that the GP would be taking no further action with regard to this persons weight loss but no amendments were made to the care plan. The other persons care plan also says to be weighed weekly and records show that they were weighed once in July and once in August. This particular care plan had been reviewed in August. Either the care plans have not been properly reviewed and kept up-to-date or staff are not following the care plans. Each resident has a daily case note file and staff make notes about how the resident has been, what they have been doing and any other relevant information. However case notes are not always being completed on a daily basis. This means that full information is not available about each individual. Up to date case notes must be kept, which contain information relating to the resident’s day and be linked to their care plan. Staff will then have up-to-date and complete information about residents when carrying out reviews or updating of care plans. Each resident has a six monthly review with other professionals as part of the Care Programme Approach (CPA). We were informed that plans were under discussion regarding the proposal to transfer 2, or possibly 4 residents to alternative accommodation. We were informed that these proposals had been initiated by the PCT, as the residents were said to be no longer suited to the service at Rook Lodge. There was no information to indicate the process used to determine their suitability, or any re-assessment of the needs of the individuals having taken place. Whilst the clinical support from the PCT is essential in meeting the mental and physical health care needs of service users, it is not for the PCT alone to determine the suitability of the placement of service users. Such decisions should be taken as part of a multi-disciplinary review, to which the resident concerned should be invited to contribute. If they are unwilling or unable to do so, we would expect the staff that know the resident well, or an independent person, would advocate on their behalf. None of the service users said that they were involved in discussions about their care plans, although some confirmed that they did attend their CPA reviews. Some also referred to an independent advocate visiting them, but, from their conversation, this did not appear to be as part of any formal review meetings. We were informed that none of the service users were subject to any section of the Mental Health Act, which would restrict their right to be involved indecisions about their lives. Prior to any decision to transfer a resident to alternative accommodation, the Commission would expect to see evidence of a re-assessment of needs having been undertaken, and that the resident and their representative had been Rook Lodge DS0000025921.V254131.R01.S.doc Version 5.0 Page 13 consulted about the proposal. This will mean that residents move on to a placement which can more appropriately meet their needs. Service users confirmed that they were consulted about day to day decisions, such as what to eat and what activities they would like to participate in. They said that staff were helpful. One person stated: “ I am glad they are there, they show you what to do and help you.” Rook Lodge DS0000025921.V254131.R01.S.doc Version 5.0 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to the seven standards. At the time of the last inspection, all of the outcome standards were assessed as met. Rook Lodge DS0000025921.V254131.R01.S.doc Version 5.0 Page 15 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 the following standard(s): 19 and 21 Service users are not being adequately supported to receive the health care that they need. There is a lack of information to guide staff in recognising and managing the needs of an aging population. EVIDENCE: This standard was tested in relation to the requirement for a policy on ageing to be produced, as many of the residents are now experiencing the problems associated with growing older, as well as those associated with the mental ill health. In addition to this the healthcare needs of one of the residents was discussed. We were informed that one of the residents was thought to have a serious and potentially life-threatening illness and was admitted to hospital for a planned operation. The resident was aware of the operation and staff discussed this with them. However when this person was discharged from hospital the service user said that they had had a different operation. An initial phone call was made to the hospital about this but the situation was not clarified. No Rook Lodge DS0000025921.V254131.R01.S.doc Version 5.0 Page 16 further action has been taken by the staff team to find out if this person had a different operation and why, or if in fact they did have a serious illness and whether any further treatment or special care is required. This is very serious and a dereliction of the homes duty of care. Prompt action must be taken to clarify the situation and to ensure that this resident gets any necessary treatment and support. The person in charge of the home was not able to produce the policy on ageing, which has been requested on 3 previous occasions. We were informed that it had been produced, but it was not available for inspection. Other staff on duty were not familiar with such a policy, but thought that there might have been one available on the policy file, although one could not be produced when requested. We could not be confident that staff would therefore have appropriate guidance on meeting the needs of older people, and how their needs could be appropriately met, including issues such as loss of independence, illness, including terminal illness and death. As one of the residents has had a serious and potentially life threatening health condition, such guidance to staff is considered very important. Rook Lodge DS0000025921.V254131.R01.S.doc Version 5.0 Page 17 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 the following standard(s): 22 Residents know who to complain to within the organisation, but do not have written information about the complaints procedure or what happens if they make a complaint. EVIDENCE: This standard was tested in relation to the requirement for service users to receive a copy of the organisation’s complaints procedure to ensure that they or their relatives are clear about how they can complain and what will happen if they do. The organisation does have a complaints procedure and form for residents. Most of the residents said that they were aware of how they could make a complaint, stating that they would speak to the manager, the service manager or to the Housing Officer, who visits weekly. However, all said that they had not received any written guidelines about making a complaint, or that they could contact CSCI, should they wish to do so. Staff on duty were not aware of any recent guidance that had been issued to residents, although they were confident that such information was provided at the time of the admission of a new resident. The timescale for a requirement concerning staff training in adult protection awareness and protection had not been reached at the time of this inspection and the requirement has therefore been re-stated in this report and compliance will be tested at the next inspection. Rook Lodge DS0000025921.V254131.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 27 The Commission is not fully satisfied that the organisation has systems in place to ensure that service users live in a home which is adequately maintained and ensures their safety. EVIDENCE: The environment was tested in relation to the previous requirements for the home to be maintained in a good state of repair; a broken sofa to be replaced; a system for checking the home for damage and wear and repair, and repair/refurbishment of a bathroom in one of the flats. There was evidence from one service user that his broken sofa had been replaced. There was evidence from discussion with staff that broken or damaged furniture was recorded in a maintenance book. However, staff stated that minor repairs often took a long time to be rectified. A broken chair and television set were left in the communal areas, posing a hazard to service users and staff, although these were removed when this was pointed out to the senior member of staff on duty. Rook Lodge DS0000025921.V254131.R01.S.doc Version 5.0 Page 19 Although the bath panel in flat 3 had been painted, it was not well secured and the floor covering was still badly stained. Therefore the requirement from the previous inspection had not been fully addressed. The bathroom doorstop was broken, resulting in the risk of the service user hurting his foot on an exposed nail. The doorstop must be repaired or replaced to prevent this. In addition, flooring in the adjacent kitchen had not been fitted well, and the seal between the lino and carpet was already presenting a trip hazard. This must also be repaired or replaced. In this same flat, the service user reported that the cooker was faulty, and that he had to turn it on and off at the mains switch. An Immediate Requirement Notice was issued at the time of the inspection, requiring the Commission to have confirmation from a qualified electrician that the cooker had been checked and was safe. This was received the following day. However we are still concerned that the cooker is badly rusted and needs to be replaced. A number of light bulbs were noted to not be working in service users’ rooms and in communal areas. These must also be replaced. All of the above issues indicate that the home is not kept in a good state of repair as required by the previous three inspections and that there is not a system to ensure that all areas of the home are checked regularly for damage and wear and tear as required by the previous inspection. Issues concerning water temperatures are commented on in Standard 42 of this report. Rook Lodge DS0000025921.V254131.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 35 and 36 The Commission for Social Care Inspection (CSCI) cannot yet be confident that residents are supported and protected by the organisations recruitment practice, including the recruitment of bank of agency staff. However, CSCI is satisfied that the organisation is actively addressing deficiencies in this area. Staff do not receive the necessary training to enable them to fulfil their duties or to fully meet residents needs. EVIDENCE: This standard was tested in relation to the requirement for the organisation’s recruitment procedure to be reviewed, to ensure that it is robust and protects service users. There was also a requirement for the registered persons to develop a training plan for each member of staff, allowing 5 days paid training a year and to ensure an appraisal system was in place. An inspection of a sample of personnel files at the organisations head office 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 have been discussed previously with the organisation. Since raising serious concerns about the recruitment practice with RCHL, the organisation has undertaken a detailed audit of staff files and reviewed their Rook Lodge DS0000025921.V254131.R01.S.doc Version 5.0 Page 21 recruitment procedure and practice to identify and rectify deficiencies and to safeguard service users. At a further visit to the organisations head office CSCI were informed of the changes made. However only one new member of relief staff had been recruited recently, and therefore insufficient information was available to test the new procedures fully. An extension of the timescale for compliance has been given, to allow for more evidence of staff recruitment to be available. The four previous inspections had required and that each of the staff have a training and development plan and five days paid training each year. Training and development folders were available in the office for each member of staff but these had not been completed. There was a notice in the office asking for staff to provide information to go into the folders. A bank staff member working on the day of the visit enquired about training opportunities, and confirmed that she had not received any training. Therefore this requirement still remains outstanding and a revised date has been set. The two support workers on duty, one a permanent member of staff and the other a bank/relief staff member said that they had not received any form of appraisal, although the permanent member of staff stated that appraisal forms had arrived. The requirement has been partly met in relation to distribution of documents, but there was a lack of evidence to demonstrate that appraisals were taking place, although the senior staff member on duty stated that this staff member’s appraisal would have been undertaken that day, had the inspection not taken place. The support worker confirmed that supervision did take place, although not regularly, as holidays and other events made it difficult to arrange. The bank/relief staff stated that she did not receive any form of supervision or training, nor had she been made aware of policies or procedures, although she was informed about service users’ care plans, from handover and from reading documentation. It is expected that all staff received formal training and supervision to ensure their competence to carry out the tasks required of their post, although the frequency of such support may need to be at a frequency relevant to the hours that they work. The timescale for requirements concerning staffing levels and staff supervision had not been reached at the time of this inspection and the requirements have therefore been re-stated in this report and compliance will be tested at the next inspection. Rook Lodge DS0000025921.V254131.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 and 43 The Commission has not sufficient evidence to determine that residents are benefiting from competent and accountable management of the home or that the home is being robustly monitored by the manager and senior members of the organisation, to ensure that residents are receiving a service which promotes their safety and well-being. The organisation has not been robust in maintaining staff records or ensuring that policies and procedures are relevant to this service. This could potentially place service users at risk. There is an improvement in some aspects of health and safety processes. However, the Commission cannot yet be confident that service users are benefiting from a strong leadership approach and competent and accountable management of the service. Rook Lodge DS0000025921.V254131.R01.S.doc Version 5.0 Page 23 EVIDENCE: This standard was tested in relation to the requirement for evidence to be produced regarding a number of safety checks concerning gas, electrical intake, hot water temperatures, the suitability of locks on the fire exit from the kitchen and the development of a business plan. Also that all of the necessary staff records are kept. The judgements above also take into account the overall management of the home and scrutiny by the organisation, as set out elsewhere in this report. All of the required residents’ records are kept, but 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 organisation had given an undertaking that all of the staff records, in accordance with Schedule 2 will be available in the home for inspection, commencing with records relating to all newly recruited staff. Records relating to existing staff will also be available in the home, and the Commission has set 31 December 2005 as a timescale for this to be implemented. Prior to the inspection, the Commission had received a copy of the landlord’s gas safety check, which was satisfactory. On the day of the inspection there was evidence of the electrical intake report, which was satisfactory, and a copy of the business plan was provided. However, a number of safety concerns were noted during a tour of the building. These issues are commented on in the section on the environment. During the inspection, we were informed that the monthly monitoring visit, required to be undertaken by the organisation’s representative to monitor the quality of the service its aims and objectives, was not being carried out unannounced, as required by the Care Homes Regulations 2001. The requirement from the previous inspection still remains outstanding. This issue has been taken up with the organisation, separate from this report. Although the manager has been in post for several years, and is experienced in the management of services for adults with mental ill health, the impression gained by the inspectors was that far more could be done to communicate a clear sense of direction and leadership, which links to the aims of the service and the statement of purpose of the home. There have been ongoing problems with the hot water system and staff confirmed that the hot water supply was still unpredictable, although it was satisfactory on the day of our visit. The requirement from the previous three inspections that the problems with the hot water system must be investigated and remedied has therefore not been adequately addressed. Hot water temperatures should be checked each week to ensure that they do not exceed the specified 43°C. In the past this has been a requirement for the home to Rook Lodge DS0000025921.V254131.R01.S.doc Version 5.0 Page 24 do. However the records show that this is not done regularly. Records show temperatures as high as 58.9°C in one of the baths and there are other occasions when the water has exceeded the safe 43°C. The record book quite clearly says that temperatures above the 43°C must be reported as this presents a risk of scalding to residents. However no action was taken by staff and this places residents at risk. The senior person on duty was asked who monitored that the necessary checks are carried out and stated that it would be one of the management team but could not be clear as to which one. The registered provider is required to establish and maintain a system for reviewing the leadership and management approach of the service, to improve the quality of care provided at the care home. This review should take into account the views of service users and a report of such a review be provided to the Commission. Rook Lodge DS0000025921.V254131.R01.S.doc Version 5.0 Page 25 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 3 X 2 X 2 Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X 2 X X x LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Rook Lodge Score X 2 X 2 Standard No 37 38 39 40 41 42 43 Score 2 X 2 X 2 2 3 DS0000025921.V254131.R01.S.doc Version 5.0 Page 26 NO 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 YA3 Regulation 12,14 Requirement Timescale for action 31/10/05 2 YA5 4,5 3 YA6 15 4 YA6 12, 14 The registered person must ensure that there is evidence that assessed needs of all service users are being met. (Previous timescales of 31 January 2005, 30 April 2005 and 31 August 2005 not met). The organisation must provide 31/10/05 each service user with a fully costed contract/statement of terms and conditions as detailed in standard 5.2. (Previous timescales of 31 January 2005, 30 April 2005 and 31 August 2005 not met). Care plans must be reviewed 31/10/05 with the service user and significant others at least every six months and updated to reflect changing needs. (Previous timescales of 31 January 2005, 30 April 2005 and 31 August 2005 not met). Prior to any decision to transfer 31/10/05 a resident to alternative accommodation, a reassessment of needs must be undertaken, in consultation with the resident and their representative. DS0000025921.V254131.R01.S.doc Version 5.0 Rook Lodge Page 27 5 YA6 15,17 6 YA19 13 Up to date case notes must be kept, which contain information relating to the resident’s day and are linked to their care plan. The situation with regard to the resident that has recently had surgery must be clarified and this person must be supported to get any treatment that they require. The home must ensure an ageing policy is produced. (Previous timescales of 31 March 2004, 31 January 2005, 30 April 2005 and 31 August not met). A copy of the organisations client complaints procedure and form must be given to all residents. (Previous timescale of 31 August 2005 not met). All staff must receive adult protection training. All areas of the home must be kept in the good state of repair. (Previous timescales of 31 January 2005, 30 April 2005 and 31 August 2005 not met). A system must be in place to ensure that all areas of the home are checked regularly for damage and wear and tear. (Previous timescale of 31 August 2005 not met). The damaged doorstop in the bathroom of flat 3 must be repaired or replaced. Any broken light bulbs must be replaced. The poorly fitted and sealed flooring in the kitchen of flat 3 must be repaired or replaced. The cooker in flat 3 must be replaced. The bathroom in flat three must be renovated to acceptable standards. (Previous timescales of 31 January 2005, 30 April DS0000025921.V254131.R01.S.doc 31/10/05 31/10/05 7 YA21 12 31/10/05 8 YA22 22 31/10/05 9 10 YA23 YA24 13 23 31/10/05 31/10/05 11 YA24 23 31/10/05 12 13 14 15 16 YA24 YA24 YA24 YA24 YA27 23 23 23 23 23 31/10/05 31/10/05 31/10/05 30/11/05 31/10/05 Rook Lodge Version 5.0 Page 28 17 YA33 18 18 YA34 19 19 YA35 18 20 YA36 18 21 YA36 18 22 YA39 26 23 YA41 17 2005 and 31 August 2005 not met). A comprehensive review must be carried out that identifies residents’ needs and matches the agreed 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. (Previous timescale of 31 August 2005 not met). 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, 30 April 2005 and 31 August 2005 not met). All staff must have regular recorded supervision meetings six times a year with a senior/manager, in addition to regular contact on ay-to-day practice. The registered provider must ensure that an appraisal system is in place and that all staff receive an appraisal annually. (Previous timescales of 1 June 2004, 31 January 2005, 30 April 2005 and 31 August 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. Previous timescale of 30 September 2005 not fully met. The registered persons are DS0000025921.V254131.R01.S.doc 30/09/05 30/11/05 31/10/05 30/09/05 31/10/05 31/10/05 30/11/05 Page 29 Rook Lodge Version 5.0 24 YA41 17 25 YA42 13 26 YA42 13 27 YA37 YA43 24 & 10 required to maintain records for the protection of service uses in line with Schedule 2 of the Care Homes Regulations 2001. For new staff, before appointment. 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. For existing staff an extended period for compliance has been given. The problems with the hot water system must be investigated and remedied. (Previous timescales of 31 December 2004, 30 April 2005 and 31 August 2005 not fully met) Hot water temperatures must be checked weekly and action must be taken to rectify problems when temperatures are outside the safe range. The registered provider is required to establish and maintain a system for reviewing the leadership and management approach of the service, to improve the quality of care provided at the care home. This review should take into account the views of service users and a report of such a review be provided to the Commission. 31/12/05 31/10/05 31/10/05 31/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. M No. Refer to Standard Good Practice Recommendations Rook Lodge DS0000025921.V254131.R01.S.doc Version 5.0 Page 30 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford 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 DS0000025921.V254131.R01.S.doc Version 5.0 Page 31 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!