Inspection on 14/03/07 for Rosehedge

This inspection was carried out on 14th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rosehedge 28/09/07

Rosehedge 09/03/06

Rosehedge 04/11/05

Rosehedge 06/12/04

Rosehedge 28/06/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Rosehedge 42 Thingwall Lane Broadgreen Liverpool Merseyside L14 7NY Lead Inspector Mrs Janet Marshall Key Unannounced Inspection 14th March 2007 09:30 Rosehedge DS0000021465.V334571.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 Rosehedge DS0000021465.V334571.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. Rosehedge DS0000021465.V334571.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosehedge Address 42 Thingwall Lane Broadgreen Liverpool Merseyside L14 7NY 0151-220-5247 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) Brothers of Charity Mrs Cecilia Baines Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Rosehedge DS0000021465.V334571.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 4 LD Date of last inspection 9th March 2006 Brief Description of the Service: Rosehedge is a care home providing personal care and accommodation for a maximum of four adults with learning disabilities. It does not provide nursing care. The Registered Provider is Brothers of Charity (BOC), a charitable company that is a well-established organisation within this field. Margaret Curzon is the newly appointed Manager. The premises are of a domestic style, which was fully refurbished and adapted for registration purposes. The ground floor consists of one bedroom, two lounges, a dining room, kitchen, utility room and laundry. The first floor has three bedrooms and a staff office/sleeping-in room. Toileting and bathing facilities are distributed evenly throughout the premises and are equipped with appropriate aids. There is no lift. The home has a very pleasant garden area to the rear of the building. The home has a call system throughout the premises. Service users do not attend day care but are occupied by the staff team. Service fees are £1000.00 per week. Rosehedge DS0000021465.V334571.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection visit (site visit) at the home this inspection year. The visit was unannounced and took place over one day for a total of 6 hours. The inspection was carried out with the staff team that were on duty at the time of the visit. The Commission considers 22 standards for Care Homes for Adults (18-65) as Key Standards, which have to be inspected at least once in a 12-month period. All Key standards, which are identified in bold within the main body of the report, were inspected during this inspection. The requirements, which were given as part of the last inspection report, were checked during this inspection. A tour of the home was conducted. Care records and other required records were inspected, they included a selection of resident’s care plans, daily diaries, medical notes, staffing rotas and medication and associated records. Two residents were “case tracked”. Case tracking means that the Inspector concentrates on the care given and experiences of one or more residents to get an idea of what is like to live at the home and how that person’s needs are being met. The nature of the disability of the residents is such that it was not possible to obtain direct views about their experiences, however, non-verbal communication and general observations took place throughout the visit and have been used towards measuring standards for the purpose of this report. A number of staff were spoken with during the inspection visit. A pre - inspection questionnaire sent to the home prior to the inspection was returned fully complete. The questionnaire provided the commission with up to date information about different aspects of the home such as the residents, staff, the premises, policies and procedures. The report has been put together using evidence from a number of different sources including peoples comments, observations and records looked at during the inspection visit, the pre-inspection questionnaire and surveys. What the service does well: The service has available up to date information about the home. This includes a statement of purpose and service user guide. Both documents are available in a clear and accessible format and provide people with the information they need to make an informed choice about living at the home. The service has procedures in place, which aim to ensure that prospective residents needs are fully assessed so that the home can be sure of meeting the person’s needs. Rosehedge DS0000021465.V334571.R01.S.doc Version 5.2 Page 6 Essential Lifestyle Plans have been put together for each person. The plans provide staff with essential information about the person including how best to support their needs and help them achieve their goals. Residents are given the assistance and communication support that they need so that they can make choices and decisions about their lives. Residents are provided with appropriate support and opportunities, which enable them to maintain fulfilling lifestyles in and outside of the home. Care plans provide staff with detailed information about resident’s routines and the type and level of personal and healthcare support that they need. Assistance with personal care was provided in a sensitive and flexible way ensuring the privacy dignity and comfort of the residents. Resident’s benefit from a staff team that have a good understanding of their roles and responsibilities and have the qualities and competencies required for the job. Staff receive a good level of training, which is linked to the aims, and objectives of the home and the needs of the residents. Residents and staff benefit from a well run home. What has improved since the last inspection? What they could do better: Care plans for two residents could not be found at the time of the visit. A member of staff said that a member of the management team had taken them from the home to be updated following recent reviews. A care plan for each service user must be available at the home so that staff have the information as to how the persons needs in respect of his health and welfare are to be met. Medication procedures, which were observed during the visit, were not completely safe putting residents at risk. They need to be carried out in accordance to the homes policies and procedures to ensure the full protection of resident’s health and safety. A number of improvements are required to the premises to ensure the comfort and dignity of the residents, they include the refurbishment of the lounge and dining area and repairs and redecoration of bathrooms. Support staff are responsible for the day to day cleaning of the home. The manager was advised to look at the possibility of appointing some domestic help to relieve support staff of the bulk of daily cleaning duties so that they can spent more quality time with the residents. Rosehedge DS0000021465.V334571.R01.S.doc Version 5.2 Page 7 The manager needs to complete and forward onto the Commission an application for his approval as the Registered manager of the home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Rosehedge DS0000021465.V334571.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 Rosehedge DS0000021465.V334571.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the service and assessment procedures are available in good detail and aim to ensure that prospective residents make the right choice about living at the home. EVIDENCE: No new residents have moved into the home since the last inspection. Available in each resident’s personal file was a copy of the homes statement of purpose and service users handbook. Both documents, which included all the required information, have been reviewed and updated since the last inspection. New information includes details about the new manager. Each persons care file contained an assessment of need, which was carried out by a care management team before they moved into the home. Records looked at showed that need assessments for each person are continually under review. Assessments provide detailed information about the kind of support residents need with such things as, communication, mobility, risk management and health, social and personal care. Rosehedge DS0000021465.V334571.R01.S.doc Version 5.2 Page 10 Available at the home were a number of policies and procedures, which aim to ensure that people make a positive choice about living there. Policies included introductory and trial visits and needs assessments. Rosehedge DS0000021465.V334571.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and supported to live independent lifestyles, however this was compromised because some information about how staff need to meet residents needs was not available. EVIDENCE: Essential Lifestyle Plans (ELPs) were available at the home for two residents. Plans for two other residents could not be found. A member of staff said that a member of the management team had taken them from the home to be updated following recent reviews. A care plan for each service user must be available at the home so that staff have the information as to how the persons needs in respect of his health and welfare are to be met. The ELPs, were looked at in detail as part of the case tracking process. They were person centred and gave fine detail around how to a person wishes/needs to be supported with personal and social support and healthcare needs such as, communication, medication, behaviour management and financial support. Rosehedge DS0000021465.V334571.R01.S.doc Version 5.2 Page 12 Case tracking showed that the plans were developed on the basis of assessments made. There was evidence to show that both plans have recently been reviewed and updated with the involvement of the resident/representative, manager and key workers. During discussion a member of staff explained in good detail how ELPs and other care records are used on a daily basis to support individuals. A learning log is kept for each service user. These are daily records, which identify particular goals set for the person to aim for, for example choosing an activity or learning a new skill. The records seen detailed how the staff have supported the resident with their care plan and how they have progressed. The learning logs place a lot of emphasis on promoting independence by supporting residents to learn and develop new skills as part of their personal development. All residents have limited verbal communication skills, however they are supported to communicate by use of other methods for example, gestures, sounds, and body language and in some instances by use of pictures. ELPs, which were seen, included detailed Information about how the person prefers to communicate and the help that they need. During the visit staff were seen communicating effectively with residents they were seen offering residents choices and encouraging them to make decisions about things such as food and activities. Because of limitations none of the residents are able to manage their own finances. Financial support that residents need was recorded in their individual plan of care. Residents money and financial records that were examined were well kept and in good order. For safety reasons there are certain restrictions placed on residents for example access without support to certain parts of the home and the community. There are also instances when some decisions and choices have to be made for residents by others. Restrictions placed upon people and choices, which need to be made by others and the reasons why, were recorded in care plans, which were seen. Risk assessments are part of each persons care plan. They have been carried out for tasks and activities which residents are involved in that are likely to pose a risk to them. Risk assessments that were seen identified potential risks and hazards and detailed the action that staff need to take so that residents are able to take risks safely as part of an independent lifestyle. Risk assessments that were viewed showed that they have recently been reviewed and updated. Rosehedge DS0000021465.V334571.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are given opportunities for personal development and enjoy an active and healthy lifestyle. EVIDENCE: Essential lifestyle plans which were looked at provided a good amount of information about the persons preferred activities, leisure and daily routines. A structured timetable of activities has been put together for each of the residents. The two care plans that were case tracked showed that the activity programmes were developed around the needs and wishes of the individual. At times throughout the visit staff were seen involving residents in tasks such as laundering their clothes and cleaning parts of the home. ELPs detailed the things that residents are able to do and the kind of support that they need. Discussion with staff and examination of records showed that residents are supported to take part in a variety of activities both in and outside the home. Rosehedge DS0000021465.V334571.R01.S.doc Version 5.2 Page 14 Activities include, watching television, listening to music, art and crafts, tabletop football game, bowling, meals out, walks and swimming. Learning logs for each resident showed that they have been supported to take part in indoor and outdoor activities that they prefer and which are set out in their plans of care. Discussion with staff and records viewed showed that staff support residents to maintain family links and friendships inside and outside the home. Records evidenced that family and friends are welcomed at the home and that residents visit them outside of the home. ELPs included information about relationships and how they need to be supported. One the day of the visit two residents went out visiting their parents. Staff were observed supporting residents at mealtime. They provided assistance and encouragement in a sensitive and flexible way. ELPs included information about resident’s likes and dislikes with regard to food. Residents were offered drinks outside of usual meal times. The kitchen was equipped with domestic style appliances. Food stores that were examined were well stocked with fresh frozen and dried goods. Rosehedge DS0000021465.V334571.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. The home provides residents with appropriate personal and healthcare support to ensure residents physical and emotional well-being, however medication procedures observed on the day did not ensure the full protection of residents. EVIDENCE: ELPs provided detailed information about the type and level of personal and healthcare support that each person requires. The persons preferred routines with regards to personal care were also available in very good detail. Information was available in a way, which ensures residents privacy, dignity and independence. Staff were seen providing personal support to a number of residents. Staff were seen respecting residents right to privacy. They carried out personal care in the privacy of bathrooms and residents own rooms. Staff were heard chatting to residents and advising them of the care and support that they were about to provide. Case tracking showed that the level of support given to residents was in accordance with their plan of care. During discussion staff showed that they provide sensitive and flexible personal support which ensures residents privacy and dignity. The following comments made by staff supported this: Rosehedge DS0000021465.V334571.R01.S.doc Version 5.2 Page 16 “When assisting residents with personal care it is important to make sure doors and blinds are shut”. “I always chat with residents when helping them”. “I encourage residents to do whatever they can for themselves” “I always make sure that personal care is carried out in a bathroom or a persons own bedroom”. “It is important to ask people what they want and to tell them what you are doing”. Care plans clearly set out the person’s healthcare, needs and procedures that are in place to address them. Records within this section showed that residents are offered minimum annual checks and that there health is regularly reviewed and monitored and dealt with appropriately. As well as visits to primary healthcare services such as dentist, opticians and doctors residents are also supported to attend specialist services. Records detailing the visits were available in good detail as was information about specialist health care needs and requirements. A weekly health check record is kept for each of the residents. The records, which were looked at, are used to monitor general health and personal care, such as weight and the care of hair and nails. Health plans provided good information about how residents communicate when they are unwell or in pain. These are particularly important for residents because they have limited verbal communication skills. A record of medication received and leaving the home was seen. Medication was stored securly. Medication and medication administration records were examined. They were in good order. A policy for the safe handling and administration of medication was availble at the home. a member of staff confirmed that medication is only administered by staff that have completed medication awareness training. Records that were seen evidenced this. A member of staff was observed administering the morning medication to two residents. The procedure observed for transporting and administering medication was not completely safe putting residents at risk. The members of staff on duty were advised of this. Safe medication procedures must be carried out at all times to ensure the health and safety of residents. Rosehedge DS0000021465.V334571.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has appropriate procedures in place for responding to concerns and complaints and for ensuring that residents are safe from abuse or neglect. EVIDENCE: A complaints procedure was on display in the hallway at the home. A copy of the procedure was on display in the main entrance at the home. The service user guide and the homes statement of purpose also included a summary of the homes complaints procedure. It was not possible to assess residents understanding of the complaints procedure due to their limited understanding. A member of staff did however state that resident’s advocates and representatives have received a copy of the procedure. A resident relative confirmed this information during a telephone interview. The relative said, “I have no complaints at all and if I did I would certainly tell someone, I have all the information I need to do this”. Staff interviewed said that they knew about the complaints procedure and would be confident about raising any concerns or complaints if they needed to. The pre-inspection questionnaire showed that there have been two complaints made at the home in the last 12 months and that they were dealt with within the appropriate timescale. The Commission for Social Care and Inspection has received no complaints regarding the service since the last inspection. Rosehedge DS0000021465.V334571.R01.S.doc Version 5.2 Page 18 During discussion staff showed a good awareness of what to do if they suspected or witnessed abuse. A Protection of Vulnerable Adults procedure was available at the home. The pre-inspection questionnaire evidenced that staff have received Protection of vulnerable adults training. Rosehedge DS0000021465.V334571.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some parts of the environment are in a poor state of repair, which compromises the comfort, and dignity of the residents. EVIDENCE: The pre- inspection questionnaire shows that there have been no changes made to the environment since the last inspection although improvements were recommended as part of the last inspection report. The home which is purpose built is a detached house in a popular residential area of Liverpool. There are gardens to the front and back of the property, which were well maintained. The home is located close to shops, pubs and other community facilities including public transport links. The relationships with neighbours were reported as being good. A tour of the home took place. Resident’s bedrooms were decorated and furnished to a good standard. Throughout the visit residents were seen using their own rooms as and when Rosehedge DS0000021465.V334571.R01.S.doc Version 5.2 Page 20 they wished. Personal items such as photographs, ornaments, TVs and music systems were displayed around the home. Bedroom furniture such as wardrobes and beds has been renewed since the last inspection. The décor and furniture in the main lounge and dining room appeared dull and worn in places. All of the bathrooms in the home used by residents are in need of some repairs. On entering the house there was an unpleasant smell coming from the ground floor bathroom. A member of staff explained that it is caused by a fault with the drainage in a bathroom directly above. Improvements must be made to parts of the environment identified to ensure the complete comfort and dignity of the residents. All areas of the home were clean and tidy at the time of the visit. Support staff are responsible for all the day-to-day cleaning of the home. They were observed carrying out cleaning tasks such as mopping floors, laundry, and vacuuming and polishing furniture. Staff were seen encouraging residents to help with these tasks. A member of staff explained that because of their limitations residents’ often loose interest very early on into the task and walk away leaving the member of staff to complete it. Cleaning routines were discussed in detail with a number of staff that felt that the time spent cleaning could be better spent supporting residents with more appropriate activities The manager was advised to look at the possibility of appointing some domestic help to relieve support staff of the bulk of daily cleaning duties so that they can spent more quality time with the residents. The pre-inspection questionnaire detailed policies and procedures relating to the environment which are available at the home including, infection control cleaning routines. Rosehedge DS0000021465.V334571.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have the qualities and experience that they need to meet the needs of the residents. EVIDENCE: Training and development records sent with the pre-inspection questionnaire and records seen at the home showed that staff complete training to update their knowledge and skills and that the training is linked to the aims and objectives of the home and the needs of the residents. Staff spoken with said that they have completed a lot of training and gave the following examples, first aid, and protection of vulnerable adults, health and safety equality and diversity and food hygiene. The pre-inspection questionnaire and staff training records held at the home evidenced that at least half of the staff team have achieved or are currently undertaking a National Vocational Qualification in care level 2 or above. Staff made the following comments about training: Staff personnel files were locked away by the manager therefore the homes recruitment and selection procedures could not be fully assessed on this Rosehedge DS0000021465.V334571.R01.S.doc Version 5.2 Page 22 occasion. However, discussion with a member of staff evidenced that strict processes are followed before a person is allowed to start work at the home. The pre-inspection questionnaire shows that no staff have left since the last inspection. There has been a low turn over of staff working at the home. Details provided in the pre-inspection questionnaire showed one person has started work at the home since the last inspection. The staff team is stable and has been for sometime. The staffing rota, which was examined as part of the inspection showed that there are four support staff on duty throughout the day and two on duty during the night. All staff that were on duty at the time of the inspection visit were spoken with. They all showed a good understanding of their roles and responsibilities and were very knowledgeable about the needs of the residents. Staff were observed interacting well with residents and treating them with respect at all times. Rosehedge DS0000021465.V334571.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and safety of staff and residents was put at risk, as it was not fully protected. EVIDENCE: A new manager, Mr Nigel Deans has been appointed to the home since the last inspection. The previous manager left voluntarily. Mr Deans needs to complete and forwarded onto the Commission an application for his approval as the Registered manager of the home. All the staff spoken with during the visit said that the home is run well. Since his appointed the manager has made some minor changes to the homes administration and recording systems. Staff reported that the changes are in the best interests of the residents. Rosehedge DS0000021465.V334571.R01.S.doc Version 5.2 Page 24 The contents of the main office which was previously upstairs has been moved to the office on ground floor so that all information is kept in one place. Staff commented on how much better this arrangement is. As Part of the homes quality assurance process and in accordance with Regulation 26 of the Care Homes Regulations 2001 Amended (2004), a representative for the home visits the premises monthly. They interview people inspect the environment. Reports are written following the visits and kept at the home. The policy and procedure check list completed as part of the pre-inspection questionnaire showed that health and safety policies and procedures relating to the environment are available at the home. On the day of the visit up to date gas and electricity safety check certificates could not be located at the home. This put people at risk, as there was no guarantee that the systems were safe. The manager who was contacted on the day of the visit confirmed that the checks had been carried out, he said that he was awaiting the certificates from head office. Copies of up to date certificates showing that the systems had been checked and are safe were forwarded onto the commission a few days after the inspection visit. Discussion with staff and examination of records showed that they have undertaken training in areas of health and safety including: First aid, fire awareness, infection control and manual handling. Records showed that these are updated at the required intervals. A handbook, which contains the homes policies and procedures, was seen in the office some policies and procedures show that they have recently been reviewed and updated in line with current legislation and working practices. Rosehedge DS0000021465.V334571.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 3 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 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Rosehedge DS0000021465.V334571.R01.S.doc Version 5.2 Page 26 No 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 YA6 Regulation 15(1) Requirement Timescale for action 31/03/07 2. YA20 3. YA24 A care plan must be kept at the home for each person so that staff have the information as to how the persons needs in respect of his health and welfare are to be met. 13(2) Safe medication procedures must be carried out to ensure the health and safety of residents. 23(2)(b)(d) The floorboards must be repaired in the upstairs bathroom to eliminate the unpleasant smell and all the bathrooms must be kept in a good state of repair and reasonably decorated. 21/03/07 30/04/07 Rosehedge DS0000021465.V334571.R01.S.doc Version 5.2 Page 27 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. Refer to Standard YA28 Good Practice Recommendations Serious consideration should be given to the redecoration of communal areas of the home to enhance the comfort and dignity of the residents. Consideration should be given to appointing some domestic help to relieve support staff of the bulk of daily cleaning duties so that they can spend more quality time with the residents. 2. YA31 Rosehedge DS0000021465.V334571.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Rosehedge DS0000021465.V334571.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. 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