Inspection on 06/06/06 for Rosecroft

This inspection was carried out on 6th June 2006.

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

The inspector found 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rosecroft 06/11/07

Rosecroft 07/12/05

Rosecroft 17/05/05

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 Norfolk NR8 6DY Lead Inspector Unannounced Inspection 6th June 2006 09:30 Rosecroft DS0000027626.V299267.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 Rosecroft DS0000027626.V299267.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. Rosecroft DS0000027626.V299267.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosecroft Address 39 Carter Road Drayton Norwich Norfolk NR8 6DY 01603 861356 01603 864449 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) www.caremanagementgroup.com Care Management Group Limited Mrs Deborah Jane Johnson Care Home 3 Category(ies) of Learning disability (3), Physical disability (3) registration, with number of places Rosecroft DS0000027626.V299267.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2005 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. The inspection report was seen in the office/sleeping in room and staff said it was available to the public or relatives. The fees for this organisation are based on the amount of care the service users need. Rosecroft DS0000027626.V299267.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection lasting six hours. During the inspection discussions were held with the manager about the progress of the home and whether requirements at the last inspection had been attended to. Records and policies were also examined. Service users were able to talk a little to the inspector but they were also observed as they went about their day. Two staff were interviewed in private and a tour was made of the building. In addition the Commission sent out surveys to the service users to see what they thought of the service. Information on the Commission’s files and contact with the home between visits has also been taken into account in the writing of this report. Not all the national minimum standards were covered in this inspection. What the service does well: The service is very good at ensuring they obtain a lot of information about each service user before they are admitted to the home. This ensures that staff know how to care for them. The care plans are detailed and regularly reviewed to make sure they are still relevant. The service is very focussed on the service users and staff provide as much choice and independence as possible. Routines are flexible, activities are individual where possible and there is usually a choice of food. There is good support in helping the service users stay in touch with their families. Overall staff do their best in promoting the service users interests and were genuinely committed to ensuring they had a good quality of life with some fun and stimulation. The service is very good at monitoring the health needs of the service users and ensuring that they receive appropriate attention from community health professionals. The home has good liaison with other services. The way the home looks after and administers medication is also good. Strong recruitment policies ensure staff have integrity and a good sense of professional values. They convey a strong sense of commitment and enjoyment of the service users. Induction and other training is consistently provided. Rosecroft DS0000027626.V299267.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: This company needs to ensure that service users’ receive interest on their money deposited on their behalf in company accounts. This has been mentioned on several occasions to the company and they still have not made this provision. Because of the needs of the service users, staff are confined in when they can take them out because they need additional support outside the home. With only ever two staff on duty this is not sufficient to take service users out safely. Service users are therefore restricted in their access to community resources and to leisure outings because of the staffing. The organisation needs to sort this out or else look at their criteria for admission to ensure they can fulfil all the needs of the service users. Renovations are taking place in the home but there is still some way to go with better maintenance of the building and the garden. The home’s system for monitoring the service they provide needs some fine tuning so they can see better themselves what improvements they need to make. Rosecroft DS0000027626.V299267.R01.S.doc Version 5.2 Page 7 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 DS0000027626.V299267.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 Rosecroft DS0000027626.V299267.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): 2 The quality of this outcome area is good. The individual needs of the service users and their quality of life issues are assessed before they are admitted into the home. EVIDENCE: Three service users’ files were examined and each contained full assessments of their needs with areas such as mobility, behaviour, daily living skills, communication, employment all covered. Information was in evidence from other agencies involved with the service user’s care and relationships with family was also mentioned. This information was used to make a care plan for staff to follow. Service users are referred via social workers and the admission process involves the service users being visited for assessment purposes before they are admitted. Rosecroft DS0000027626.V299267.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 this outcome area is good. Care plans and risk assessments are in place ensuring that staff know how to help the service users with their needs and wishes. Service users also have good access to their money which in the main is well looked after. However interest must be given when money is deposited in a company account. EVIDENCE: Care plans were in place for each service user generated from the assessment. The plan set out what assistance each service user needed and where specific interventions were necessary. The activities they were involved in were also listed. There were goals for staff to work to like walking a service user more to achieve better mobility and encouraging speech. These goals were reviewed monthly while staff wrote daily notes on what kind of day the service users had spent and with observations about their health, mood and activities. Rosecroft DS0000027626.V299267.R01.S.doc Version 5.2 Page 11 Service users are encouraged to make as many decisions as they can and this was noticed in observing how staff interacted with them. Service users are able to spend their own money as they like though need help in looking after it and in how to budget. Two of the service users have their own bank accounts with all their benefits paid in directly. Evidence of this was seen. This is an improvement since the last inspection when a requirement was made for more transparency but found not to be met when a follow up visit was made. The service users need help to access their money and the home keeps a record of how they use this. All three have money held by the home and accounts are kept of how this is spent. Two records were checked against the cash held and found correct. One service user still has her money held in a company account and it was verified that her benefits were paid into this account. It is acknowledged that it is difficult to open a bank account nowadays and the head office of this organisation have been in touch with the Commission about working hard to remedy this problem. It is accepted that it may be inevitable that company accounts have to be used. However the service user is entitled to some interest on their money and this was not being given. This practice has been highlighted in other reports but this company is still not taking notice. A further requirement is made. Risk assessments were in place on all the care files to ensure the safety of the service users in various situations eg behaviour outside, or how they deal with being in the car. Action is taken to minimise the risks and staff are given instructions about what to do. Rosecroft DS0000027626.V299267.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 this outcome area is good. There is a very good atmosphere in the home with staff really committed to supporting the service users with activities, opportunities and family relationships. They want to do more but cannot because the needs of the service users outside of the home are not met with sufficient staffing or transport. These standards could have been judged as excellent except for these difficulties and the management need to sort out the problems. EVIDENCE: Service users are not able enough to work though one attends the local adult training centre five days a week. The remaining two attend the company’s own skills centre twice a week with staff accompanying them. One staff said she was exploring the possibility of one of the service users attending a local horticultural college. Rosecroft DS0000027626.V299267.R01.S.doc Version 5.2 Page 13 Service users are taken out whenever possible into the community with visits to shops, pubs and parks. One service user was wearing new clothes which she had bought the day before when staff took her for a trip to the city centre. They reported that she was able to visit different shops before making up her mind about what to buy. Service users are also taken for walks in the local community and staff report that people in the street know them well. In order for service users to go out into the community, there has to be enough staff on duty. Currently there are always two staff on duty all day until 7.30. However one of the service users has to have two people with her if she is outside leaving no staff to care for the other service users. This is the position on three days a week (for two days they are all out at skill centres) At weekends when staffing is the same, but all three are at home, one service user needs two staff, another needs to be pushed in her wheelchair and the other needs some support from staff. The way the home is staffed makes this impossible. During the week in order for the one service user who needs two staff to be taken out, the remaining service user has to be taken to another home (the company own five small homes in the area). This clearly depends on the other home having adequate staffing, the service user being willing and on the home having transport to take the service. This is not satisfactory. Staff said they were constantly frustrated because of their inability to leave the premises with the service users without elaborate arrangements with other homes. The lack of transport was also exacerbating the situation as although they shared a vehicle with another home, the other home took precedence because they had to take a service user out to a day centre every day. However even with transport, and the possibility of an outing, the service users would not be able to leave the vehicle because there would be only two staff with them when two were needed for just one of the service users if they got out of the vehicle leaving the others without support. This is clearly unsatisfactory. There must be some way for the organisation to arrange extra staffing at particular times and at weekends to allow service users to leave the premises. A requirement has been made to get this right. There is good support to the service users to maintain links with their families and staff reported that they actively promote this. Two service users are now going regularly to stay with their families, one every six weeks and another every three. The service users were happy about this and were able to tell the inspector about this. The other service user has visits from her relatives and goes out for days with them. A communication book was seen which worked between the parent and the home to ensure continuity and understanding. The home also used the homes transport and staff to take the service users home which is excellent practice especially when parents live at some distance. The home overall did well on liaison with relatives. Service users are friends with service users in other homes and do visit them frequently. The inspector also overheard staff organising an outing to the races for one of the service users with a few friends and staff for his birthday. This was also good practice showing service users were given imaginative choices and opportunities. Rosecroft DS0000027626.V299267.R01.S.doc Version 5.2 Page 14 Service users’ rights to choice and independence are promoted with flexible routines. Service users have a daily bath but can choose their time, meals are flexible and depend on the activities of the day, and service users can spend time in their rooms as they like. Staff were observed to be very interactive with the service users involving or talking to them during their chores and asking for their opinions all the time. Staff conveyed a sense of commitment to the service users wanting the best for them and the way they related and referred to them showed respect and understanding. One service user was deciding what she wanted for breakfast when the inspector arrived and agreed on a big bowl of fruit and yoghurt with juice and a cup of coffee. Another service user told the inspector he had had toast and tea but before that he had had a cup of tea in bed. Staff said they offered the service users a choice and they had breakfast at different times depending when they got up. Lunch was later observed. Service users had it in the garden as it was such a lovely day and the meal of ham and salad looked very appetising. The menus were available and looked varied and nutritious except for the lunches which were mainly confined to sandwiches (though today that was not the case). A recommendation was made for lunches to be more varied. There were no special diets. Overall there seemed to be a lot of choice offered to the service users and a flexible approach by staff to when the meals were served. Rosecroft DS0000027626.V299267.R01.S.doc Version 5.2 Page 15 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 this outcome area is good. Service users receive personal care in a private and dignified way and their health care needs are properly monitored. Medication is looked after appropriately and administered well by staff. EVIDENCE: The service users are all given support in their personal care but are assisted in private. One male member of staff can give extra attention to the male service user. Service users had chosen their own clothes and wherever possible choose their own routines, one going to bed quite early another saying he liked to watch television till late. Equipment like a bath hoist is used where appropriate. Rosecroft DS0000027626.V299267.R01.S.doc Version 5.2 Page 16 There appeared to be good liaison with health professionals. Each of the care records showed appointments with the GP or when the district nurse had been in attendance. There were regular footcare appointments and evidence of continence advice. The physiotherapist was involved with one service user with instructions to keep the person mobile with regular walking. Staff were able to explain how they actioned this. There was also evidence of contact with the local learning disability social worker and the consultant psychiatrist’s outpatient clinic. Visits to dentists, opticians and for appropriate health checks were also seen. Staff also monitored weight and nutrition as well as health and mood. Overall there was good monitoring of health issues. The medication systems in the home were examined. Policies and procedures are in place for the safe storage and administration of medicines and medication is safely locked away. The administration record was checked against the tablets in store and found correct. Staff were correctly signing to show they had been given out. One staff was observed giving out a lunch time tablet and this was carried out correctly. Staff files showed that staff had been trained in the administration of medication and only trained staff had this duty which is good practice. Rosecroft DS0000027626.V299267.R01.S.doc Version 5.2 Page 17 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 this outcome area is adequate. The service users are listened to by staff who will try to make the situation better. However the policies and training on abuse need to be better. EVIDENCE: There is a clear complaints procedure in the service users guide and the address of the Commission is provided. The home has received no complaints since the last inspection. Nor has the Commission. Policies were seen in the staff manual about how to deal with allegations of abuse and what it was. However this was written as a national policy and did not relate to the local Adult Protection Unit where allegations in Norfolk are dealt with. Clearer information about referral to that organisation needs to be in place so staff are clear about the actions they are to take. Nor was there any information about referrals to POVA when staff may have been involved in abuse. Other policies were in place dealing with physical intervention and harassment. Good emphasis is given to the training of staff in the standards of practice expected and what to do if they have suspicions of abuse. However two staff seen had not received such training and this should be given some priority. Rosecroft DS0000027626.V299267.R01.S.doc Version 5.2 Page 18 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 this outcome area is adequate. The laundry facilities are acceptable but there are still improvements needed in the building and garden. EVIDENCE: The home is an adapted bungalow which is located in a residential area on the outskirts of Norwich. It has one lounge diner and each service user has a single room. The home is homely and comfortable and the bath and toilet are equipped with a hoist and handles to make them easier to use. There is a ramp outside into the garden. Two of the rooms have been recently redecorated in lovely colours chosen by the service users. The home has been criticised in past inspections for poor décor and maintenance and it was pleasing to see a start to the renovations had been made. Some radiator covers had also been installed for safety and the handyman was on site making more. The carpets were poor in places and the outside paintwork is extremely poor. The garden also needs to be more regularly maintained. Clearly renovations need to continue to bring the home up to standard. Rosecroft DS0000027626.V299267.R01.S.doc Version 5.2 Page 19 The home is clean and free from any offensive odours. Continence is promoted and special equipment is available where required. The disposal of soiled articles is appropriately dealt with. The home does not have a separate laundry as there are only three service users. The washing machine is in the kitchen. Staff report that there is very little infected linen and the machine has a high temperature facility if required. Overall procedures are in place to keep the home hygienic. Rosecroft DS0000027626.V299267.R01.S.doc Version 5.2 Page 20 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 this outcome area is adequate. Some of these standards relating to staffing were good including the recruitment practice, supervision of staff and the quality of the existing staff bringing benefits to the service users. However it was not possible to judge this section as good overall because there was concern about the amount of staffing in relation to the needs of the service users. EVIDENCE: This being a small home staff were observed in action and showed they were accessible to and approachable by the service users. They involved the service users in what they were doing and were interested and committed. When asked questions about the service users they were very knowledgeable and knew how to best communicate with the service users and how to manage specific behaviours or needs. Two of the staff are reported to have their NVQ certificate which is currently 50 of the staff group which meets the standard. Rosecroft DS0000027626.V299267.R01.S.doc Version 5.2 Page 21 Two staff were on duty on the day of the inspection and this corresponded to the rota. One of the staff was a bank staff but worked in the home quite a lot and knew the service users. Staff reported that they are always on duty with another staff member except in the evening when only one staff is on duty after 7.30. Staff said this evening coverage was satisfactory as the service users go to bed quite early or are quite relaxed in the evening. The use of agency staff has declined recently with the recruitment of more staff. At one stage staffing was a problem giving concern to the Commission and the situation was unstable. However no staff have left the home since the last inspection and the situation is more stable. The use of their own bank staff is also helpful and provides consistency. One male staff is on the rota which is good for the male resident. However there is a problem with staffing not being adequate enough for service users to go out. One service user needs the assistance of two staff when outside and any other service user, either to also go on the outing or to stay at home, requires more staff. However this is not in place and the staff reported that to go out with the service user who needs two staff, the other service users have to be taken to other homes to be looked after – see standard 13. At weekends when three service users are at home, the situation is even worse. One service user returning the Commission’s survey said he did not like living at the home and left some questions blank in the form. His keyworker was spoken to who had helped him fill in the form and she felt he was unhappy because he had to stay in the house with the other service user so much and if he could get out more which he enjoyed, it would help him. That was a good example to show how the staffing was not sufficient to meet the needs of the service users and needs to be improved. A requirement has been made. Two staff recruitment files were checked at random. Both contained references, a criminal records check and medical declaration. Identity documents were in place though photos were missing and need to be in place. Interview notes are now kept and both staff had received a contract and a job description. These practices are now thorough and have been improved in the last year. Both staff files examined at the inspection contained induction training initialled by the trainer and the staff member. The training included fire and health and safety instruction, emergency aid and food hygiene, as well as values and key working. Staff had received other training in adult abuse, medication and epilepsy and their certificates were on file. However there was not a development plan for each staff member nor a training analysis and development plan for the home. This would demonstrate where training needs to be focussed and ensure statutory training was up to date. The moving and handling certificates were not seen in the staff files though the manager reported that this training had been arranged for 13th June. Rosecroft DS0000027626.V299267.R01.S.doc Version 5.2 Page 22 Staff are now being supported well in the home with one to one supervision arranged at regular intervals. Two staff interviewed during the inspection confirmed that they do receive supervision though the bank staff had not received it as frequently as she should. Nevertheless, a lot of progress has been made on this and staff felt they did have someone to turn to and that they were happy in their work. Staff meetings are also now being arranged. Rosecroft DS0000027626.V299267.R01.S.doc Version 5.2 Page 23 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 this outcome area is good. The management structure has improved bringing more stability and more secure systems to the home benefiting the service users. The quality assurance system still needs some work to ensure it works as a way for the home to self monitor and develop the home for the service users, but it is on its way. Health and safety systems are in place to safeguard the service users. EVIDENCE: The manager has only been registered a few months but is experienced in the care sector. She has yet to complete her NVQ4 certificate. She has responsibility for the five small homes in this organisation and is helped by a team manager in each home. The manager has worked hard to bring these homes up to standard and ensure that procedures are complied with and maintained. The service users are now benefiting from a stable staff group. Rosecroft DS0000027626.V299267.R01.S.doc Version 5.2 Page 24 There has been progress on the quality assurance system with questionnaires in place for service users, their relatives and staff. The manager said these had been sent off in May and they were awaiting their return. Regulation 26 visits where the area manager visits monthly and makes reports are also used as part of the quality assurance. Suggestions were made for other standards such as ensuring regular supervision of staff, reviews of service users, a review of the building, an analysis of complaints etc. The Commission will expect the home to analyse their findings from their surveys and measurements against their quality standards and produce an improvement plan for the next year. This is not quite in place but the system has been started. In terms of the health and safety of the service users, policies are in place including the responsibilities of the employers and the needs for training for staff. As mentioned earlier, moving and handling training is arranged for staff and the files confirmed that staff received emergency aid, fire safety and food hygiene as part of their initial training. Risk assessments were seen on all the care files showing that risks to service users were analysed and instructions given to staff on how to deal with them. Hot radiators were being covered to prevent burning. Not all the relevant certificates for servicing were seen on this occasion but overall the inspector felt that the home was acting responsibly in terms of health and safety. Rosecroft DS0000027626.V299267.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 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 3 STAFFING Standard No Score 31 x 32 3 33 1 34 3 35 2 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 3 13 1 14 x 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 x x 3 x Rosecroft DS0000027626.V299267.R01.S.doc Version 5.2 Page 26 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 YA7 Regulation 17 Requirement A record must be kept of all the money received on the service user’s behalf including records of any money deposited on their behalf in the bank and the interest received. Previous timescale 30/06/05, 31/01/06 and 31/03/06. This requirement has now been substantially dealt with except that the interest on the service users money is still not being given A system for reviewing and improving the quality of care provided at the Home must be established and maintained. Previous timescale 31/03/06. This requirement has been partially dealt with but work needs to be continued to make it a useful system The registered person shall consult service users about their social interests and make arrangements for them to engage in social and community activities. In this instance the DS0000027626.V299267.R01.S.doc Timescale for action 31/08/06 2. YA39 24 30/09/06 3 YA13 16(2)(m) 31/08/06 Rosecroft Version 5.2 Page 27 4 YA33 18(1)(a) 5 YA23 13(6) provision of staff and lack of transport is proving to be a barrier to service users going out. The registered provider must ensure that the numbers of staff on duty are appropriate for promoting the welfare of the service users. In this instance more staff is required to enable service users to go out more frequently. The registered person must make arrangements to protect service users from abuse by the training of staff and ensuring that procedures relating to local protocols are in place. 31/08/06 31/08/06 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 4. Refer to Standard YA17 YA24 YA34 YA35 Good Practice Recommendations It is recommended that more variety is brought to the provision of lunches. In this instance too many sandwiches are provided. It is recommended that the renovations continue in a timely manner and that the garden is regularly maintained. It is recommended that recruitment procedures which are generally good are checked to ensure that all staff have photographs on file. It is recommended that there is a staff training and development plan. Rosecroft DS0000027626.V299267.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Norfolk Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Rosecroft DS0000027626.V299267.R01.S.doc Version 5.2 Page 29 - 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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