Inspection on 07/06/06 for Rook Lodge

This inspection was carried out on 7th June 2006.

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 no outstanding requirements from the previous inspection report, but made 5 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 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 Key Unannounced Inspection 7th-22nd June 2006 10:00 Rook Lodge DS0000025921.V299179.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.V299179.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.V299179.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 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.V299179.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 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. The basic charge per week for each service user is between £670 & £770. This information was provided at the time of the visit. Information about the service provided is contained in the service users guide. Rook Lodge DS0000025921.V299179.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection visit lasted for about seven hours and took place from 10 am. The manager, staff and residents were spoken to. All of the communal rooms and one flat were seen and care and other records were checked. Care staff were asked about the care that residents receive, and were also observed carrying out their duties. Staff, relatives and other professionals were contacted and asked for their opinions of the service. Feedback was received from five relatives and the consultant psychiatrist. The inspector also attended a residents meeting. In addition the organisation’s head office was visited and staff records checked. This was a key inspection and all of the key inspection standards were tested. In October 2005 the organisation was served with an enforcement notice for ongoing failure to meet requirements and as a result of this additional visits were made to the home in November 2005 and March 2006. This was to monitor the progress towards meeting the requirements. What the service does well: What has improved since the last inspection? Since the last statutory inspection the organisation has put a lot of additional support into the home and this has meant the outstanding requirements have been addressed. Care plans and recordings have improved and are up-todate. This means that staff have current information about residents’ needs. Staff are now receiving more regular supervision and attending training courses and this means that they are getting the support and information that they need to provide a good service to residents. Staff said that communication has improved and that the changes are all positive. One of the residents has moved out of the maisonette into more independent living and another resident has moved into the vacated maisonette. He is very pleased by this and sees it as a step towards more independent living. Rook Lodge DS0000025921.V299179.R01.S.doc Version 5.2 Page 6 After several years of problems the hot water system is being changed and although the work has not been finished staff have said that baths fill quickly now and toilets flush properly. Also the water does not get too hot anymore. When this work is finished the shared bathroom is going to be renewed and the home redecorated. When all of the work is finished residents will live in a comfortable and safe home. The organisation has looked at all of their staff records and made sure that all of the required checks have been made on staff in post. They have also made their recruitment procedure better. This will help to keep residents safe. 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. Rook Lodge DS0000025921.V299179.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.V299179.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 & 5 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the 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 now 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: A new resident has 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 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 Rook Lodge DS0000025921.V299179.R01.S.doc Version 5.2 Page 9 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-sit. One resident has recently moved out of the maisonette to more independent accommodation. Another resident has moved from one of the flats into this maisonette. From discussions with him it was apparent that he was very pleased by this move and viewed it as a step towards more independent living. 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. During previous inspections there have been concerns that one of the residents of the flats needs more supervision and support than usually given and that this person appears happy when in the communal areas and functioned better with less responsibility. At the time of this visit this resident was still living in one of the flats but was having his meals in the communal area and was spending more time there. He appeared to be quite relaxed and said that he was okay. A meeting has been arranged with the resident, his family and other professionals to discuss his future levels of support and accommodation. Two other residents now need a higher level of support and arrangements have been put in place for their needs to be reassessed with a view to identifying alternative placements that will be more appropriate to their needs. In the interim the staff team are giving these residents the support that they need. Another of the residents said that he is well supported by the staff team and that they give him help and “push him” when needed. Therefore residents’ needs are being met as required by previous inspections. 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.V299179.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the 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. These take into consideration personal, healthcare and social support needs. In response to requirements about care plans and reviews an assistant director of operations has been providing additional support and guidance to the service and all support workers have had one to one input on care plans. In addition one member of staff has been allocated time to ensure that care plans are reviewed and that residents are involved in the care planning process. The previous inspection recommended that where residents are known to have certain specific needs at night, an appropriate care plan is in place and is reported on every night. This has been done. Daily reports are made and these are linked to the care plans. Night Rook Lodge DS0000025921.V299179.R01.S.doc Version 5.2 Page 11 reports are also made. Therefore there is a record of residents’ care and wellbeing. Each resident has a six monthly review with other professionals as part of the Care Programme Approach (CPA). Prior to the Care Programme Approach (CPA) meeting the manager writes a report containing all the relevant information. Copies of reports and notes from the most recent CPA meeting were seen on a residents’ file. Overall sufficient detailed information is available so that staff can meet resident’s needs. There are risk assessments in place. These identify risks for the residents and staff and indicate ways in which the risks can be reduced to enable the residents’ needs to be met as safely as possible. The risk assessments have been reviewed and were up to date. 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. One resident said that he is treated with respect and that his views are listened to. Independent advocacy is available to the residents and the advocate was at the residents meeting. He explained how they could contact him and the sort of things that he could assist with. Rook Lodge DS0000025921.V299179.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Residents have opportunities for personal development and 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 to enabling them to move on to more independent accommodation. The consultant psychologist said that there was “a good rehabilitation ethos at the home”. Rook Lodge DS0000025921.V299179.R01.S.doc Version 5.2 Page 13 All but one of the residents can go out without support from the staff team. Residents go out when they want to. One resident said that he likes to busk, go to the pub and to play bingo. Others go to college and to various support groups. One resident goes to a Jewish club. Another said that he was always “busy”. Residents were involved in discussions about plans for a holiday. 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. On the day of the visit one resident was meeting her sister to go to have lunch and to go to bingo. 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. Rook Lodge DS0000025921.V299179.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 & 21 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to the 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. The administration and recording of medication has been changed to ensure that the 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. 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. Feedback from the consultant psychiatrist was that “the staff manage well with behavioural difficulties in residents”. Individual’s mental health needs are reviewed as part of the Care Programme Approach (CPA). However there is not any clear information as to what would indicate that an individual was Rook Lodge DS0000025921.V299179.R01.S.doc Version 5.2 Page 15 having a relapse or that they were not taking their medication regularly. This might mean that problems would not be highlighted at an early stage and may therefore not be addressed. Each resident must have a relapse plan which indicates the signs and symptoms of deterioration in an individuals mental health and the action to be taken. 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. Two residents are supported to self medicate. The chemist dispenses most of the medication but some residents collect other medication from the hospital. Most of the support workers received medication training last year. Medication records are appropriately completed. However senior staff had been filling dossette boxes to make it more straightforward for the staff to administer medication. Repackaging medicines into another container with the intention that a different care worker will give it to the resident at a later time is called ‘secondary dispensing’. Both the Royal Pharmaceutical Society and the Nursing and Midwifery Council state that this is an unsafe practice that can potentially cause drug errors. This was discussed with and explained to the senior on duty at the time of the inspection. Subsequently this practice was stopped. Therefore at the time of the conclusion of the inspection process, medication was being appropriately and safety administered. However some residents receive PRN (as required) medication and protocols/guidelines are needed for all of these to ensure that all staff know when to give this medication and for what purpose. A draft policy on ageing has been produced as required by previous inspections. Residents’ files contained information on their, or their families, wishes in the event of death. Rook Lodge DS0000025921.V299179.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the 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. The advocate also holds monthly surgeries that residents can attend. 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. All of the residents collect the 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 Rook Lodge DS0000025921.V299179.R01.S.doc Version 5.2 Page 17 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. Therefore systems are in place to protect residents from financial abuse. Rook Lodge DS0000025921.V299179.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 28 & 30 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to the service. When the work that is in progress has been completed the 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. 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 Rook Lodge DS0000025921.V299179.R01.S.doc Version 5.2 Page 19 around the home independently. There is a call alarm system within the home and most of the residents are able to use this. In response to concerns and requirements about the environment a lot of work is being carried out in the home. To address the problems with the hot water temperatures a completely new hot water system is being fitted. This work was being carried out during the course of the inspection. When the work is finished all of the communal areas will be redecorated and the organisation will redecorate residents’ accommodation. They will prioritise this according to need. In addition to this the communal bathroom is going to be refurbished. This work should be completed within a couple of months and will be checked during the course of the next inspection. At the time of this visit the home appeared to be clean and there were no obvious signs of disrepair of health and safety risks. New furniture had been purchased for the garden and residents were making use of this. A weekly walking route has been introduced whereby staff check all areas of the home for any damage, breakages or health and safety risks. Examination of the repairs book showed that repairs had been action in a timely manner. Feedback from staff was that a lot of work was going to be done and theyre getting a better response when repairs are reported. All of this action meets requirements of the previous inspection and when completed should mean residents live in comfortable and safe environment. Rook Lodge DS0000025921.V299179.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to the service. The Commission for Social Care Inspection (CSCI) is now confident that residents are supported and protected by the organisations recruitment practice, including the recruitment of bank of agency staff. Staff are receiving the necessary training to give them the skills to meet service users’ current needs and provide an appropriate service for them. Staffing levels are sufficient to allow for this but may be affected by the manager needing to carry out management duties when he is the third person on shift. The practice of some staff regularly working double shifts may also have a detrimental effect on the quality of the service provided. 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. EVIDENCE: Staff have 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 the previous requirements with regards to staff Rook Lodge DS0000025921.V299179.R01.S.doc Version 5.2 Page 21 recruitment and checks have now all been addressed. The organisation worked cooperatively with the Commission and reviewed their procedures and all of their staff files. They then took the necessary action to address any shortfalls and to ensure that the future recruitment procedure would be robust and would safeguard residents. During previous inspections feedback from staff was that training was very limited. This has now been addressed by the organisation. Three staff have completed a six-month mental health training course, all staff have attended adult protection, medication and care planning training. In addition to this all staff now have personal development folders and have all had appraisals as required by previous inspections. 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. During an additional visit in November 2005 the manager stated that a review of staffing had been undertaken, in relation to the assessed needs of residents. As a result, minimum staffing levels were set, and the hours worked by the manager changed, to allow for increased managerial supervision. Examination of current rotas shows that three staff are on duty during the day and one waking and one sleeping in staff at night. These staffing levels are sufficient to meet residents’ needs. However the current rotas showed that the manager is regularly the third person on the shift and management time is not indicated. Therefore this may have an effect on the service provided to residents, as the manager will inevitably be required to carry out management tasks. Sufficient staff must on duty at all times to meet the assessed needs of the residents. In addition to this the rota shows that staff routinely work double shifts. The manager said that this was only done when absolutely necessary and would not be required when new staff are recruited. However the examination of the current four-week rota indicated that for some staff this is part of the shift pattern rather than a necessity. This is not good practice and it is recommended that shift patterns be reviewed to ensure that staff do not regularly work double shifts. Staff are receiving more 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.V299179.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 and 43 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to the service. The home is adequately managed and provides a safe environment for the residents. The manager and organisation monitors the quality of the service provided to residents to check if their needs are being met. However the manager does not have designated management time and this may affect his ability to fulfil his management duties effectively and to adequately monitor and develop the service. EVIDENCE: The manager is a qualified psychiatric nurse and has extensive experience of managing services for people with mental health difficulties. Staff spoken to said that they get good support from the manager and that they can talk to him if there are difficulties. The manager and staff have been given additional support by a senior officer of the organisation and improvements in the service provided had been indicated in previous sections of the report. In addition to Rook Lodge DS0000025921.V299179.R01.S.doc Version 5.2 Page 23 this the organisations monthly monitoring visits have been more comprehensive. A quality audit was carried out in November 2005. A report was written as result of this, which gave feedback for residents and also recommendations for improving the service. In addition to this financial audits have also been carried out with regard to residents’ finances. As part of these audits and reviews feedback is sought from residents and other stakeholders. As previously stated an independent advocacy service is now involved and will be attending residents meetings and providing support. Therefore systems are in place to ensure that the home is functioning adequately and providing an appropriate service to the residents. However as stated in the previous section the rota shows that the manager routinely is the third person on shift and regularly works his contracted hours over a two and a half day period. Therefore the manager does not have any allocated management time to fulfil his management duties. Previous inspections have highlighted a lot of concerns with regards to the performance of the service and it is important that the improvements seen at the time of this visit are maintained and that the staff are supported to continue to develop the service. To do this the manager will need designated management time. Additionally it is recommended that the managers shift pattern be reviewed. This is both to ensure that he does not regularly work double shifts but also that the home has management support throughout the working week. All of the required residents’ and staff records are kept. Records seen at the time of the visit were up to date and had been appropriately completed. Systems are now in place to ensure that all the necessary health and safety checks are carried out. Evidence that these had been completed was seen during the visit. At the time of the visit the gas safety inspection was overdue and this needs to be arranged to ensure that the home continues to be safe in terms of gas safety. A copy of this certificate must be forwarded to the Commission. However overall actions being taken to ensure that the residents live in a safe environment. Rook Lodge DS0000025921.V299179.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 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 2 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 2 X 3 X 3 2 3 Rook Lodge DS0000025921.V299179.R01.S.doc Version 5.2 Page 25 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 YA19 Regulation 12 Requirement Each resident must have a relapse plan which indicates the signs and symptoms of deterioration in an individuals mental health and the action to be taken. Protocol/guidelines must be in place for each PRN (as required) medication there has been prescribed to individuals. Sufficient staff must on duty at all times to meet the assessed needs of the residents. The manager must have designated management time to enable him to fulfil his managerial duties. A satisfactory Landlords Gas Safety certificate must be obtained and a copy sent to the Commission. Timescale for action 30/09/06 2. YA20 13 15/08/06 3. 4. YA33 YA37 18 18 31/08/06 31/08/06 5. YA42 13 15/08/06 Rook Lodge DS0000025921.V299179.R01.S.doc Version 5.2 Page 26 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. 2 Refer to Standard YA33 YA37 Good Practice Recommendations It is recommended that shift patterns be reviewed to ensure that staff do not regularly work double shifts. It is recommended that the managers shift pattern be reviewed. This is both to ensure that he does not regularly work double shifts but also that the home has management support throughout the working week. Rook Lodge DS0000025921.V299179.R01.S.doc Version 5.2 Page 27 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. 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