Inspection on 17/05/05 for Rosecroft

This inspection was carried out on 17th May 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Rosecroft 06/11/07

Rosecroft 06/06/06

Rosecroft 07/12/05

Rosecroft 16/12/04

Rosecroft 15/04/04

Rosecroft 16/09/03

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

CARE HOME ADULTS 18-65 Rosecroft 39 Carter Road Drayton Norwich NR8 6DY Lead Inspector Dot Binns Unannounced 17 May 2005 3.00pm The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Rosecroft I55 S27626 Rosecroft V229466 170505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Rosecroft Address 39 Carter Road Drayton Norwich NR8 6DY 01603 861356 01603 864449 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Care Management Group Limited Andrew John Nelson Care Home 3 Category(ies) of Learning Disability (3) registration, with number Physical Disability (3) of places Rosecroft I55 S27626 Rosecroft V229466 170505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three (3) people with Learning Disability may be accommodated. 2. Three (3) people with Physical Disability may be accommodated. 2. The total number not to exceed three (3). Date of last inspection 16 December 2004 Brief Description of the Service: Rosecroft is a care home providing personal care and accommodation for up to 3 younger adults with a learning disability. The service user may also have a physical disability. Care Management Group Limited whose registered office is located in London owns Rosecroft and four other small homes in Norfolk There is quite a lot of sharing of procedures and records and service users in each home visit each other. The home is located in a residential area on the outskirts of Drayton and close to the city of Norwich. Local amenities, shops and pubs are also close by. The home consists of an adapted bungalow. All bedrooms offer single occupation, however one of the bedrooms is below 9.3 sq. metres. None of the bedrooms have en-suite facilities. There is ample communal space. Limited off-road parking is available. Rosecroft I55 S27626 Rosecroft V229466 170505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection lasting two hours. The purpose of the inspection was to see how the Home operated on an ordinary day. Two staff were on duty when the inspection began and a team leader who floats between the five small homes of this organisation arrived about half way through. Some of the requirements from the last inspection report were discussed and several records were examined. Staff were spoken to together and the service users were observed in the lounge with some interaction between them and the inspector. What the service does well: What has improved since the last inspection? Fire safety training is now offered regularly with staff and service user drills. The formal supervision of staff has started with staff seeing a manager on a one to one basis every two months to discuss their work. The complaints procedure has been sent out to relatives to ensure they know what to do if they have a concern. Rosecroft I55 S27626 Rosecroft V229466 170505 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Rosecroft I55 S27626 Rosecroft V229466 170505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Rosecroft I55 S27626 Rosecroft V229466 170505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards were inspected. EVIDENCE: Rosecroft I55 S27626 Rosecroft V229466 170505 Stage 4.doc Version 1.30 Page 9 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 standard(s) 6,7 and 9 Care plans are in place outlining the assessed and changing needs of the service users. Records about the service users’ money are not available and this fails to meet the regulations which are in place to protect the service users. Service users are supported to take risks and be as independent as possible. EVIDENCE: Two of the care plans were inspected and found to contain detailed information about the service user showing what their abilities were and what assistance they needed. The care plan was regularly reviewed. Staff also wrote full daily reports outlining any events, activities and mood as well as health aspects. These records gave a clear picture of what happened to the service users and how they were cared for. They were good records. The care plans also contained appropriate risk assessments for instance, one on self harm was seen. This weighed up the rights and risks involved and set out what needed to be done to limit the risk. Both files had several risk assessments covering areas where there may be a danger for the service user. Rosecroft I55 S27626 Rosecroft V229466 170505 Stage 4.doc Version 1.30 Page 10 Again this is good practice as it shows the staff are thinking through the care needed and the actions required. Only one aspect of standard 7 was inspected and that was to do with how the Home looked after the service users’ finances. There were no records in the Home and staff said they only received the personal allowances of service users when they needed them. They reported that the service users’ benefits go to the manager of the main home who hold the bank statements and then the accounts are held at one of the group homes. This is not acceptable as the Home is unable to account for how money belonging to the service users is spent and the accounts were not able to be inspected. This is not acceptable and a more transparent system must be put in place. Rosecroft I55 S27626 Rosecroft V229466 170505 Stage 4.doc Version 1.30 Page 11 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 standard(s) 14,16, and 17 There are appropriate leisure facilities provided for the service users. The service users rights are respected and staff understand their responsibilities for taking decisions on their behalf. The food offered to service users is nutritious and to their taste. EVIDENCE: Service users are unable to go outside unaccompanied and depend on staff assisting them to engage in leisure facilities. Staff reported that they take it in turns to take service users out into the community every day. Two service users are able to walk and are taken to the shops. One person went swimming the day before the inspection. Activities at home are also provided like music and games and some housework. Special outings are provided like visiting Sea Life in Gt Yarmouth or going out for lunch. Two of the service users attend some outside centres, one going five days a week to a day centre and the other having weekly exercise sessions. This activity demonstrated that appropriate activities were considered a necessary part of the care of the service users. Rosecroft I55 S27626 Rosecroft V229466 170505 Stage 4.doc Version 1.30 Page 12 Service users need full personal care and are not able to exercise much independence. They do have their own rooms but usually need to be overseen by the staff in the communal rooms. However there was evidence in the records and from what staff said that routines were flexible and the service users could decide themselves when to get up. Staff confirmed that they adapt to what the service users want and could tell if they were tired and needed to go to bed. Within the limits of their disabilities service users rights are respected. Menus are decided by the staff but based on what they know the service users like. One person is on a low fat diet for weight reduction. On the days menu for the evening meal and seen being prepared was chicken supreme and rice. Lunch is a snack and the staff said this had been baked beans on toast with a piece of fruit. One service user has a packed lunch at the day centre. Breakfast was described as cereals and toast with a cooked breakfast at weekends. It was not possible to talk to the service users but on the evidence of staff and what was seen being prepared the food looked nutritious. Rosecroft I55 S27626 Rosecroft V229466 170505 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19,20, The health needs of the service users are being met. There are safe procedures and facilities in place to deal with service users’ medicine. EVIDENCE: The service users need full personal support from staff and rely on staff to attend to their healthcare needs. The records showed that there was good liaison with the GP and there was evidence of service users attending hospital appointments, seeing an optician and of involvement by the learning disability nurse in their assessment and review. The files also showed staff were monitoring diet and exercise. The system for looking after medication was inspected. Drugs were appropriately locked up and the record showed that they were administered correctly. The system is being transferred to the monitored dosage system supplied by Boots so extra training is being provided to ensure safety. Rosecroft I55 S27626 Rosecroft V229466 170505 Stage 4.doc Version 1.30 Page 14 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 standard(s) 22 Procedures are in place to attend to concerns of the service users and their relatives. EVIDENCE: The complaints procedure was seen and it contains the address of the Commission. Staff reported that the relatives of the service users had received copies of the procedure on the service users behalf. A record of complaints was also seen. It was not possible to interview service users because of their disability to see whether they felt listened to. However the Commission has not received any complaints about this Home. The links with community nurses and the social services learning disability team (seen in the records) mean that others outside the Home are monitoring the needs of the service users and provide an extra safeguard for them. Rosecroft I55 S27626 Rosecroft V229466 170505 Stage 4.doc Version 1.30 Page 15 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 standard(s) None of these standards were inspected. EVIDENCE: Rosecroft I55 S27626 Rosecroft V229466 170505 Stage 4.doc Version 1.30 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34,35 and 36 Service users are supported by competent and trained staff who benefit from managerial support. The numbers of staff on duty ensures the staff team are effective. Documentation is not in place in the Home. EVIDENCE: There were two support workers on duty at the time of the inspection. This corresponded with the rota. The rota showed that there were consistently two staff on duty throughout the day (in two shifts) until 8pm when one staff was on duty. At 10pm the sleeping in staff came on duty. This was considered to be satisfactory allowing staff to have time with one service user as required and for the day to day running of the Home. Staff confirmed that sometimes three staff were on duty to cater for a special event eg. a planned outing. Staff talked knowledgably about the service users indicating they were aware of their particular needs and were able to communicate with them. Interaction between the staff and service users was noted to be warm and attentive. Rosecroft I55 S27626 Rosecroft V229466 170505 Stage 4.doc Version 1.30 Page 17 All staff were reported to be over 18 years of age. Both staff on duty had worked in the Home for about a year. In terms of the Home’s recruitment policy, it was not possible to check the staff records as these are held at the organisation’s main home. These will be inspected at the next inspection. Staff did confirm that they had had to provide references and criminal records checks before recruitment and had been interviewed. Staff also confirmed that they had received induction training, completing a workbook and shadowing an experienced colleague for a time. There was however no documented evidence of this at the Home nor was there any training assessment and profile of each staff. Staff did confirm they receive individual supervision sessions with their manager. Again however this documentation is not held on the premises. Evidence of this practice will be inspected at a later date when the records will be expected to be available. The team leader for the group of homes arrived during the inspection and also confirmed much of the above regarding staffing. She also confirmed that in the Home’s staff group, one staff had completed her NVQ2, one the NVQ3 and another was in the process of doing the NVQ3. Overall from talking to staff, it appeared that the staff were well trained and supported and the inspector had no reason to distrust what they said. There were however no written records to support what was said. Rosecroft I55 S27626 Rosecroft V229466 170505 Stage 4.doc Version 1.30 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Training for staff has improved but there are still concerns regarding the fire precautions. EVIDENCE: A requirement had been made at the last inspection for staff to receive fire safety training at least twice a year. The record was inspected and it showed that fire drills take place every month with the service users and staff also have drills on a regular basis. A day’s fire training has also been held. A recent fire officer’s report recommended the installation of an emergency lighting system. This has not been taken up by the Home. The fire officer also asked for all exits to open easily from the inside and without a key. Currently the French windows from the activity room and the back door need keys for opening. A requirement was made at the last inspection by the Commission for this to be addressed and the home agreed to comply by January 2005. This has not happened and needs to be dealt with as soon as possible. Rosecroft I55 S27626 Rosecroft V229466 170505 Stage 4.doc Version 1.30 Page 19 Staff confirmed that they had received other health and safety training such as food hygiene and moving and handling. The accident record was also checked Rosecroft I55 S27626 Rosecroft V229466 170505 Stage 4.doc Version 1.30 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 1 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x x x 3 x 3 3 Standard No 31 32 33 34 35 36 Score x 2 3 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Rosecroft Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x I55 S27626 Rosecroft V229466 170505 Stage 4.doc Version 1.30 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 17 Requirement A record must be kept of all money deposited by a service user or received on the service users behalf. The record must also include the purpose for which any money was spent on behalf of the service user and any money returned to the service user. A record of all persons working at the care home including the information listed in Schedule 4 and Schedule 2 must be kept and available for inspection at any time. The registered person is required to fit a quick releasing lock to the emergency exit door leading to the back garden. This was a requirement of the last inspection report and had a timescale of 31.1.05 which has not been met. Timescale for action 30.6.05 2. 34, 17 30.6.05 3. 42 23(4)(b) 30.6.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Rosecroft I55 S27626 Rosecroft V229466 170505 Stage 4.doc Version 1.30 Page 22 No. 1. Refer to Standard 32,35 and 36 Good Practice Recommendations It is recommended that the training assessments and profile of each staff and the induction course covered is kept in a record in the Home. There should also be evidence that supervision is taking place.f Rosecroft I55 S27626 Rosecroft V229466 170505 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 3rd Floor Cavell House St Crispins Road Norwich NR3 1YF 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. 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