Inspection on 19/03/04 for Rosebank

Care Homes For Adults (18 ­ 65)Rosebank52 Leyland Road Southport Merseyside PR9 9JQUnannounced Inspection19th March 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) Vacant at present. 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 No YES 5th & 6th June 2003 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 319th March 2004 10:00 am Miss Orla MurphyID Code073536Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different Not Applicable perspective to the inspection process Name of Specialist (e.g. Not Applicable Interpreter/Signer) (if applicable) Name of Establishment Representative at Mr Gerard Cunningham. the time of inspectionRosebankPage 2 CONTENTSIntroduction to Report and Inspection Inspection visits Description of service Part A: Summary of Inspection Findings Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods Used & Findings The Standards. 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: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration ( if applicable) Lay Assessors summary (where applicable) Providers Response Providers comments Action Plan Providers agreementRosebankPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC) 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 NCSC in respect of Rosebank. The inspection findings relate to the National Minimum Standards (NMS) for Care Home 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 NCSC 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 · Report of the Lay Assessor (where relevant) · 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 and the Children Act 1989 as amended. 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 have, in addition, a mental health difficulty. Nursing Care is not provided. A private individual, Mr Gerard Cunningham, owns the home. Mrs Carol Hall was the Registered Manager but has moved to another position outside the company. Mr David Hall was the Deputy Manager and is now Acting Manager. 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 inspection took place on 19th March 2004. It found that most of the National Minimum Standards assessed were met and that some of the requirements from the last Announced Inspection had been actioned but some remain unaddressed. Some Care Plans have improved and the Home Staff continue to work towards meeting the NMS. Only core standards were assessed, as this was an unannounced Inspection. This report should be read in conjunction with the last Announced Inspection report (05&06/06/03) to find 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) 2 out of the 2 Standards assessed were met. The current Service User group are 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 seen were detailed, appropriate and satisfactory. Evidence suggests that systems are now in place to provide adequate information and opportunities to any prospective Service Users. Contracts were in place for those Service Users case tracked. Individual needs and choices (Standards 6-10) 2 of the 3 Standards assessed were met. Two care plans were case tracked. The home is 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 type. The plan seen in the new format was positive and achievable for the Service User concerned. All risk assessments seen for both Service Users case tracked were up to date & satisfactory.RosebankPage 6 Lifestyle (Standards 11-17) 3 of the 3 Standards assessed were met. The Service Users case tracked had planned individual and group activities, which have been determined through the assessment and planning process. Service Users spoken with were enthusiastic about their lives and were involved in activities with staff at the time of the Inspection. Personal & Healthcare Support (18-21) 2 of the 2 Standards assessed were met. Service Users have detailed annual health assessments, carried out with local community services and the homes previous Manager. Procedures and observations reflected that staff are positive and sensitive in supporting Service Users in these areas. Environment (Standards 24-30) 2 of the 3 standards assessed were met. The environment is generally comfortable and homely but is showing signs of wear and tear in places. The Provider is reported to be planning a redecoration schedule for the home from April 2004. 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) 3 of the 3 Standards assessed were met. Staff files were randomly checked and were found to contain all the required information and checks. Staff training was evidenced on the files checked and the home has a Training & Development Plan, which was seen 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 2 Standards assessed were met. The Manager left her post in the last few months. The Deputy Manager is currently acting in the Managers position and will have to submit an application to CSCI (formerly the NCSC) to become the Registered Manager. 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. No. Regulation Standard Required actions Timescale for action Mental Health Training should be cascaded to staff and recorded. 1 18 YA35 NVQ training for care staff and the Manager should continue to attain future targets identified in the NMS. The homes annual audit should be carried out and a copy of the outcomes sent to the NCSC. 1st September 2004 & 1st April 2005224YA391st July 2004.Action is being taken by the National Care Standards Commission 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).MET (YES/NO)RosebankPage 8 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 and recommendations 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, the National Minimum Standards and the relevant sections of the Childrens Act. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action 1 24 YA39 The homes annual audit must be carried out and a copy of the outcomes sent to the NCSC. Must ensure all care plans are transferred to the IPP format and reviewed 6 monthly. Must ensure all staff receive POVA training. Must produce a planned schedule of redecoration with timescales to address wear and tear in the home. Must submit an application for an individual to CSCI to become the Registered Manager. Must ensure Providers visits are carried out monthly and a report produced from the visit. 1st July 2004 1st August 2004 1st September 2004. 1st September 2004. 1st June 2004. 1st May 2004.215YA6323YA35424YA245 68 26YA37 YA39RosebankPage 9 RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) 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.PART BINSPECTION METHODS & 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: YES YES NA YES YES NO YES NA YES YES YES YES NO YES NA NA NA YES YES YESRosebankPage 10 Number of Service Users spoken to 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 seen CRB check for the Manager seen 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)3 0 0 YES NO YES YES X 0 19/03/04 11.20 AM 2.75The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards 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 11 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, 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 Key findings/Evidence This Standard was not assessed at this inspection.Standard met?0Standard 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? The home carries out its own initial assessment on Service Users, which is in addition to any assessment provided by a placing authority. Many original assessments on file were seen previously. These are from several years ago and were limited, but the home has developed good levels 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 12 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. 3 Key findings/Evidence Standard met? Terms & conditions were seen for both the Service Users case tracked. These were examined and found to contain all the required detail including accommodation, facilities and fees to be paid. Both documents were signed by the Service Users and a member of their family and were dated appropriately.RosebankPage 13 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 as part of the inspection. Both these care plans were examined. 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. 1 Care plan was focussed on two or three pertinent needs in the individuals life. Needs ranged from personal hygiene to daily living skills. Aims were focussed on becoming more independent in these areas within the individuals abilities. One IPP was also examined and this was far more detailed and encompassing; providing staff with a very clear idea about the Service Users history, personality, wishes and aspirations in addition to specific areas of need and goals relating to these. 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. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection. 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 14 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. 3 Key findings/Evidence Standard met? Both Service Users files that were tracked all contained risk assessments both within the care plan and annual health care assessments. Risks identified ranged from relating to manual handling, the environment and behavioural issues/ personal safety.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. Service Users spoken with previously 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 seen.RosebankPage 15 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. 3 Key findings/Evidence Standard met? Service Users living at Rosebank have varied interests and occupations. The two Service Users case tracked had very different interests; one choosing to be more solitary and the other accessing a range of activities. Home staff work closely with local services such as Link to access opportunities for individuals. One Service User was enthusiastic about his activities & interests when discussed with the Inspector. He stated going out (with staff) was great and, I love it sic. Service Users range in age and needs. This means that some have more active lives than others due to choice and availability of appropriate services. The home has a vehicle for use which all have reported to increase access and independence for the Service User Group. 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 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 16 Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to and choose from a range of appropriate leisure activities. 3 Key findings/Evidence Standard met? Records seen and discussions with Service Users and (previously) parents revealed that individuals attend the local theatre, bowling, sports facilities, restaurants and pubs with staff support. The homes people carrier also provides opportunities for Service Users to access the local area and further afield. Service Users have varied requirements and wishes in relation to holidays and have chosen various short trips/holidays or day trips. The two Service Users case tracked held care plans/IPPs and risk assessments in relation to accessing the community. 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). 3 Key findings/Evidence Standard met? There is a good level of family involvement in the home and the home has a newsletter, which is sent out to interested parties. The Provider holds regular meetings with families also. Family members always attend Announced Inspections to give feedback to the Inspector. Many Service Users visit family & friends and some evidence of this was within the daily records of those Service Users case tracked. 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. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection.RosebankPage 17 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 procedure 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? The two Service Users care plans seen reflected they were more independent in their personal care. Discussions with these Service Users confirmed this but both were aware support was available from staff & stated they would ask for help. Service Users range in the level of input and support they need. One Service user has technical equipment to support in bathing and lifting. Individual preferences and requirements in relation to personal care were recorded on the two files seen. Staff were observed supporting Service Users discreetly and respectfully. The home operates a key worker system and the Manager previously reported that Service Users chose their key workers, which lends to a positive relationship. Service User satisfaction questionnaires confirmed they had been involved in choosing their key workers. 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 & Emergency during last 12 months No of service users with pressure sores at the time of inspection (from information taken from care notes) 003 Key findings/Evidence Standard met? Each Service User case tracked was found to be registered with a local GP. Previous inspections revealed all Service Users were registered locally. The homes Manager works closely with the local Learning Disabilities Community Nurses. 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.RosebankPage 18 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 assessed at this inspection. 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 19 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 times-scales 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 NCSC Percentage of complaints responded to within 28 days 1 1 0 0 0 1 100 3 Key findings/Evidence Standard met? There has been one complaint since the last announced inspection. This was investigated by the NCSC and was upheld. The home has taken the required action to address the issue. The home has its own complaints procedure, which was seen and was satisfactory. A newsletter and family meetings are in place regularly and it is hoped concerns can be voiced at this forum, where required. Service Users families always attend the homes announced inspection and spend a lot of time giving the Inspector feedback & sharing their opinions.RosebankPage 20 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 year. Criminal Record Bureau records for both staff files examined were in place and satisfactory. All Staff must undergo POVA training as part of basic required training within care environments. The training schedule seen on the day of the Inspection details Adult Protection training on offer for staff between 25/03/04-12/05/04.RosebankPage 21 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? One Service User who requires aids and adaptations is accommodated on the ground floor. The Acting Manager stated there is a plan to implement a programme of repair and redecoration in this cycle, which will address the parts of the home that are showing obvious signs of wear and tear. The home is generally comfortable and homely and Service Users were observed accessing all areas of the home freely on the days of the inspection.RosebankPage 22 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. YES NO NO X X X X Standard met? 0 X XX X X XStandard 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. Key findings/Evidence This Standard was not assessed at this inspection. Standard met? 0RosebankPage 23 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. 2 Key findings/Evidence Standard met? There are 5 WCs for Service Users use in addition to 4 bedrooms, which have en suite facilities. One assisted bath is located on the ground floor with 2 bathrooms and two shower rooms on the first floor. These areas were seen and would benefit from redecoration. 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. 2 Key findings/Evidence Standard met? There are two communal areas for Service Users use. Activities and facilities are available in both and Service Users were observed accessing these during this and previous inspections. As stated previously some parts of these areas are showing signs of wear and tear and need redecoration. Seating within the communal areas is appropriately arranged given the large group and doesnt appear rigid or impersonal. Private facilities are limited to the homes office or individuals bedrooms. 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. 3 Key findings/Evidence Standard met? One Service User requires aids & adaptations and a ground floor bedroom. An assisted bath and mobile hoist is available within the home. Physiotherapy and Occupational Therapy support and input has been accessed by the home. Accommodation on parts of the upper floor would not be accessible to individuals with significant mobility difficulties. This does not affect current Service Users but should be considered where any prospective Service Users are concerned or the needs of the current group change.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 inspection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 0 Key findings/Evidence Standard met? This Standard was not assessed at this inspection.RosebankPage 24 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.RosebankPage 25 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. 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 XX0Key findings/Evidence This Standard was not assessed at this inspection.Standard met?0Standard 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. 3 Key findings/Evidence Standard met? The Staff rota was examined and was found to meet requirements set by the previous regulating authority. Discussions between the NCSC and the Proprietor following the last announced Inspection led to an agreement that some ancillary hours would be reduced to add more efficiently to care. This will continue to be monitored by the regulating authority. Three care staff are on duty at all times in the day. Two staff are on duty at night. Sufficient Staff were observed supporting Service Users on the day of the Inspection.RosebankPage 26 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. 3 Key findings/Evidence Standard met? Two staff files were examined on the day of the Inspection. They were found to be up to date and contained 2 satisfactory references, copies of passports & birth certificates, Health declarations, application forms, job descriptions, criminal record checks, evidence of qualifications/training and photographs. The home has taken care to develop these records and this was evident in the records seen. The home has satisfactory procedures in relation to recruitment and employment. 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. 3 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 & Safety and Fire Safety. The first round of training was planned for the period between 25/03/04 and 12/05/04. An external training provider is providing all of this training and written confirmation was seen. Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? The Homes Acting Manager is available, on shift, on a full time basis. Staff interacted positively and professionally with each other, Service Users and Management on the day of the Inspection. The Acting Manager is carrying out formal staff supervision with staff regularly and this should be continued. Staff files reflected staff inductions and supervision from Managers.RosebankPage 27 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 or equivalent. NO2 Key findings/Evidence Standard met? The Acting Manager is currently undertaking Level 4 in NVQ, which he hopes to complete later this year. The previous Manager left the home in December 2003 and the Provider must now submit an application to CSCI identifying a Manager to undergo the Fit Person process and become the Registered Manager of Rosebank. The Acting Manager demonstrated a commitment to the Service Users and to addressing care planning and other recording issues in the next cycle.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 28 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. 2 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. Service Users and family satisfaction questionnaires are in use at the home and these were all seen at the last inspection. These should be continued as part of annual Quality monitoring. Regulation 26 visits were not fully available and the Provider should ensure these are carried out m monthly with a report generated.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 Younger Adults. 3 Key findings/Evidence Standard met? The homes policy & procedure has been developed and is in line with Appendix 2 of the NMS. Induction records on staff files demonstrated that policies/procedures are addressed with new staff as part of the induction process. 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. 0 Key findings/Evidence Standard met ? This Standard was not assessed at this inspection.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. 3 Key findings/Evidence Standard met? All equipment, electrical, gas and COSHH checks were seen, and found to be up to date and satisfactory. Fire records were examined and reflected there have 4 fire drills since the last announced Inspection. The home carries these out at all times of day to ensure Staff and Service Users are aware of procedures in different conditions. Times of drills should always be recorded clearly with persons present listed.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 29 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateOrla Murphy Lorraine Maguire 7/04/04Signature Orla Murphy Signature Signature Lorraine MaguireRosebankPage 30 PART D(where applicable) Not ApplicableLAY ASSESSORS SUMMARYLay Assessor Date Public reportsSignatureIt should be noted that all NCSC inspection reports are public documents.RosebankPage 31 PART EE.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 19th March 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the NCSC in response to provider comments: Rosebank Page 32 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. E.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 33 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.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 E.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 34 - 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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