Inspection on 14/08/06 for Rosebank

This inspection was carried out on 14th August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rosebank 08/08/07

Rosebank 01/02/06

Rosebank 30/12/04

Rosebank 25/08/04

Rosebank 02/02/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Rosebank 58 Bergholt Road Colchester Essex CO4 5AE Lead Inspector Marion Angold Key Unannounced Inspection 14th August 2006 9:35 Rosebank DS0000017921.V308756.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 Rosebank DS0000017921.V308756.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. Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosebank Address 58 Bergholt Road Colchester Essex CO4 5AE 01206 853091 01206 273165 whcock@supanet.com 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) Mr Michael Cockman Mrs Marie Cockman Warren Cockman Care Home 7 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (7) of places Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 7 persons). Persons of either sex, over the age of 65 years, who require care by reason of a learning disability (not to exceed 7 persons). The total number of service users accommodated must not exceed 7 persons. 1st February 2006 Date of last inspection Brief Description of the Service: Rosebank is a detached property, in a residential area, on the outskirts of Colchester town centre. Local shops, the train station and a large supermarket are within a few minutes walk and the town centre can be accessed either by walking or public transport. The home is registered for seven people with learning disabilities and the individuals currently in residence have been there for many years. Most of the accommodation offered is in single rooms on first floor level, to which there is no lift. Residents have a choice of communal areas and an ample back garden. There is roadside parking at the front of the home (restricted Monday to Friday 8.00-10.00 and 16.00-18.00 hours); parking for three cars at the back, is accessed along an unmade track. The current weekly charge for a room is between £386.82 and £479.07. Additional charges are made for chiropody, manicures, hairdressing, toiletries, transport, holidays, outings, meals out, snacks and drinks, additional to the daily menu. Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector went to the home without telling anyone she was going to visit on the morning of Monday 14 August 2006. During this visit the inspector • • • • • talked with residents talked with the deputy manager and some staff watched how residents and staff got along together looked around some of the home looked at some records. The inspector went back to the home on Thursday 17 August 2006 to meet with the manager, Mr Warren Cockman, and to look at staff records. In writing this report, the inspector also used records she already had about the home, including information sent in by the people in charge. Over all, 23 Standards were inspected. • • • 12 Standards were ‘met’. These are the things the home does well for residents. 8 Standards were ‘nearly met’. These are the things that need a little improvement. 3 Standards were ‘not met’. These are the things that need to be a lot better or where what is wrong means that residents could be made safer. What the service does well: These are a few of the good things that the inspector saw and the residents and the staff told her about. What residents said showed that they: • • • • • liked their home enjoyed their meals enjoyed their activities and holidays felt comfortable with staff and the people in charge felt confident that staff and people in charge would listen to them and give them the support they needed What staff said showed that: • They worked well together as a team and that this was having a good effect on the way they shared information and supported residents. Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 6 • • They had meetings with senior staff, or the people in charge, to talk about anything that would help them improve the way they supported residents. The people in charge were prepared to listen and change things, which is a good way to run a home. What the inspector saw and heard showed that: • As far as possible, residents had a say in how they lived their lives and, if it was necessary for staff to make decisions for residents, this was clearly shown in their care plan. Staff allowed residents to take risks but helped them to be as safe as possible. Staff tried to give residents what they liked and treat them as individuals. Staff did the right things to keep people healthy. Staff showed they understood what residents needed, even if the residents could not tell them in words. • • • • What has improved since the last inspection? What they could do better: Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 7 The inspector found that the home could improve the way it supported residents with their own money. For example, residents should have more information about what they have to pay for (on top of their fees). It should be easier to see from the records and receipts that everything has been done properly. To make sure there are no mistakes, the owners of Rosebank should arrange for all the records to be checked by a person who is qualified to do so and does not work at the home. Staff knew what individual residents liked to eat and residents had a say in what was included on the menu but the home should make it possible for them to choose what they fancied sometimes by making alternatives available. Not all staff who were giving residents their medication had received the training they must have. This could mean residents being given the wrong medication. Some areas of the home still needed to be redecorated. Although it had been arranged for this work to be done during the summer, the decorator had not been able to come as planned. The owners must make sure that all radiators are working and that residents cannot burn themselves on them. Two people were on duty to support residents during the day and one person at night. This was enough some of the time but meant that some residents could not go out very often or only for a short while. If the home employed an extra person sometimes, it would mean that residents could do more of the activities in their care plan. Not all of the important information was on staff files. There are some things that the people in charge need to know about staff to make sure they are the right person for the job they are doing. For example, all of the places they have worked in the past and if there is anything that would mean they should not be supporting vulnerable people. They must also make sure that new staff have had enough training and have shown they know how to support residents before they are expected to do so. Although is some ways the home was well run and the people in charge have taken into account what residents think of living at Rosebank, they had not completed all the things they are required to do by law as owners and managers of a care home. 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. Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these Standards were inspected. The quality of service in this outcome area has not been assessed. EVIDENCE: NMS 2 was not inspected because all the residents had lived at Rosebank for a number of years. The manager was in the process of updating the Statement of Purpose and Service Users Guide, which had previously met regulatory requirements. Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 The quality of service in this outcome area has been assessed as adequate, based on the following judgements: • • • Where possible, residents were involved in determining how their needs and goals would be met. Residents were given support to make decisions about their lives but procedures for helping residents with their financial affairs did not fully safeguard their interests. Residents were supported to take risks as part of an independent lifestyle. EVIDENCE: A sample of residents’ records showed that care plans covered a range of strengths, needs, risks and preferences, which had been reviewed and updated, where possible, in discussion with the resident concerned. Staff showed a working knowledge of these care plans and the inspector saw examples of care plans being followed. Residents said that they received the care and support they needed. Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 11 Care plans also specified situations where the person’s rights were infringed because other people were making decisions or doing things on their behalf. Particular residents had signed the records to show they had agreed with decisions made. It was evident that some residents were involved in transactions with their personal money as they had agreed a budget plan and signed most of the entries in the record of transactions. One person came to the office to request their daily allowance. However, some residents had no understanding of money and the providers were acting as appointees for handling their financial affairs and making decisions about expenditures on their behalf. Receipts were not available for all the expenditures recorded and some of the items debited were not included on the home’s list of additional charges. It also was unclear why some residents should have been paying more than others when the cost of something was shared. The registered persons must make sure that residents and their representatives have full and complete information about any extras charged to residents over and above their fees. They should also have the records of incoming and outgoing payments in respect of residents’ personal money independently audited/monitored. Staff allowed residents to take risks but helped them to be as safe as possible. This process included identifying the risks in the individual care plan, talking with the resident about the risk and agreeing the safeguards to be put in place. For example, in relation to an identified risk, one care plan specified that staff would agree with the person a time to get back when they went out by themselves. The inspector saw the person going out and returning according to plan. They had been shown how to use a phone card when they were out so they could contact the home if necessary. Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 The quality of service in this outcome area has been assessed as adequate, based on the following judgements: • • • • • Residents’ ability to take part in appropriate activities was sometimes limited by staffing levels. Residents were participating in the local community. Residents had contact with the significant people in their lives. Residents’ rights were respected and responsibilities recognised in their daily lives. Residents enjoyed their meals and mealtimes. EVIDENCE: Care plans identified the ideal frequency for residents’ preferred activities in the community, such as walks, car rides, excursions to the shops, cafes or cinema and holidays. Activity records for 5/8/06 to 13/8/06 included some of these events, and residents had enjoyed one or two holidays in 2006. However, certain days had no record of activities. Minutes of a staff meeting on 30/6/06 showed that key workers had been reminded of their responsibility Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 13 to ensure that individual activity plans were followed but, it was evident that, with their other responsibilities, staff did not have much time to support residents with outside activities and particular residents could spend much of the day unoccupied. Residents described an enjoyable and active 4 days in the Isle of Wight. Four residents had also spent a week in Minorca. One person said they had talked about holidays and where they would go. Residents, who were able to make informed choices, decided for themselves whether they would go to Minorca or remain at Rosebank. Arrangements for residents to keep in touch with family and representatives had not changed since the last inspection, when the Standard was met. One person, without family or friends, continued to be visited occasionally by an advocate. More independent residents were able to determine their own routines. Night records showed that residents went to bed and got up at varying times, indicating that routines were not imposed on residents, who were less able to direct their own lives. Staff demonstrated respect for residents’ privacy. More independent residents had keys to their rooms and staff had been instructed only to enter residents’ rooms with a good reason and to await a reply. Staff interacted with residents throughout the day but were also aware of individual need for space and quiet. Residents said they enjoyed their meals. One person said they preferred the meals at Rosebank to the meals they had had on holiday. Menus were reviewed at residents’ meetings and individual likes and dislikes recorded in their care plans. Residents were not offered a choice but staff were familiar with their preferences and tried to give them what they liked. For example, they discovered on holiday that one of the residents liked wine and had arranged for this person to have a glass some evenings. Residents also had a stock of drinks and snacks purchased with their own money. All the residents came together for their meals and a relaxed, family atmosphere prevailed. It was evident that residents were used to being presented with what had been prepared for them but would benefit from the introduction of some choice of menu. Meals were flexible to accommodate planned activities but residents, who went out independently, tended to structure the day around meals and drinks and return in time for them. One resident also made a cup of tea during the inspection. Meals brought everyone together and a family atmosphere prevailed with staff providing necessary assistance and encouraging conversation. Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The quality of service in this outcome area has been assessed as adequate, based on the following judgements: • • • Residents received personal support in an appropriate manner. Residents’ health needs were met. Residents were not fully protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Arrangements for giving residents personal support had not changed since the last inspection, with key workers having a significant role in this area. It was evident from discussion and observation that staff encouraged residents to be independent, supported them sensitively with personal care and dressing, respecting their dignity and the privacy of their rooms. Appropriate referrals had been made for physiotherapy and occupational therapy. It was evident from records and discussions that residents’ health continued to be closely monitored. Care plans showed how decisions had been reached in respect of routine screening. Residents who were able to comment said they always received the medical support they needed. Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 15 Following observations made at the last inspection, sample signatures of staff administering medication had been attached to the Medication Administration Records. The home had also attached a photograph of each resident to their individual medication records, for identification. Records of a recent care review showed that medication had been discussed and agreed with the resident concerned. Staff continued to work in pairs to administer residents’ medication. They had to be reminded during the inspection that the person, who administers the medication, must be the one who signs the administration record. One person had signed the medication administration records on 17/8/06, who was not on the list of signatories, had only just started working at the home and not had time to receive adequate training for the task. This arrangement had put residents at risk and resulted in the Commission issuing an Immediate Requirement Notice to the providers. Arrangements for ordering, storing and securing medication were satisfactory, although it was found that, in particular circumstances, such as residents going on holiday, staff were decanting medication into monitored dosage boxes. Only the dispensing pharmacist is meant to do this. If a resident was not well or had difficulty walking, the home contacted the right people for help and advice. They also arranged for people to have their health checked even if they did not appear unwell. This could help to prevent residents from becoming ill. Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The quality of service in this outcome area has been assessed as adequate, based on the following judgements: • • Residents felt their views were listened to and acted on. Residents were put at risk by poor recruitment and training practices. EVIDENCE: The home had received no complaints since 2003. Some residents did not understand the concept of making a complaint but three residents identified staff, who they would speak to, if they were unhappy about something, and expressed confidence that staff would listen to what they had to say and take appropriate action. One resident had written on their questionnaire that they would complain about the food if it did not taste right. The home’s Protection of Vulnerable Adults (POVA) Procedures, mislaid at the last inspection, were available for staff reference. Three staff had attended related training in relation to protecting vulnerable adults since the last inspection. Residents showed they were at ease with approaching staff and those, able to comment, spoke well of the way residents were treated. However, as highlighted under the section on Staffing, management had not taken all the necessary steps to make sure that the people recruited to support residents were fit and trained to do so. Also, procedures for helping residents with their financial affairs did not fully safeguard their interests. Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The quality of service in this outcome area has been assessed as adequate, based on the following judgements: • • Residents were living in a homely, comfortable and safe environment, for which necessary improvements had been planned. The home was clean and hygienic. EVIDENCE: No changes had taken place to the environment since the last inspection. Residents’ holidays had been planned to coincide with the redecoration of the first floor hall and utility/laundry room but the decorator cancelled at short notice. This work had been re-scheduled to 9/10/06. Residents felt their home was fresh and clean and this was the case on the day of inspection. Action had been taken to address the requirements arising from an environmental health inspection. One wheelchair user was dependent on taxis for outings because, although the back of the house was accessible, it was served by an unmade road, unsuitable Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 18 for wheelchairs. The inspector was informed that there were plans for a proper road to be built but this was outside the providers’ control. The manager agreed to review risk assessments relating to radiators remaining without covers. Since the last inspection, hand driers and paper towels had been introduced to reduce the risk of cross infection, although a communal hand towel was still in use in the staff toilet. This should be removed. Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 The quality of service in this outcome area has been assessed as poor, based on the following judgements: • • • Residents were supported by an effective staff team, although minimum staffing levels sometimes impacted on the quality of their lives. Residents were not always protected by the home’s recruitment and training practices. Residents were benefiting from well-supported and supervised staff. EVIDENCE: Residents who were able to comment said that staff were always available to help when needed. However, the home was operating with minimum staffing levels, which had impact on the quality of life for residents who were more dependent on staff support for all their activities. Typically, two people covered each daytime shift, one of which might be the manager or provider and their duties included cleaning, shopping, meal preparation and record keeping. As one of the two staff needed to remain on the premises at all times there was limited scope for meeting the social and recreational needs of 5 residents, who had to be escorted or supported with outings. Further reference to this is made under the section headed ‘Lifestyle’. Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 20 Only one member of staff was on duty for the night shift but records showed that residents mostly slept through the night. No one had got up during the night of 16/7 August 2007. A second person came on duty at 7.30 am to support residents getting up and the manager stated that the providers were on call during the night and could be at the home in five minutes, if necessary. It was evident that one of the providers recently had provided additional support through the night when a resident became unwell. As recommended at the last inspection, a sound monitor was in use for two residents, who were unable to make their needs known during the night. Staff on duty showed familiarity with the particular needs of residents and their non-verbal communication. For example, they knew that one person’s behaviour meant they wanted to be in a quiet place and took appropriate action. Residents expressed confidence in the support they received from staff. Only one of the current staff team had completed the recognised vocational training for care staff (National Vocation Qualification in care Level 2) although the manager reported that 4 staff had made applications to start training and had completed the Learning Disability Award Framework (LDAF) training, in preparation for the NVQ Award. The registered persons should ensure that this training is progressed so that the home achieves the recommended ratio of qualified staff. Records were inspected for the 3 newest members of staff. These included the required Criminal Record Bureau disclosures and written references. However, only one had a complete application form; one of the others had gaps in the employment history, which needed to be explored. In one case the sections on education and work were blank. These omissions showed a need for a more robust approach to recruitment to ensure that residents were in safe hands. There were no records for a close relative of the providers and manager, who worked intermittently at the home and had accompanied residents on holiday. This constituted a serious breach of the Care Homes Regulations 2001, which specify the information and documents, which must be obtained in respect of all persons working at a care home. Two new staff had attended a 2-day external induction course covering all the health and safety topics and protection of vulnerable adults training. Information supplied with this training evidenced that all these areas had been covered. The manager was informed about the new Common Induction Standards, recently introduced by Skills for Care and was advised to access the Skills for Care website to ascertain how this new package linked with the Learning Disability Award Framework. Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 21 A new recruit to the staff team had covered the night shift alone after one experience of shadowing a colleague and no formal induction training. This person had no experience in care. They had also been involved in administering medication, as evidenced by their signature on the Medication Administration Records. This arrangement had put residents’ safety at risk and the Commission’s concern was sufficient to warrant an Immediate Requirement Notice in respect of these breaches of regulation. Records for another member of staff suggested that they had only attended protection of vulnerable adults training, although the inspector was informed that they had completed an induction programme with one of the providers. It was reported that, since the last inspection, staff had variously attended courses in relation to health and safety, medication, first aid, food hygiene and the protection of vulnerable adults. The home also had a series of training videos, covering a range of topics, but there was no evidence that these were being used systematically as part of planned approach to training. Staff affirmed the strength of their team and positive working relationships between junior and senior staff. They spoke positively about their experience of one-to-one supervision. Records sampled were for newer staff but, one person, who had been working several months at the home, had received regular and appropriate supervision. Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The quality of service in this outcome area has been assessed as adequate, based on the following judgements: • • • In the main, service users were benefiting from a well run home but, in some respects, management were not meeting regulatory requirements and compromising the safety and welfare of residents. Residents’ views were considered in the monitoring, review and development of the home. The health and safety of residents were put at risk by inconsistencies in provision of health and safety training for staff. EVIDENCE: The Manager continued to be involved in training for much of the week. The deputy manager and registered providers shared the day-to-day management of the home with the registered manager, each having particular areas of responsibility, including monitoring care practice. Staff indicated that registered persons were receptive to ideas and suggestions. However, when Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 23 the manager, deputy manager or providers were on duty, they counted as one of the two people covering the shift. This inevitably compromised both the time given to management and residents. A number of the shortfalls identified in this report involved key management tasks, such as recruitment and training. The manager had completed a Quality Assurance report, in October 2005 based on the views of residents and broadly covering the National Minimum Standards. Although the report included shortfalls identified through inspection and a brief plan of action, the home had not, in fact, fully met the requirements made in CSCI inspection reports. Observation and records showed that, in the main, the registered persons had continued to make appropriate arrangements to promote the health, safety and welfare of people living and working at the home. The manager was introducing changes, following attendance on a course entitled ‘Safer Foods’, led by the Environmental Health Department. He was also in the process of updating all health and safety policies. Action had been taken to comply with the requirements of an Environmental Health inspection. Records evidenced regular testing of fire equipment and staff being reminded of evacuation procedures. One resident said they had also been informed about fire safety. The First Aid Box was adequately stocked. However, as recorded under the section headed ‘Staffing’, the health and safety of residents were put at risk by inconsistencies in provision of mandatory health and safety training for staff. Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 1 35 1 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 2 X 2 X X 2 X Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 YA7 Regulation 17 Sch 4 Requirement Timescale for action 31/10/06 2. YA20 YA23 13 3. YA24 13, 23 The registered persons must make sure that residents and their representatives have full and complete information about any extras charged to residents over and above their fees. 15/09/06 The registered persons must be able to evidence that all staff administering medication have received accredited training in the areas covered by Standard 20.10. THIS REQUIREMENT HAS EXCEEDED AGREED TIMESCALES FOR ACTION SINCE THE INSPECTION ON 16/08/05. The registered persons must ensure that arrangements for the recording, handling, storing and administration of residents’ medication meet safety requirements. The registered persons must 30/09/06 ensure, so far as reasonably practicable, that all parts of the home, to which service users have access, are free from hazards to their safety. They must also ensure that the home is well maintained. THIS REQUIREMENT HAD EXCEEDED DS0000017921.V308756.R01.S.doc Version 5.2 Rosebank Page 26 4. YA12 YA32 YA35 YA34 18 5. 17 Sch 4 19 Sch 2 6. YA37 YA39 43, 44 AGREED TIMESCALES FOR ACTION BUT WAS BEING PROGRESSED AT THE TIME OF INSPECTION. The registered persons must ensure that residents are supported by sufficient numbers of trained and qualified staff. The registered persons must ensure that they carry out all required checks before prospective employees begin work at the home and retain all the information and documentation stipulated under these regulations. THIS REQUIREMENT HAS EXCEEDED AGREED TIMESCALES FOR ACTION SINCE THE INSPECTION ON 16 AUGUST 2005. The registered persons must ensure that the home complies with the Care Homes Regulation 2001and that action is progressed to implement requirements identified in CSCI inspection reports. 31/10/06 15/09/06 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA7 YA17 YA32 Good Practice Recommendations The registered persons should arrange for records, relating to all incoming and outgoing payments of residents’ money to be independently audited/monitored. It is recommended that the registered persons introduce some choice of menu. The registered persons should ensure that 50 of staff have achieved, or are in training for, the National Vocational Qualification in care, Level 2. Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Rosebank DS0000017921.V308756.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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