Inspection on 11/08/04 for Rosebank

Care Homes For Adults (18 ­ 65)Rosebank52 Leyland Road Southport Merseyside PR9 9JQUnannounced Inspection11th August 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Rosebank Address 52 Leyland Road, Southport, Merseyside, PR9 9JQ Email address Tel No: 01704 535548 Fax No:Name of registered provider(s)/company (if applicable) Mr Gerard Cunningham Name of registered manager (if applicable) Mrs Carol Hall Type of registration Care Home No. of places registered (if applicable) 17Category(ies) of registration, with (number of places) Learning disability (17) Registration number F030000366 Date first registered 25th July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 25th July 2002 yes YES 19/03/04 If Yes refer to Part CRosebankPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 309th August 2004 11:00 am Miss Orla MurphyID Code073536Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionNA Mr Mark CunninghamRosebankPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods and Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementRosebankPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Rosebank. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.RosebankPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Rosebank provides personal care and accommodation for up to 17 persons with learning disabilities, three of whom also have mental health difficulties. Nursing Care is not provided. A private individual, Mr Gerard Cunningham, owns the home. Mr David Hall was the Acting Manager but has left the home. Mr Mark Cunningham is currently acting in the managerial role. The home is situated on Leyland Road, Southport and is close to the town centre, the seafront and has good access to public transport, shops and leisure facilities. The home has its own transport in the form of a minibus. The detached house has adequate parking in its grounds and a maintained garden to the rear. Service Users accommodation is situated on the ground and first floors. There are adequate bathing and toilet facilities within the home. There are two comfortable communal areas for Service Users use.RosebankPage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This Unannounced inspection took place on 9th September 2004. A complaints investigation was carried out within the Inspection. It found that some of the National Minimum Standards assessed were not met, these had minor shortfalls. The requirements from the last unannounced Inspection had not been addressed. The complaint investigation demonstrated that a lack of guidance and leadership in the home had led to deterioration in some systems within the home. A core group of standards were assessed in addition to specific standards relating to complaint allegations. This report should be read in conjunction with the next Announced Inspection to determine the outcome of all standards. Standards are scored from 0-4 and page 12 of this report explains which scores denote whether a standard is not met, met or exceeded. The Inspector used case tracking which involves the examination of documents/records, discussion (with staff and the individual Service Users) and evidence in relation to individual Service Users to determine how the National Minimum Standards work for them in practice. Two Service Users were case tracked on this occasion. Choice of Home (Standards 1 - 5) 1 out of the 1 Standard assessed was met. The current Service User group is long standing and referrals; assessments and plans that were provided to the home several years ago were minimal. Managers, staff and health care professionals have worked together to record individuals history and identified needs to develop assessments for these long standing Service Users. The assessments viewed were detailed, appropriate and satisfactory. Individual needs and choices (Standards 6-10) 1 of the 3 Standards assessed was met. Two care plans were case tracked. The home remains between care plan formats at the moment with some being transferred to a new format and some on the old format. The Acting Manager needs to develop plans to a satisfactory and consistent format. The plan viewed in the new format was positive and achievable for the Service User concerned. All care plans must be reviewed every 6 months. All risk assessments viewed for both Service Users case tracked were up to date and satisfactory. Lifestyle (Standards 11-17) 1 of the 3 Standards assessed was met. The Service Users case tracked had some planned individual and group activities, which have been determined through the assessment and planning process. Service Users spoken with were enthusiastic about their lives but it was evident that activities and opportunities to access the community have been poor in recent months and systems are now in place to ensure Service Users social activities are improved, recorded and maintained. Rosebank Page 6 Personal and Healthcare Support (18-21) 2 of the 2 Standards assessed were met. Service Users case tracked had detailed annual health assessments, carried out with local community service. Procedures and observations reflected that staff are positive and sensitive in supporting Service Users in these areas. Complaints and Protection (Standards 22-23) 0 of the 2 Standards assessed were met. There have been 2 complaints made to CSCI regarding the service. One of these was investigated during this inspection with some issues upheld and others not upheld. All staff require POVA training and all staff checks must be up to date. Environment (Standards 24-30) 1 of the 4 standards assessed was met. The environment is generally comfortable and homely but is showing signs of wear and tear in places. The Provider must plan a redecoration schedule for the home. This schedule should be recorded so it can be audited against actual works. Service Users accommodated on the first floor must be mobile to access these areas. Service Users were observed accessing all areas of the home on the day of the inspection. Staffing (Standards 31-37) 0 of the 3 Standards assessed were met. Staff files were randomly checked and were found to contain most of the required information and checks but some CRB reference numbers were not in place. Staff training was evidenced on the files checked but some require updating. The home has a Training and Development Plan, which was viewed and is satisfactory. Staffing hours continue to meet those agreed with the previous Regulating Authority. Staff were all observed interacting positively and respectfully with Service Users on the day of the inspection. Conduct and Management ( Standards 38-43) 0 of the 4 Standards assessed were met. The Manager left her post at the beginning of the year. The Deputy Manager was acting in the Managers post but has left the position. Management has been inconsistent in the last cycle and this is reflected in aspects of care practices in the home. The current Acting Manager must submit an application to CSCI to become the Registered Manager. The fire door identified must be shaved to ensure it opens effectively. Some staff require statutory training updates. Health and Safety checks were up to date and satisfactory. The homes management should ensure that all consultation with Service Users is recorded to reflect the level of consultation and action in the home. A Quality Audit should be produced annually and the Providers Regulation 26 visits must be carried out monthly and kept up to date.RosebankPage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 2 3 4 24 15 23 24 YA39 YA6 YA35 YA24 The homes annual audit should be carried out and a copy of the outcomes sent to the NCSC. Ensure all care plans are transferred to the IPP format and reviewed 6 monthly. Ensure all staff receive POVA training. Produce a planned schedule of redecoration with timescales to address wear and tear in the home. Submit an application for an individual to CSCI to become the Registered Manager. Ensure Providers visits are carried out monthly and a report produced from the visit.5 68 26YA37 YA39Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). RosebankMET (YES/NO)Page 8 RosebankPage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 24 YA39 1st The homes annual audit should be carried out November and a copy of the outcomes sent to the CSCI. 2004 Ensure all care plans are transferred to the IPP format and reviewed 6 monthly. Ensure all staff receive POVA training. Produce a planned schedule of redecoration with timescales to address wear and tear in the home. Submit an application for an individual to CSCI to become the Registered Manager. Ensure Providers visits are carried out monthly and a report produced from the visit. Any joint purchases made by Service Users should be supported by a recorded agreement with them and their representatives. The range of activities external to the home for Service Users must be continued, maintained and built upon. 23rd October 2004 8th January 2005 23rd October 2004 23rd October 2004 23rd September 2004 23rd September 2004. 23rd October 2004.215YA6323YA35424YA2458YA37626YA39712YA7813YA12RosebankPage 10 916YA30Household chores carried out by Service Users must be rotated and allocated evenly.23rd September 2004. 23rd October 2004. 1st December 2004. 23rd October 2004.1019YA34All staff must have CRB checks All staff must have up to date statutory training and 50 of staff must be trained to NVQ Level 2. Staff must receive 6 formal, recorded supervisions per year and 6 staff meetings, recorded must be held per year.1118YA351218YA36RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are viewed as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard ** Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.RosebankPage 11 PART BINSPECTION METHODS AND FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken with at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual viewed CRB check for the manager viewed Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NA YES YES YES YES NA YES YES YES YES YES YES NA NA NA YES YES YES 8 X X YES NO YES YES X X 09/08/04 11 AM 5RosebankPage 12 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.RosebankPage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. X X Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Toiletries and personal belongings 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection. Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? 6 Service Users care plans were examined and two assessments were viewed as part of this process. The home has developed a good level of information on the Service Users during the time they have been living there. The two Service Users case tracked held detailed assessments of need on file which were informative and meet this Standard. Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection.RosebankPage 14 Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection. Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection.RosebankPage 15 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 2 Key findings/Evidence Standard met? Two Service Users case files were tracked, and 6 care plans examined as part of the inspection. Care plans were detailed with realistic needs and strengths identified. Care plans are due to be reviewed every six months but some had missed the deadlines. The Acting Manager stated he would address this. The Care planning system is in the process of being redrafted to Individual Personal Plans (IPP) but this has halted since the departure of the Manager. This needs to be re started and all IPPs should be in place in this coming cycle. All Care plans should be transferred to the IPP system and reviews kept up to date. Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 2 Key findings/Evidence Standard met? Service Users jointly purchased a games item but no formal permission or agreement on ownership was recorded. The recording must be drawn up in consultation with Service Users and their representatives or the monies reimbursed. Any future purchases must be carried out with formally recorded agreements. No other issues in relation to decisionmaking were identified. Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection.RosebankPage 16 Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection. Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? All records relating to Service Users are held in an office, which is locked when unoccupied. Most Service Users spoken with understood they could access their records when required. The home has a confidentiality policy and procedure for staff to follow. Confidentiality is also addressed within the recruitment and induction procedure and is included in job descriptions viewed.RosebankPage 17 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 2 Key findings/Evidence Standard met? Examination of Activity logs, the handover book and 6 Service Users daily records reflected that in the last month, activities external to the home had increased greatly. 11 Service users were noted as having trips out in the minibus and by foot to the Pine Woods, Southport Town centre, Liverpool, and Woodvale. Some Service Users go out with staff on a one to one basis. One Service User informed the Inspector she regularly went out with staff. The Proprietors representative stated this was an area that had diminished but systems, including shift plans, are now in place. The Inspector could see these and the improvements that had been made. This is an area the Acting Manager must continue to develop and improve opportunities in this area. Service Users spoken with stated they had been out on trips and staff take them out by arrangement. Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 0 Key findings/Evidence Standard met? This Standard was not fully assessed at this inspection. Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection.RosebankPage 18 Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 2 Key findings/Evidence Standard met? The two Service Users case tracked held care plans and risk assessments in relation to accessing the community. As described previously, access to and opportunities for social and leisure activities must be continued, built upon and maintained. Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection. Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection. Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Food stocks were examined and found to be available in good quantities and quality. Food was stored safely. Service Users spoken with stated they liked the meals provided, were involved in choosing meals and could have a different meal if they wish to. Service Users access the kitchen to make drinks and snacks. A cook is employed daily.RosebankPage 19 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? Two of the Service Users care plans viewed reflected they were varying in independence in their personal care. Discussions with Service Users confirmed they were supported by staff and could ask for help. Service Users range in the level of input and support they require. Individual preferences and requirements in relation to personal care were recorded on two of the files viewed. Staff were observed supporting Service Users discreetly and respectfully. Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) XX3 Key findings/Evidence Standard met? Each Service User case tracked and an additional four Service Users was registered with a local GP. Previous inspections revealed all Service Users were registered locally. Healthcare assessments have been carried out on all Service Users and these are reviewed annually. The two Service Users case tracked held detailed records about all GP visits, medication and contact with or treatment from other health care services. Concerns raised in a complaint regarding concerns about some Service Users health were not upheld.RosebankPage 20 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 0 Key findings/Evidence Standard met? This Standard was not fully assessed at this inspection but some medicines were examined in relation to a complaint investigation. Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection.RosebankPage 21 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 2 0 1 1 1 2 50 2 Key findings/Evidence Standard met? There have been two complaints regarding the home in the last cycle. The most recent was investigated through this Unannounced Inspection. Requirements are addressed in the beginning of this report. The home has a complaint procedure, which complies with the requirements of this standard. Service users spoken with, where able, informed the Inspector they would talk to various named staff or a member of their family if they were concerned or upset.RosebankPage 22 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES02 Key findings/Evidence Standard met? The home follows Seftons Protection Of Vulnerable Adults Procedure (POVA). There have been no identified protection issues in the past cycle. Criminal Record Bureau records for most staff files examined were in place and satisfactory but two new staff require a CRB check. All Staff must undergo POVA training as part of basic required training within care environments. The training schedule viewed on the day of the Inspection details Adult Protection training on offer for staff in the coming cycle. This must be addressed as a matter of urgency.RosebankPage 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? Building work has been underway at the home for the last few weeks as renovations are made to a bathroom and two double bedrooms. Double bedrooms are being converted to single accommodation and a new bathroom has been created. The home is generally comfortable and homely and Service Users were observed accessing all available areas of the home freely on the days of the inspection. The Acting Manager stated several areas, which are showing signs of wear and tear, would be redecorated in the coming cycle. The Fire escape door on the top floor requires shaving to prevent it sticking.RosebankPage 24 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence This Standard was not assessed at this inspection. NO NO YES X X X X Standard met? 0 X XX X X XRosebankPage 25 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 2 Key findings/Evidence Standard met? All bedrooms viewed on the day of the inspection were clean, tidy and personalised. Some are in need of redecoration. This is reported to be addressed in the next few months as double accommodation is reverted to single. Part of the complaint investigated, related to the condition of a particular mattress. This mattress was examined and found to be in satisfactory condition. All bedrooms viewed were personalised to individuals tastes and preferences. Service Users spoken with were enthusiastic about the changes to the home and all stated they liked their bedrooms. Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? A new bathroom is in place and was found to be pleasant and welcoming. There are sufficient bathing facilities in place. The upstairs shower room is no longer in use. Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection. Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 9 Key findings/Evidence Standard met? No disability equipment is currently required for this home. Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 2 Key findings/Evidence Standard met? The home was clean, tidy and hygienic on the day of the inspection. Ancillary staff are employed and Service Users are expected to assist with some household duties. Part of the complaint investigated related to one Service User carrying out a household chore every day, single-handedly. This was discussed with the Service User concerned and whilst the Service User enjoys this task and wants to do it, chores should be shared to reflect normal expectations of group living. The Inspector explained this to the Service User and they stated they were happy to share the task with others.RosebankPage 26 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection. Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 2 Key findings/Evidence Standard met? A fully planned training programme was available for inspection and was satisfactory. Some staff files examined reflected that some statutory training requires updating and most staff need to undertake POVA training. NVQ training needs to meet the 50 target by April 2005.RosebankPage 27 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXX2 Key findings/Evidence Standard met? A staffing tool was not used at this inspection, as it was unannounced. The staff rota for a 4 week period was examined and it reflected that the staffing meets the numbers required set by the previous regulatory authority. Staff training, both statutory and NVQ must be addressed in the next cycle. Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection.RosebankPage 28 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 2 Key findings/Evidence Standard met? The staff training and development programme was examined and detailed the following training which will be rotated for staff throughout the year: Manual Handling, Food Hygiene, First Aid, Medication Administration, Bereavement, Adult Protection, Health and Safety and Fire Safety. Staff files examined reflected that some staff need to undertake statutory training and NVQ training to meet standards. Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. Key findings/Evidence Standard met? This Standard was not assessed at this inspection.0RosebankPage 29 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. NO1 Key findings/Evidence Standard met? The Management of the home has been unstable in the last few months and this has had an impact on administrative systems and care practices. This has led to some unsatisfactory events and standards of record keeping within the home. This is now being addressed and an Acting Manager is in place. Many areas will require a lot of input by the Acting Manager and the staff team to raise and maintain systems and standards. Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection.RosebankPage 30 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 1 Key findings/Evidence Standard met? An annual audit needs to be developed and carried out with an annual development plan drawn from its results and both forwarded to CSCI. Given the highlighted concerns regarding a lack of leadership and deterioration of recording and other administrative systems, it is imperative that all Quality systems are in place and effective to enable future gaps to be identified and addressed. Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection. Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met ? As highlighted previously, financial agreements regarding purchases and all staff files must be in place, up to date, agreed and satisfactory. Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? Some staff statutory training requires updating or undertaking. All equipment, electrical, gas and COSHH (Control of Substances Hazardous to Health) checks were viewed, and found to be up to date and satisfactory. Fire records were examined and reflected there has been 1 fire drill since the last Inspection. The home carries these out at different times of day to ensure Staff and Service Users are aware of procedures in different conditions, and this should continue. Part of the complaint investigated related to the electrical system but this was found to be satisfactory. The upstairs fire door is sticking and requires shaving/levelling. Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? This Standard was not assessed at this inspection.RosebankPage 31 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition Learning Disabilities CommentsComplianceYESCondition 16 Adults CommentsComplianceYESCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateOrla Murphy NA Lorraine Maguire 09/09/04Signature Orla Murphy Signature Signature Lorraine MaguirePublic reports It should be noted that all CSCI inspection reports are public documents.RosebankPage 32 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 11th August 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: Rosebank Page 33 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action plan YESOther: enter details here RosebankPage 34 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Mr Gerard Cunningham of Rosebank confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I Mr Gerard Cunningham of Rosebank am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.RosebankPage 35 Rosebank / 11th August 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000005359.V144838.R01© This report may only be used in its entirety. 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