Inspection on 23/01/07 for Rose Manor

This inspection was carried out on 23rd January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rose Manor 12/10/07

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

CARE HOME ADULTS 18-65 Rose Manor 18 Bensham Manor Road Thornton Heath London CR7 7AA Lead Inspector David Halliwell Key Unannounced Inspection 23rd January 2007 09:30 Rose Manor DS0000066693.V327794.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 Rose Manor DS0000066693.V327794.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. Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rose Manor Address 18 Bensham Manor Road Thornton Heath London CR7 7AA 020 8239 7518 020 8239 7518 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) Rosenmanor Ltd (T/A Rose Manor) Mr Kris Nagalingum Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Mental disorder for up to 5 adults 18 – 65 years old. Date of last inspection Newly registered service. Brief Description of the Service: Rose Manor is a large house in South Norwood, well situated for access to the centre of Croydon and its many community based facilities, and good transport links. The property comprises of 2 day rooms (lounge and dining area) on the ground floor, and a smoking room in the conservatory. There are 5 single bedrooms, all fitted with hand basins and shower facilities. There are 2 WCs including a bathroom. Some off-street parking is provided to the front of the house. The stated aim of the home is to provide rehabilitative care for people with mental health problems over a 2-year period. This may be extended as required and in agreement with the clinical teams. The standard fees of a placement are £1100 per week. Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced and first inspection visit of this new service at Rose Manor. The Inspection covered all the key standards and involved a tour of the home, a review of all the homes records and formal interviews with 2 staff and the acting Manager, a visiting Community Psychiatric Nurse and the 2 service users who are residents. 1 requirement has been made as a result of this inspection and 6 recommendations. Feedback on the requirement and recommendations was fully explained to the acting Manager at the end of the inspection visit. The Inspector found the residents and staff most helpful and they are to be thanked for the assistance that they gave him over the course of this inspection visit. The Inspector was very impressed by the commitment and enthusiasm of the acting Manager and of the staff group and of the quality of the services being provided at Rose Manor. The acting Manager informed the Inspector that the standard fees for a standard residential placement at this home are £1100 per week. What the service does well: The home is able to demonstrate that it is assessing and meeting the needs of service users admitted to the home. Prospective service users, their relatives and friends are able to visit and to assess the quality, facilities and suitability of the home. The health and social care needs of service users are being well met. Service users are living in a safe, well-maintained environment, with access to safe, pleasant and comfortable facilities. Service users presented as being well settled and very happy in their environment, and very satisfied with the staff, their care support and the communal and personal facilities provided. Yvette Thomas is managing the home in an open, professional and competent manner. Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 6 The filing and administrative systems are well organised in a logical way and all the information was easy to find, read and understand. Yvette is to be complemented as are her staff team. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Rose Manor DS0000066693.V327794.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 Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2, 4, & 5 were inspected at this inspection. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Prospective service users may be fully assured that their needs are assessed and that their individual aspirations and wishes will be taken into account in the assessment process. They may also be assured that they will be offered an opportunity to visit and to “test drive” the home. Each service user has an individual written contract and is provided with a copy. EVIDENCE: Standard 2 – The acting Manager told the Inspector that for each prospective placement at Rose Manor the referring agencies are asked to submit their own comprehensive assessment of the individual’s needs. For the 2 existing residents their referring agencies submitted their own comprehensive needs assessment as a part of the Care Programme Approach. Since the admission criteria for Rose Manor are for placements of people with mental ill health, referrals in the main come from mental health teams, which Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 9 use the Care Programme Approach (CPA). The processes involved in the CPA include comprehensive needs assessment and care planning tools. When this information has been received the acting Manager at Rose Manor undertakes a needs assessment and does this by meeting the prospective resident and their clinical team and by using the CPA documentation. A provisional care plan is then drawn up by Rose Manor staff, which sets out how the identified needs of the person may be met. Once completed the assessment and the care plan is sent to the referring agency for their agreement and that of the prospective resident. The Inspector looked at the files of the 2 residents currently living at Rose Manor and on both found the CPA needs assessments and the needs assessments and care plans drawn up by Rose Manor staff. These documents were comprehensive in that they covered all aspects of the residents needs including: • Physical needs • Healthcare needs • Mental health needs • Social care needs • Personal support needs • Cultural and faith needs • Communication needs • Service users preferences and wishes. On reviewing these documents of the residents at Rose Manor it was also clear to the Inspector that the service users had been involved in the process and had had input to what had been written about them on their behalf. Therefore service users can be certain that not only will their needs be assessed but also that they will be able to contribute to the process appropriately. As well as the needs assessment and care planning documentation risk assessments had also been completed, more of which is described later in this report under Standard 9. Family and close relationship needs of both the service users files inspected had been included in the assessment and care planning processes. When the Inspector spoke with one of the residents it was clear from what she told the Inspector that she had been and is still fully involved in the process and that she is very satisfied with the outcomes of her care package at Rose Manor as a result. Standard 4 – The acting Manager told the Inspector that all prospective residents are encouraged to make a preliminary visit to Rose Manor in order to familiarise themselves with the home and to provide them hopefully with enough information from which they may decide to go to live there. Following this visit prospective residents are offered a 6 weeks trial period over which Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 10 they can better decide if Rose Manor is right for them. Families and friends are said to be encouraged to visit the home over this period. At the end of the trial period there is a meeting with the prospective resident and their clinical team which has referred them and the staff at Rose Manor and a decision is then made as to whether the placement will proceed or an alternative resource found. Both the residents spoke to by the Inspector confirmed the process above with the Inspector and said that they had found it very useful in helping them to decide whether they wanted to live at Rose Manor or not. They decided they did wish to and remain happy with this decision. Standard 5 – Each service user file inspected contained a written and costed contract which specified all the terms and conditions as set out under Standard 5 of the National Minimum Standards. Service users had signed their agreement and they have a copy of the contract on their own service user handbook files that may be kept in the resident’s own bedrooms. Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, & 9 were inspected at this inspection. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users may be assured that their assessed and changing needs and personal goals will be reflected in their care plans. They may also be assured that they will be able to make decisions about their daily lives and be enabled to take risks as part of developing a more independent lifestyle with support, as they need it. EVIDENCE: Standard 6 - There are 2 residents living at Rose Manor at present and both their files were inspected over the course of this inspection. All the documents set out under Schedule 3 of this Standard 6 were seen to be held on the files. As already indicated under Standard 2, service user plans or care plans have been drawn up and were also seen on the files. Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 12 The acting Manager informed the Inspector that the care plans seen by the Inspector were based on the needs assessments that had been drawn up from the CPA needs assessment and their own needs assessment for the person concerned (described more fully under Standard 2 in the previous section of this report). Close inspection of the care plans by the Inspector evidenced this and the Inspector was impressed with the quality of the care plans seen. They had been clearly divided into sections (relating to the identified needs) with care plan objectives and action plans which addressed the needs and set out identified milestones, so that clear monitoring and review could then be achieved. Monthly reviews by the care staff team were evidenced on the files and involvement of each of the residents in these reviews was also evident. They confirmed their involvement in the review and care planning process at interview that was a part of the inspection process. Inspection of the review reports showed that changing needs of service users had been identified and that appropriately revised care plan objectives had been drawn up together with the service user. Formal 6 months reviews are planned and held with the clinical teams and the service users. At the time of the inspection the acting Manager was completing the review report for one of the residents whose review was to be held the next day at the community mental health team’s offices. The service user concerned confirmed that they had been asked for their input into the review report and that they would be attending the review with staff from Rose Manor. Both the residents at Rose Manor have their own key workers and the acting Manager told the Inspector that residents can choose their key workers if they wish. Residents confirmed to the Inspector that they are happy with their key workers and find them helpful, supportive and friendly. Standard 7 – Over the course of this inspection the Inspector witnessed staff respecting resident’s rights to make decisions about their daily lives. One resident decided that she wanted to go swimming on the day of the inspection and staff assisted her to do so with their support. This marked a positive progression for this particular resident in her rehabilitation programme. The acting Manager told the Inspector that residents do have their own residents meetings and that meetings are minuted. The minutes of these meetings were shown to the Inspector by the acting Manager. The records show that meetings are held every 2 months, they indicate who has attended the meetings and what issues have been discussed. Standard 9 - Risk assessments were seen on the residents files inspected both as a pre-admission assessment tool and also following admission, being used to assist service users to be appropriately supported to take risks as a part of Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 13 developing a more independent lifestyle wherever possible. These risk assessments are agreed with the service user and the relevant professionals. So service users can be assured that they will be supported to take risks as part of developing a more independent lifestyle wherever this is possible. Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 & 17 were inspected at this inspection. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users may be assured that they will be able to take part in appropriate activities, some of which will be based in the local community. That they will be supported to maintain appropriate personal relationships with family and friends; and that their rights will be respected and their responsibilities recognised in helping them to construct an appropriate programme of activities in their daily lives. EVIDENCE: Standard 12 – The acting Manager showed the Inspector the daily activities sheets that records the activities of each resident and links this with their care plan objectives or service user plans. The care plan objectives identify activities for each resident that are appropriate to their age and cultural needs. Residents interviewed by the Inspector said that they participate in the activities they wish to do and no service user said that they wanted to do an Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 15 activity but were not allowed to do so or were not enabled or supported by staff to do so. The actual range and scope of activities undertaken by the service users however is limited by the extent of the resident’s mental well health and wishes at the time. The acting Manager told the Inspector that as a part of trying to maintain continuity for the residents in their daily lives and to support their rehabilitation, where ever possible previous interests, pastimes, hobbies and relationship are encouraged and built into the daily activities plan for service users. As an example one of the residents loved to go swimming before she became resident at Rose Manor, staff encourage this now and it is built into her weekly activities plan. The Inspector spoke to the service user over the course of the inspection and she confirmed that she is supported by staff to go swimming and she also said how she has always liked to go swimming. As a part of the care plan review it was evident that significant relationship links for the residents are recorded in the care plans and that the importance for the residents of these links is not underestimated. One resident is encouraged to maintain her relationship with her boyfriend and visitors are made welcome when they come to the home. Information about local activities was seen on the notice boards within the home and staff who were interviewed by the Inspector said how they will support residents, in their capacity as care support workers, to take as much of an active role in the community as is appropriate for residents. One member of staff at the time of the inspection was engaged in completing a referral form for one of the residents to attend a local social club and talked to the Inspector about the importance for the residents to get out and about and socialise with other people and to have a chance to talk to other people. Another resident told the Inspector that she had expressed a wish to attend church regularly in order to meet her faith needs. She is now supported by staff to attend church on a regular basis. So it seems to be that service users are supported and enabled to take part in appropriate activities and that they are able to express their wishes and be listened to and responded to with active and appropriate support. Neither of the residents attend colleges or adult education at the present time as this would not now be appropriate for their needs. Standard 13 – The fairly central location of the home in Croydon would make access easy for those service users able to use public transport. However at present the 2 residents currently living at Rose Manor are not able to do so as a result of their disabilities. As already indicated above, 1 resident said that she does go to church with the support of staff and is also looking forward to being able to make use of some day centre provision in and around Croydon if her recent application is accepted. When the Inspector asked residents about Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 16 going to the cinema or theatres they were less than enthusiastic about using these forms of entertainment. The acting Manager informed the Inspector that all residents are registered to vote and are encouraged to use their votes. Service users confirmed with the Inspector that they are supported and enabled to vote. The acting Manager told the Inspector that relations with the local neighbours are good with no problems arising up to this point in time for the home or for the neighbours. From this inspection it would seem as if service users are engaged as much as is possible with their local community and that this will be likely to expand as their skills and abilities increase. Standard 15 – Interviews with the 2 service users confirmed that where possible they do maintain regular contact with members of their families and either go out to visit their relatives or receive them at Rose Manor. Staff interviewed by the Inspector said that they encourage these visits and are sometimes involved in helping their resident’s sort out difficulties that they experience their relationships with their relatives as this often has a direct bearing on the mental well being of the resident. Visitors to the home are encouraged and use the visitor’s book to sign in. The Inspector saw information made available within the home about local activities for residents to take up if they wish. Standard 16 - Policies seen by the Inspector to be established within the unit ensure that service users rights to privacy, respect and dignity are respected. Residents who were interviewed also confirmed that they felt staff respected these rights. Residents said that they have a key to their own bedrooms, that staff uses their preferred form of address and that staff do knock on their doors before entering. The Inspector observed staff to be interacting with residents in a friendly and respectful manner and staff confirmed in interview that they understand how to respect the privacy and dignity needs of the residents. The acting Manager explained to the Inspector that all incoming and outgoing mail is logged into a record book and where residents need some assistance in opening and reading their mail, the resident is always asked first if they do want this assistance on that occasion. The acting Manager showed the Inspector the logbook and regular and up to date entries were seen up to the date of the inspection. Residents also confirmed to the Inspector the practice explained by the acting Manager. Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 17 Interviews both with staff and residents confirmed that residents participate in household chores as a part of the rehabilitative process and this participation was seen to be supported in residents care plans. There is a specific area for smokers and there are appropriate policies regarding drug and alcohol taking on the premises. Standard 17 – Food menus shown to the Inspector indicate that menus are varied, choices are provided and that service users assist in the drafting of the food menus. A 4-week rolling programme is used within the home. No complaints about the meals arose during the inspection in fact both those service users interviewed said that they like the food provided at Rose Manor. It was noted that a wide range of meals were listed which cater for the multicultural needs and wishes of the residents. The Inspector asked the acting Manager if a dietician is used to advice on the menu planning in order to ensure that the food provided is always healthy and nutritious. The Manager said that a dietician is used in some cases where there is a specific need but not as a general rule. The Manager showed the Inspector a detailed food record that is kept for each resident and that is useful to help ensure that the service users maintain an appropriate diet that is healthy and nutritious. Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 18 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, & 20 were inspected at this inspection. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users may be assured that they will receive personal support in the way they prefer and require, they may also be assured that their physical and healthcare needs will be appropriately met. Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Standard 18 & 19 – Service users interviewed confirmed with the Inspector that they receive their care in the way they prefer. They confirmed that they are able to decide themselves about their daily routines and care staff interviewed by the Inspector also confirmed this. Service users confirmed that they keep in regular contact with their General Practitioner and psychiatric team and evidence of these contacts was seen on file in the daily notes. Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 19 Also at the time of this inspection a Community Psychiatric Nurse was visiting one of the residents in order to administer a depot injection and the Inspector took the opportunity to speak to him about the quality and level of contact he and his clinical team have with the resident. He reported that it was excellent and that he finds he is able to work well with the staff at Rose Manor in the delivery of the care packages to the residents. The acting Manager informed the Inspector that both the residents are registered with dentists, opticians, chiropodists and community nurses in order to maintain their all round good health. Residents interviewed were able to confirm this. Information in their case files also evidences it by the recording of their contact with these services. It was confirmed that annual healthcare checks are routinely carried out by GPs. It was confirmed by the staff and the residents that they are able to choose when they get up, when they go to bed, when they have a bath, what they wear and what they will do during the day. A member of staff interviewed explained how when drawing up the weekly activities chart, which is based on the care plan, they always sit down with the service user and go through the programme in order to gain the residents approval and choices. Standard 20 – The home’s policies and procedures manual contains appropriate policies for the control of medication. The Inspector reviewed the records for the administration of medication to residents (MAR sheets) and these were seen to be appropriately completed and in line with the home’s policies and procedures. Photographs of the service users were attached to the MAR sheets which helps to ensure that staff administer medications to the right resident and guidance is also provided about PRN medications that are used for residents stating when PRN medication should be used and the potential side effects for the individual resident. The Inspector did a spot audit check on the stock control system and this proved satisfactory with the levels of medications being as stated on the control sheets. A check on the storage facilities for the medication was seen to be appropriate and although controlled drugs are not currently in use within the home there is appropriate provision for doing so i.e. there is a lockable metal cupboard within a locked metal cabinet. There is also a refrigerated cupboard for those drugs requiring cool conditions. Boots the chemists provides training in medication, the acting Manager informed the Inspector that this is mandatory training for all staff. The 2 members of staff interviewed said they had both received this training. At present neither of the service users are able to administer their own medication. The home actively supports service users who wish to self Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 20 medicate and appropriate facilities (e.g. lockable cabinets bolted to the walls) have been installed in each bedroom. Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 21 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22, & 23 were inspected at this inspection. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users may be assured that their views will be listened to and that they will be protected from abuse, neglect and self-harm. EVIDENCE: Standard 22 – Service users spoken to by the Inspector confirmed that they feel their views are listened to and acted upon. They said that if they had a complaint they know the procedure to be followed and would do so if they needed to. Staff interviewed confirmed with the Inspector that the residents were all aware of the complaints process and that the whole staff group took any issues raised by residents seriously. The homes’ complaints policy was inspected and the contact information for the CSCI was found incorrect. This was the only error found but it appeared in all the complaints leaflets i.e in the resident’s handbook, on the notice board and in the policy file. The acting Manager assured the Inspector that this old information would be replaced in all the formats immediately that same day. The Inspector asked the acting Manager to see the home’s complaints record and although no complaints had been made since the home opened no formal record book has been used. The acting Manager assured the Inspector that this would be drawn up immediately and staff will be made aware of it and how and when it is to be used. It is recommended that a complaints record be drawn up and that monthly monitoring reports are sent to the Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 22 proprietor for their information and also to inform the quality assurance process for the home. Residents confirmed with the Inspector that there had not been any occasion when they had wished to make a complaint. Standard 23 - The home has an adult protection policy that links directly into the L.B.Croydon’s adult protection policy. The acting Manager informed the Inspector that all staff are enrolled for the next protection of vulnerable adults training course with L. B. Croydon in the next 3 months. Neither of the two staff interviewed by the Inspector had attended the training as yet. It is recommended that all staff undertake POVA training at least once every two years on an authorised training course preferably offered by L.B.Croydon. The Inspector saw the allegation of abuse record; no allegations had been made since the last inspection. The acting Manager confirmed this to the Inspector. The policies and procedures manual for the home includes a whistle blowing policy and a policy on dealing with violence and aggression. Understanding the policies and procedures is a part of the staff induction process and evidence was seen on file that as a part of the induction staff are asked to sign to say that they have read and understood the policies and procedures for the home. The acting Manager obviously takes the issue seriously and explained to the Inspector how staff are allocated some time each week in which they are asked to read the home’s policies and procedures. They then have an opportunity to discuss anything not understood with their supervisor in their 1:1 supervision sessions. The Inspector suggested that after these supervision sessions would be an appropriate time to ask staff to sign off the policies and procedures as understood. Since not all policies and procedures had actually been signed by all staff to say that they have read and understood them it is now recommended that all staff are asked to sign all the homes policies and procedures. The home does at present look after 1 resident’s money and the Inspector reviewed the financial records for these transactions that were in order. All transactions are dated and signed for by both staff and residents to confirm satisfaction by all parties. The Inspector found no anomalies. Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 23 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 & 30 were inspected at this inspection. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users at Rose Manor are able to live in a homely, comfortable and safe environment. The home is also clean and hygienic and well looked after by staff. EVIDENCE: Standard 24 – A tour of the home together with the acting Manager was undertaken as a part of the inspection and the home was seen to be clean and tidy in all areas. Not all areas of the home are accessible to wheelchair users and at present only one resident sometimes uses a wheelchair. Her bedroom is on the ground floor where most facilities are accessible. The general condition of the home and the facilities is good; communal areas and bedrooms are kept clean and odour-free. The staff provide a ‘homely’ touch through supplementary decoration and ornaments / flower decorations Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 24 and pictures hanging on all the walls. A lock on the 1st floor toilet was not working properly, the Inspector told the acting Manager about this. There is a conservatory at the back of the house that is used for the smoking area. The acting Manager showed the Inspector the fire records for the home. The LFEPA last visited Rose Manor in May 2006. 3 requirements were made. The Inspector viewed each requirement and can now report that they have been met and this was subsequently confirmed by the LFEPA. Records were also shown to the Inspector by the acting Manager for other safety checks that have been carried out over the last year and that are part of a regular process of checks carried out to help ensure the safety of the residents. Environmental Health have not made a visit yet to the home and it is recommended that the acting Manager request L.B.Croydon’s environmental health officer to do so. This will ensure that the relevant standards are being met within this home, however no problems are anticipated due to the high standards being maintained. The acting Manager advised the Inspector that a handyman is employed to carry out routine maintenance around the home and that a programme of repairs is kept. Standard 30 – The acting Manager showed the Inspector the home’s infection control procedure, which seems comprehensive and to be effective in practice. At the time of this inspection the home was clean and hygienic. Staff interviewed confirmed that they are issued with appropriate clothing and equipment for them to carry out their work appropriately The laundry facilities in the home are somewhat limited at present are appropriate for the number of residents currently living within the home. The Inspector was informed that laundry is not taken through any areas where food is being prepared. The acting Manager advised the Inspector that the Proprietors are planning an extension at the back of the main building which should include improved laundry facilities and this will be necessary if more residents are to be admitted over and above the 5 people that the registration category allows at present. Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 34, 35 & 36 were inspected at this inspection. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users benefit from the clarity of staffing roles and responsibilities and they can be assured that they are supported by competent, appropriately trained, qualified and supervised staff. The homes recruitment policy and procedures helps protect the residents. EVIDENCE: Standard 31 – On inspection of the files in the main office at Rose Manor the Inspector found job descriptions (JDs) for all posts. These JDs are clear and cover the full range of duties that are expected of the staff they apply to. Copies of the JDs were also found on the staffing files and the 2 staff interviewed said they have copies of their JDs. Reference has already been made under Standard 23 about policies and procedures and the opportunities staff have to discuss them and sign to say they have read and understand them. Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 26 The acting Manager told the Inspector that each member of staff is provided with a copy of the General Social Care Council’s standards Code of Conduct. This should assist staff to recognise the standards of care that they are working within. Rose Manor does not have volunteers working in the home. Standard 32 – The Inspector saw care staff working at Rose Manor to be approachable for the residents and in taking time to deal with their questions appropriately and patiently. The acting Manager told the Inspector that the training programme for staff is comprehensive and covers all the essential training required by the staff to do their jobs well and proficiently. The provision of funding for training is also said to be good and the acting Manager told the Inspector that if a staff need for training is identified then a training course is provided. The acting Manager also informed the Inspector that the whole staff group is enrolled for the next local authority Protection of vulnerable adults training course and for NVQ training for those staff who have not already achieved it. The impression provided by the acting manager and by the documentary evidence that supported what had been said, is very positive. Training records were examined by the Inspector and evidence was seen that evidenced staff having completing the following training courses: • 1st aid • Fire safety • Moving and handling • Food hygene • Breakaway techniques • Health & safety • Safe handling of medications • Understanding dementia • Essential hygiene • Infection control • Understanding confidentiality • Boundaries The Inspector discussed with the acting Manager and the staff group the need for training on “understanding mental ill health, the signs and symptoms “ and the acting Manager said that this training had not been provided but would be very useful for staff to assist them in carrying out their jobs more effectively. It is therefore recommended that a course be provided for staff on mental health awareness. With regards to the need for National Vocational Qualifications at level 2, 4 of the six staff have this qualification and evidence was seen on staffing files by the Inspector, which evidenced this. The 2 remaining and recently employed Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 27 staff are enrolled for NVQ training and have just completed the assessment process last week before they commence the training in the near future. Standard 34 - The acting Manager told the Inspector that the home does have a recruitment policy and procedure and that all staffing posts are filled by application and interview. Evidence of these processes being used was seen by the Inspector on the staffing files. The acting Manager said that she, the Proprietor and sometimes a senior Care Worker constitute the interview panel. Review of the staffing files evidenced that suitable application forms are completed, that 2 references are obtained including one from the last employer. All staff files reviewed by the Inspector evidenced that proper CRB checks have been carried out for staff employed within this unit. Equally that all other documentary evidence required (under Standard 34) to be gathered for staff was seen to be held on the staff files reviewed. Staff interviewed confirmed that all have a contract of employment and that they understand their terms and conditions as well as their roles and responsibilities within the home. Standard 35 – As already indicated earlier in this report the acting Manager has said that there is an overall training and development plan and budget for the home. The acting Manager informed the Inspector that a structured induction programme is offered to new staff and documentary evidence of this was seen by the Inspector and supported in interview with staff. It includes: • Safe working practices • The workers role • Meeting the needs of service users • The home’s policies and procedures. Standard 36 – The acting Manager told the Inspector that there is a properly structured staff supervision policy and procedure. Records were inspected and both the policy and the supervision tools comprehensively cover the areas that are required in order to implement an effective supervision process. When fully implemented this will ensure that residents do benefit from well-supported and supervised staff. Inspection of the supervision records that are held on staffing files showed that staff have only received 1 formal supervision session since April 2006. The acting Manager said that they do receive ongoing support in their work sometimes on a daily basis, but agreed that the more formal supervision approach needs now to be properly implemented and told the Inspector that the staff will from now receive formal supervision at least once every 4 – 6 weeks. It is a requirement that staff receive regular supervision using the policy and procedures already in place. Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 28 The acting Manager also informed the Inspector that annual appraisals will be implemented mid year when staff have been in place for the year since the unit opened. The processes used for both supervision and appraisals should be closely linked as together as they form a useful tool in the effective management of staff and in the proper delivery of care for residents. Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 29 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 & 42 were inspected at this inspection. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users can be confident that they benefit from a well run home. The quality assurance system will help ensure that their views underpin monitoring and review of the homes developments. Service users may also be confident that their rights and best interests are safeguarded by the home’s record keeping policies and procedures. EVIDENCE: Standard 37 – The acting Manager has achieved almost a year’s experience of management experience at Rose Manor. She holds her registered managers Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 30 award at level 4 completed in February 2006 and is about to submit her application to the CSCI to become the Registered Manager of the unit. The service users spoken to by the Inspector felt that the home is being well run and evidence seen by the Inspector supports this view. The homes records and administration systems were seen by the Inspector to be in very good order and overall the impression was extremely positive. Interviews with staff reflected a positive and caring approach towards the residents. Service users can therefore be assured that they are benefiting from a well run home. Standard 39 – The acting Manager explained to the Inspector the quality assurance processes being used within the home to ensure that resident’s views underpin all self-monitoring review and development by the home. The Manager said that there is an annual management audit undertaken that reviews all health and safety issues, statutory and legal issues, the effective implementation of the homes policies and procedures, the environment and the building, staff and employment issues and training issues. A service user questionnaire is used to gain feedback from the residents and other questionnaires have also been devised to get feedback on issues to do with quality, from friends, families and visiting professionals. Quality checks are made on the recruitment procedures used to employ staff and a room-byroom risk assessment of the building is completed annually, information from which also informs the developments to be made in the home. The Inspector saw evidence of the feedback questionnaires and it was very positive in its detail. It is recommended that the feedback gained from all these areas are analysed and used to inform an annual development plan for this home. Standard 42 – The Inspector was shown information to do with relevant Health and Safety legislation. Policies and procedures were also seen for Health and Safety, risk assessment, moving and handling and fire. The acting Manager informed the Inspector that all staff receive training in moving and handling, fire safety, first aid, food hygiene, and infection control. This was supported by staff interviewed that confirmed that they had received training in these areas. Up to date certificates were seen by the Inspector for: Boiler – 13.7.06 Gas – 20.11.06 Fire alarms – 26.9.06 Fire extinguishers – 3.06 Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 31 All food was seen to be stored appropriately and properly labelled with dates of opening and expiry. An accident record book is being used at the home to record any accidents to staff although nothing had been recorded since the home opened. Records were seen by the Inspector that confirmed regular tests had been carried out for the: fire alarm Fire extinguishers Emergency lighting Fridge and freezer temperatures all within the acceptable ranges Hot water temperatures all within the acceptable range. At the time of this inspection no fire doors were seen to be wedged open and the building appeared to be secure. Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 32 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 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 33 Are there any outstanding requirements from the last inspection? N/A 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 YA36 Regulation 18 Requirement That staff receive regular supervision, once every 4 – 6 weeks using the policy and procedures already in place. Timescale for action 01/03/07 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 YA22 Good Practice Recommendations That a complaints record be drawn up and that monthly monitoring reports are sent to the proprietor for their information and also to inform the quality assurance process for the home. That all staff undertake POVA training at least once every two years from an authorised trainer preferably L.B.Croydon. That all staff are asked to sign all the homes policies and procedures. That the acting Manager request L.B.Croydon’s environmental health officer to undertake an inspection. That a course be provided for staff on mental health awareness. That the feedback gained from all these areas are analysed and used to inform an annual development plan for this home. 2. 3. 4. 5. 6. YA23 YA23 YA24 YA32 YA39 Rose Manor DS0000066693.V327794.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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