Inspection on 12/08/05 for Rook View

This inspection was carried out on 12th August 2005.

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

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

Other inspections for this house

Rook View 13/02/07

Rook View 05/01/06

Rook View 20/12/04

Rook View 20/07/04

Rook View 19/02/04

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Rook View 46 Rook Lane Chaldon Surrey CR3 5AB Lead Inspector John Chivers Unannounced 12 August 2005 12:00 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 Older People and 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 View ho9 H58 s13769 Rook View v244333 120805 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Rook View Address 46 Rook Lane, Chaldon, Surrey, CR3 5AB 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) 01883 383817 Surrey Oaklands NHS Trust Mrs Kim Susan Mott CRH Care Home 9 Category(ies) of LD Learning disability, 5 registration, with number LD(E) Learning dis - over 65, 4 of places Rook View ho9 H58 s13769 Rook View v244333 120805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 The number of persons for whom residential accommodation with both board and personal care is provided at any one time shall not exceed NINE (9). 2 FIVE (5) WITHIN THE CATEGORY LD (LEARNING DISABILITIES) & FOUR (4) WITHIN THE CATEGORY LD(E) (OLDER PEOPLE/LEARNING DISABILITIES 3 The age/age range of the persons to be accommodated will be: FIVE (5) IN THE RANGE 30-65 YEARS, FOUR (4) OVER 65 YEARS Date of last inspection 20-December-2004 Brief Description of the Service: Rook View is registered to Surrey Oaklands NHS Trust and is one of a number of Residential Homes managed by the organisation The home is registered to accommodate a maximum of nine residents of either gender, five residents within the age range of thirty to sixty five years and four residents over the age of sixty five years. All of the residents have learning disabilities. The home is detached and shares a site with another Residential Care Service managed by the Trust. Local facilities and amenities are close by. The home provides a caring and supportive service and encourages residents to be as independent as practicable within an agreed risk assessed framework. The home maintains residents in day centres and encourages contact with reatives, friends and the local community. Rook View ho9 H58 s13769 Rook View v244333 120805 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was undertaken on 12th August 05. The duration of the inspection was 3.5 hours. As part of the inspection process discussion/communication was held with five residents and one member of staff was formally interviewed. In addition discussion was held with the home’s manager. The inspection included examination of the home’s policies, procedures and records. The resident’s personal files and staff personnel files were scrutinised. An inspection of the premises was also undertaken. The findings of the inspection were positive and evidenced some good examples of management and practice. The staff team were observed to be competent at meeting the needs of the residents and pro-active at engaging with them. Residents were seen to be settled and content within the home and stated/indicated their contentment in discussion/communication. Written assessments and care plans were in place with evidence of residents progress being monitored and reviewed. Staff training is active; however updated/refresher training in the Protection of Vulnerable Adults is needed regarding some staff. Some areas of the home have been refurbished and other parts are scheduled to be completed at a later stage. The service provides a homely and comfortable environment; however some shortfalls regarding potential health and safety hazards were identified and a number of utility test certificates need to be obtained in order to evidence certain systems as safe. A total of thirteen requirements and one recommendation are made as a result of this inspection. What the service does well: The staff team demonstrated their competence at meeting the needs of the residents and their combined knowledge, skills and experience enable the home to meet its aims and objectives. Relationships between staff and residents were sound and residents are encouraged to participate in purposeful activities, attendance at day centres and live as independently as practicable. The home monitors and reviews resident’s assessments and care plans and their personal files are well organised and maintained. The home’s recruitment and vetting procedures are basically sound with all required information held in all but one of the sample staff files inspected. Rook View ho9 H58 s13769 Rook View v244333 120805 stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Rook View ho9 H58 s13769 Rook View v244333 120805 stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Standards Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Rook View ho9 H58 s13769 Rook View v244333 120805 stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitablity of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2. The home has regard for obtaining written assessments prior to admission into the home and reviews each case as appropriate. EVIDENCE: Written needs assessments were available in the sample of residents files inspected. The assessments covered a range of areas and were signed and dated with documented evidence of reviewing. Rook View ho9 H58 s13769 Rook View v244333 120805 stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 9. The home has regard for enabling residents to make decisions consistent to their individual risk assessments and decisions agreed at statutory and nonestatutory meetings. EVIDENCE: Decision-making arrangements are entered in resident’s individual care plans and are discussed/agreed at reviews etc, in consultation with appropriate parties Consultation regarding decision-making is also facilitated via key working and at resident’s meetings, which are held once per month. Minutes of resident’s meetings were available and included pictorial images in the minutes. Rook View ho9 H58 s13769 Rook View v244333 120805 stage 4.doc Version 1.40 Page 10 Risk taking is discussed and agreed in the same manner as above and written risk assessments were held in the sample of resident’s files inspected. The risk assessments evidenced regular review showing that some assessments had been reviewed on five and nine occasions in the sample inspected. Resident’s indicated in discussion that they have choice and were consulted by staff regarding making decisions. Rook View ho9 H58 s13769 Rook View v244333 120805 stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experiencd in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15 and 16. Rook View ho9 H58 s13769 Rook View v244333 120805 stage 4.doc Version 1.40 Page 12 The home encourages and maintains resident’s in day centre placements and has regard for providing them with a range of purposeful activities both within and outside the home. The home is aware of the importance of resident’s retaining contact with their families and significant others and is welcoming when they visit. EVIDENCE: Resident’s attend day centres and their weekly activity programmes were available for inspection. The programmes evidenced a range of activities that resident’s participate in. Reports on individual resident’s are prepared by the day-centres and forwarded to the home. These reports were evidenced on resident’s files. The resident’s participate in activities and events in the local community and some residents attended a short excursion during the inspection. Upon their return resident’s indicated that they enjoyed the outing via verbal communication and gestures. A holiday and day trips are planned for September 05. Resident’s maintain relationships with their families, relatives and friends. Contact is agreed at assessments and care planning and visits are recorded in resident’s individual daily notes and the home’s communication book. One resident had a visit from a ‘girl friend’ during the inspection. The visitor was welcomed into the home by staff and other residents and appeared at ease in the home, whilst she was waiting for the resident to return from an outing. The resident’s undertake daily tasks and jobs around the home. These were evidenced via the daily roster and shift plans. Daily routines were observed to be that of an ordinary household and residents were relaxed and at ease in their environment. Resident’s also stated / indicated that they were “happy” in the home and “liked” the activities and outings provided. Rook View ho9 H58 s13769 Rook View v244333 120805 stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 19. The home has regard for providing resident’s with personal care and is diligent regarding their health/medical needs. EVIDENCE: The home has a policy regarding privacy, dignity and the provision of personal care. Most of the resident’s receive personal care and this is referenced in assessments and care plans. The manager stated that all of the resident’s are currently within the home’s remit regarding all aspects of their care and that specialist guidance and support would be accessed in the event. Health care and medical details are held in assessments and care plans and are reviewed and updated as necessary. Visits to the GP and other health care professionals are clearly recorded. Rook View ho9 H58 s13769 Rook View v244333 120805 stage 4.doc Version 1.40 Page 14 Health care and medical related correspondence was also held in the sample of resident’s files inspected. Resident’s indicated in discussion/communication that they visited the GP and that the home “looks after their health”. Rook View ho9 H58 s13769 Rook View v244333 120805 stage 4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16, 18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are sageguarded. (OP NMS 35) The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 16, 18 and 35 (Older People) 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. The home has regard for taking complaints seriously; however the resident’s pictorial complaints procedure needs to be expanded. The home is committed to the protection of its residents; however staff training in this area needs to be enhanced. EVIDENCE: The home has a written complaint procedure and a procedure in pictorial form is also available for the residents. This policy has been thoughtfully prepared; however it is important that the contact address and telephone number of the CSCI Surrey Local Office is included in the pictorial version. The home’s complaint file was available. The file evidenced that no complaints have been received. Resident’s indicated in discussion/communication that they had no complaints about the staff or service provided. Rook View ho9 H58 s13769 Rook View v244333 120805 stage 4.doc Version 1.40 Page 16 The home has an internal policy and procedure regarding the Protection of Vulnerable Adults. In addition the home holds the Surrey County Council MultiAgency Adult Protection procedures. There was evidence that staff have attended training in the protection of ‘Vulnerable Adults’; however in most cases this was some time ago. It is important that those who received training in 2003 receive updated training in this area. A requirement will be made regarding this. It was also noted that the manager had not received the Surrey Council Multi-Agency training in the Protection of Vulnerable Adults. It is important that such training is arranged. A requirement will also be made regarding this. A sample of the resident’s personal finances was inspected. The cash held was consistent with the balance in the resident’s individual account books. Resident’s indicated in discussion/communication that they had no concerns about the way staff treat them. Rook View ho9 H58 s13769 Rook View v244333 120805 stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28 and 30. Whilst the interior of the premises is homely, comfortable and well looked after by staff and residents, some rooms still need to be refurbished. Some potential safety hazards were evident. Rook View ho9 H58 s13769 Rook View v244333 120805 stage 4.doc Version 1.40 Page 18 EVIDENCE: The home is a detached property situated on a site shared by other Residential Care Facilities managed by the NHS trust. The home is situated off a main road within reasonable reach of two town centres with their facilities and amenities. The exterior of the home is in good order. The interior of the home is currently subject to on-going refurbishment and it is important that this work is completed in order to complement the areas already refurbished. The communal and private areas provide adequate space for the residents are homely and comfortable. The resident’s bedrooms are tastefully furnished with their own items and are personalised. The kitchen is modern and of a domestic size. It was noted that the banister at the foot of the stairs was loose and needs to be secured to the wall. A requirement will be made under Standard 42 of this report regarding this. The laundry is well equipped and suitable for its purpose. It was noted that the COSHH cupboards were unlocked at the time of the inspection. It is important the cupboards are kept locked when not in use. This was brought to the attention of the manager who took immediate action. Nevertheless a requirement will be made under Standard 42 of this report regarding this. Bathrooms and toilets are of a good standard and afford privacy. The home has an infection control policy. Cleanliness and hygiene were of a good standard throughout the home and staff and resident’s keep all areas well organised and tidy. Rook View ho9 H58 s13769 Rook View v244333 120805 stage 4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 34 and 35 (Adults 18-65) and Standards 27,29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 and 35. The home’s recruitment and vetting procedures are basically sound, although confirmation of photographic and certificated identity needs to be pursued regarding one member of staff. The home has regard for the area of staff training, appraisals and development. EVIDENCE: The home has a staff recruitment policy and procedure. A sample of staff personnel files was inspected. The files inspected held an abundance of information and in the main included: contract, POVA check, health questionnaire, two/three references, confirmation of identity (via copy of birth certificate and photograph, Home Office and Immigration information, driving documentation, interview notes, job descriptions, person specifications and application forms. Criminal Record Bureau checks were also in evidence. It Rook View ho9 H58 s13769 Rook View v244333 120805 stage 4.doc Version 1.40 Page 20 was noted however that one file did not contain the member of staff’s photograph or copy of their birth certificate. It is important that these items are pursued and held on file. All new staff have an induction programme. There was recorded evidence that staff have received training in a number of relevant areas over the last year and this was confirmed by staff during in discussion. It was also evidenced that staff have a ‘personal development plan’ and an annual appraisal. The manager holds the NVQ level 4 qualification, one member of staff holds NVQ level 3, three staff are currently undertaking NVQ level 2 training and three staff are due to commence NVQ level 2 training in the near future. Another member of staff is a State Enrolled Nurse. Rook View ho9 H58 s13769 Rook View v244333 120805 stage 4.doc Version 1.40 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 39 and 42 (Adults 18-65) and Standards 33,35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42. Whilst there was evidence of areas of good management and practice, there were shortfalls in others, particularly around the testing of utility services, two potential safety hazards, evidencing current insurance cover and absence of the service providers Regulation 26 visit for the month of July 05. Rook View ho9 H58 s13769 Rook View v244333 120805 stage 4.doc Version 1.40 Page 22 EVIDENCE: Internal quality assurance questionnaires that residents, relatives and care managers have completed were in evidence. The feedback from all parties was complementary. The manager monitors the service and signs and dates certain records etc. Regulation 26 visits are undertaken unannounced and reports on the visits were available for the months of December 04, January 05, February 05, March 05, April 05, May 05 and June 05 were available. It was noted however that no visit occurred for July 05. It is important that the NHS Trust visits the home every month and submits a written report to the home and the CSCI Surrey Area Office. It was also noted that the home did not have a development plan for the current year. It is important that the NHS Trust prepares such a plan in consultation with the home’s manager. Requirements regarding the two areas mentioned above will be made. The home has a Health & Safety policy. The home’s Health & Safety ‘Law’ poster was prominently displayed. The home had a current fire risk assessment and fire evacuation drills and weekly fire alarm tests were evidenced. The home had a range of written risk assessments. These were reviewed in 2004 and will be due for further review later this year. The home did not have current safety certificates for the testing of its gas and electricity systems; however portable electrical appliances were tested this year. The home did not have a legionella test certificate or written risk assessment regarding the prevention of Legionella. It was also noted that hot water temperatures are not taken or recorded. It is important that safety certificates for the above utility services are obtained and kept available for inspection. The home’s accident record book was available. Recording was clear and provided sufficient detail. Environmental Health Department inspection reports regarding (health & safety and food hygiene) were held. The health & safety report dated 28th July 04 was satisfactory and requirements set at he food hygiene inspection on 28th October 02 had been addressed. It was noted that the home’s current insurance liability certificate had expired 31st March 05. The manager stated that the NHS Trust had not yet forwarded the new certificate to the home. It is important that the certificate is forwarded to the home. A requirement regarding this will be made. Rook View ho9 H58 s13769 Rook View v244333 120805 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x 3 x x x Standard No 22 23 Score 2 2 Score ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 x 3 x x 3 3 x 3 3 x Standard No 24 25 26 27 28 29 30 STAFFING 3 3 3 3 3 x 3 Score 11 12 13 14 15 16 17 Standard No 31 32 33 34 35 36 x x x 2 3 x x x 2 x x 1 x Version 1.40 Page 24 CONDUCT & MANAGEMENT PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Rook View Score 3 3 x x 37 38 39 40 41 42 43 ho9 H58 s13769 Rook View v244333 120805 stage 4.doc 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 22.1 Regulation 22, (7) (a) Requirement That the contact address and telephone number of the CSCI Surrey Local Office is included in the residents pictorial complaint procedure. That the manager receive Surrey County Council Multi-Agency training in the Protection of Vulnerable Adults. That some staff receive updated/refreshr training in the Protection of Vulnerable Adults. That photographic and certificated proof of identity is obtained regarding the member of staff referred to in Standard 34 of this report. That the service provider undertake Regulation 26 visits each month. That a current annual development plan for the home is drawn up in consultation with the homes manager. That the service provider forward a copy of the homes current insurance liability certificate to the home. That the loose banister rail is secured to the wall. Timescale for action 30.9.05 2. 35 18, (1) (c ) (i) 18, (1) (c ) (i) 19, Schedule 2 (1) (2) 26, (3) 24, (1) 1.12.05 3. 4. 35 34. 1 1.12.05 15.9.05 5. 6. 39 39.2 1.9.05 31.12.05 7. 43.5 25, (2) (e) 13, (4) (a) 1.9.05 8. 42. 3 (vi) 20.8.05 Rook View ho9 H58 s13769 Rook View v244333 120805 stage 4.doc Version 1.40 Page 25 9. 10. 11. 12. 42. 3 (i) 42.3 (ii) 42.3 (iii) 42.3 (iv) 13, (4) (a) 13, (4) (a) 13, (4) (a) 13, (4) (a) 13, (4) (a) 13. 42.3 (iv) That the COSHH cupboards are kept locked when not in use. That a test certificate for the homes gas system is obtained. That a test certificate for the homes electricity system is obtained. That the home have its water systems tested regarding the prevention of Legionella and the test certificate is kept available. That the home take and record its hot water temperatures on a weekly basis. 16.8.05 10.9.05 10.9.05 1.10.05 30.8.05 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 24. Good Practice Recommendations That the home complete its refurbishment programme in order to complement areas already completed. Rook View ho9 H58 s13769 Rook View v244333 120805 stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. 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