Inspection on 28/09/07 for Rosehedge

This inspection was carried out on 28th September 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Rosehedge 14/03/07

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 Unannounced Inspection 28th September 2007 09:30 Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 1 Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 2 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.V351753.R01.S.doc Version 5.2 Page 3 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.V351753.R01.S.doc Version 5.2 Page 4 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 Nigel Alan Deans Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 5 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only: Code PC, to people of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Learning disability: Code LD The maximum number of people who can be accommodated is: 4. Date of last inspection 14th March 2007 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.V351753.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection. The Commission considers 22 standards for Care Homes for Adults as Key Standards, which have to be inspected during a Key Inspection. The report has been put together using information gathered from a number of sources including information that the commission have received about the service since the last inspection and details provided in the Annual Quality Assurance Assessment (AQAA). The AQAA, which is in two parts, a selfassessment and dataset, has replaced the pre-inspection questionnaire. The document, which was sent out to, the service was completed and returned to the commission before the site visit took place. A number of surveys were sent out to people as part of the inspection but none of them were returned. The inspection also involved an unannounced visit to the home (site visit). Records that were examined, staff comments and observations made during the visit have also been used as evidence for the report. All the residents that live at the home have limited verbal communication skills so were unable to express their views and opinions about the service. However, a number of residents were case tracked. This process involved talking to staff, looking at the environment and a selection of residents records such as assessments, care plans and daily notes to get an idea about peoples experiences and to find out if they are receiving the care and support that they need and which have been agreed by their representatives. What the service does well: Assessment and admission policies and procedures aim to ensure that people are only admitted to the home after a full and detailed assessment of their needs is carried out so that they can be sure their needs will be met at the home. Each resident had an Essential Lifestyle Plan (ELPs). The plans were very person centred enabling people to have maximum choice and control over their own lives. Staff communicate very well with residents who have limited verbal communication skills they do this by use of other methods such as sign language, gestures and body language. Residents are encouraged and supported to make choices and decisions as part of their everyday life. During the inspection visit staff were observed treating residents with respect and carrying out personal care in a flexible and sensitive way. Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 7 The home has in place appropriate procedures for responding to concerns and complaints and for ensuring that residents are safe from abuse, harm or neglect. The commission have not received any complaints about the home since the last inspection. Staff spoken with during the inspection said that they understand the homes complaints procedure and know how to make a complaint if they needed to. People knew who to talk to if they were unhappy about something and were confident that their complaints would be listened to and dealt with in the correct way. There has been little change to the staff group at the home for a number of years, which has meant that residents have benefited from familiarity and continuity of care. During this and previous inspections the staff have shown good knowledge and a clear understanding of the needs of each resident. More than half of the staff team have achieved or are working towards a National Vocational Qualification in Care level 2 and above. Staff are involved in an ongoing programme of training, which is relevant to the work that they carry out. What has improved since the last inspection? What they could do better: Further improvements should be made to the environment to ensure the complete comfort of the residents. Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 8 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.V351753.R01.S.doc Version 5.2 Page 9 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.V351753.R01.S.doc Version 5.2 Page 10 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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are only admitted to the home after a full and detailed assessment of their needs is carried out to show that their needs can be met there. EVIDENCE: There have been no new residents admitted to the home since the last inspection. Information provided in the AQAA and discussion with a member of staff showed that the four men that live at Rosehedge have done since the home opened in 1999. The AQAA showed that the service has written polices and procedures for assessing and admitting new residents to the home. The processes were summarised in the AQAA and clearly explained by the acting manager at the inspection visit. This showed that a detailed needs assessment would be undertaken by the service manager with the involvement of the prospective resident, their family/representatives and other relevant professionals including a social worker. The assessment is used to help decide if the persons needs can be met at the home and if is the right place for them to live. A new resident would be introduced to the home over a period of time to ensure that the move is least stressful as possible to the person. Before moving in they would visit the home several times, to get to know the other residents, the staff and to become familiar with the environment. Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 11 The AQAA showed that when a placement has been agreed, a person centred care plan and risk assessments based on the pre – admission assessment would be developed to enable staff to meet the needs of the resident once they have been admitted to the home. Each of the resident’s personal files contained a copy of the homes service user guide and statement of purpose. These documents, which were looked at in more detail as part of the last inspection, include all the required information. Both of the documents are nicely presented and available in large clear print with pictures and symbols so that people with difficulties reading can understand them better. Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 12 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. Person centred plans ensure that people have maximum control and choice over their owns lives. EVIDENCE: Each resident had an Essential Lifestyle Plan (ELPs). The plans were very person centred enabling people to have more choice and control over their own lives. Two plans were looked at in detail as part of the case tracking process. They covered all aspects of each person’s personal and social support such personal care, independent living skills, accessing the community, relationships and financial needs. Health action plans were also part of each persons care plan. The plans cover in detail things such as what is important to the person, what they are good at doing, what they dislike, what they need help with and what they want to happen with their lives. There was information to show that plans have been reviewed and updated at regular intervals. Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 13 Residents do not have the ability to understand or sign their care plans, however they showed the involvement of other important people such as family, advocates, service managers, key workers, social workers and other health care professionals. All the residents that live at the home have limited verbal communication skills however they are able to communicate clearly in other ways such as by use of sign language, body language, sounds and gestures. ELPs detailed each persons preferred methods of communication. Staff were seen communicating with each of the residents by use of these methods. On the day of the visit residents made choices and decisions about such things as what to eat and what activities they took part in. 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 many 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 the individual’s plan of care. 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. Risk assessments were part of each persons care plan. A selection of risk assessments was viewed as part of the case tracking process. They showed that staff have the information that they need to support residents to take responsible risks as part of an independent lifestyle. Risks assessments included information about the action, which staff need to take to minimise risks and hazards so that residents can enjoy and take part in their preferred activity or choice. Risk assessments were also available for the use of equipment such as bathing aids and outdoor activities. Risk assessments that were viewed showed that they have recently been reviewed and updated. Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 14 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 appropriate opportunities to lead active, enjoyable and healthy lifestyles. EVIDENCE: Essential Lifestyle plans and activity programmes provided information about the kind of things that residents like to do both at home and in the community. Each resident has an individual learning log, which is, used daily by staff to record significant information and then at reviews to monitor and evaluate people’s lifestyle and routines. Discussion with staff and examination of a selection of daily records showed that residents are provided with a lot of opportunities to do the things that enjoy both at home and in the community. Activities which residents have recently taken part in include trips to the cinema, shopping, horse riding, BBQs, meals out and swimming. Walks around the local community and in the countryside are also part of resident’s daily routines and they have shared use Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 15 of a vehicle to enable them to go further a field. Records showed that residents enjoyed a five-day break to the Lake District earlier this year. As well as recreational and leisure activities resident are also encouraged and supported to help with small tasks around the house such as cleaning their bedrooms, laundering their clothes polishing and shopping for personal items and food. On the day of the visit staff were seen encouraging and appropriately supporting residents with some of these tasks. None of the residents have keys to the front door or their own bedrooms this is because assessments showed that it is not safe for them. This information and the reasons why was recorded in their plans of care. Daily records showed that residents are encouraged to maintain contact with family and friends and personal relationships are respected and appropriately supported by staff at the home. Menus which where viewed at the home showed a variety of healthy meals. Staff explained that the menus could be changed if residents request it. A member of staff showed a good awareness of the importance of nutritious and balanced diets. Records showed that staff have undertaken training in food hygiene. Residents use the dining table, which is situated in the dining room, at meals times. 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 plenty of drinks and snacks outside of usual meal times. A good stock of fresh, frozen and tinned food was seen at the home. There were also sufficient crockery, cutlery pots and pans, which were of good quality. There was a fridge, freezer and microwave which were all of a domestic style and in good condition. A member of staff confirmed that residents are always involved in the main weekly shop for food as well as shopping daily for essentials such as fresh bread and milk. Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 16 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 is good. This judgement has been made using available evidence including a visit to this service. Resident’s health and personal care needs are well recorded and monitored to ensure they stay healthy. Procedures for recording medication are more robust minimising the risk to resident’s health. EVIDENCE: Care plans 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 good detail. During the inspection visit staff were observed assisting residents with personal care, they ensured residents privacy and dignity at all times by making sure rooms were clean and warm and doors were shut. Staff were heard talking to residents in a gentle and polite way whilst assisting them with personal care. Each person care plan included a section, which covered in detail their healthcare, needs and the support that they need to stay well. Records within this section showed that they are offered minimum annual checks and that there health is regularly reviewed, monitored and dealt with appropriately. As well as visits to primary healthcare services such as dentist, opticians and Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 17 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. Where appropriate visits to the home by healthcare professionals are arranged. The service operates a key worker system to enable residents to develop a closer relationship with a specific staff member particularly in the areas of health and personal care. The key worker is responsible for reviewing the resident’s monthly plan and to arrange healthcare appointments etc. for residents. During discussion a member of staff described clearly their role and responsibilities as a key worker. During this inspection visit all medication and medication administration records were examined. Medication and records were stored in a locked cabinet in the office. Staff were observed administering medication in the correct way. Discussion with staff and examination of records showed that staff have completed medication awareness training. A requirement was given as part of the last inspection because a member of staff was observed administering medication to two residents incorrectly putting them both at risk. A number of processes have been put in place to make sure this doesn’t happen again. They include regular training and checks to make sure that staff are handling, recording and giving out medication in the correct way. Records of the checks were avaialbe to show that they are taking place. A policy for the safe handling and administration of medication was availble at the home. A member of staff showed a good awareness of the homes medication polices and procedures. Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 18 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. Policies and procedures at the home aim to ensure that people’s views are listened to and acted upon and that they are protected from abuse. EVIDENCE: A complaints procedure was on display in the hallway at the home. The service user guide and the homes statement of purpose also included a summary of the homes complaints procedure. The information was available in large clear print supported by pictures and photographs. 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. 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 AQAA showed that there has been one complaint made at the home in the last 12 months and that it was dealt with within the appropriate timescale. Records of the complaint including the action taken and the outcome were available at the home. The Commission for Social Care and Inspection has received no complaints regarding the service since the last inspection. During discussion staff showed a good awareness of what to do if they suspected or witnessed abuse. Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 19 A Protection of Vulnerable Adults procedure was available at the home. The AQAA showed that staff have received Protection of vulnerable adults training. Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 20 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 good. This judgement has been made using available evidence including a visit to this service. Improvements made to the home have enhanced resident’s comfort and dignity. EVIDENCE: 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. A number of requirements were given as part of the last inspection report. This was because resident’s comfort and dignity was undermined by parts of the home and items of furniture, which were in poor condition. The AQAA showed that since the last inspection the home has been redecorated and provided with items of new furniture and floor coverings. All parts of the home were looked at as part of the visit. This showed the following improvements since the last inspection: • All rooms and the hall, stairs and landing have been painted Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 21 • • • • New sofas and easy chairs have replaced the old ones in the main lounge New colourful pictures have been bought and displayed around most parts of the home Residents bedrooms have new curtains and curtain poles Repairs have been carried out to both bathrooms Some further improvements are still required to fully ensure residents dignity and comfort, they include: • The lounge carpet, which was badly stained in most parts, should be replaced • The dining room table which was badly marked should be replaced • Resident’s bathrooms and toilets, which were quite plain in appearance, should be made to look and feel more homely. The acting manager said that there are plans to make these improvements in the near future. All areas of the home were clean and tidy at the time of the visit. At the last inspection support staff explained that they were 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. Because of this 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 acting manager explained that since the last inspection an extra fifteen hours per week has been allocated to cleaning the home. The AQAA detailed policies and procedures relating to the environment which are available at the home including, infection control, disposal of waste and cleaning routines. Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 22 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. Recruitment and training procedures ensure that residents are protected and supported by qualified and competent staff. EVIDENCE: The AQQA showed that there are eight full time care staff and two part time care staff working at the home. Discussion with the manager and details provided in the AQAA showed that two staff members have left the home and one new member of staff has started since the last inspection. There has been little change to the staff group at the home for a number of years, which has meant that residents have benefited from familiarity and continuity of care. During this and previous inspections the staff have shown good knowledge and an understanding of the residents needs. A Personnel file for the new staff member was viewed. The file contained a fully completed application form, two references, identification, a CRB check and training records. The AQAA showed that all people who have worked at the home in the past 12 months had satisfactory pre-employment checks. Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 23 An equal opportunities policy and procedure was available at the home. Records viewed and information provided in the AQAA showed that staff of various age, gender, culture and religion are recruited at the home. The acting manager and three support workers were on duty at the time of the site visit. Copies of staffing rotas were viewed. They showed that there is a minimum of four staff on duty through out the day and two staff on duty during the night. The daytime staffing levels allow for one to one support for residents. As part of the inspection visit staff practices and attitudes were observed. They were all seen interacting well with residents. They treated residents in a polite and respectful way and were flexible and positive in their approach. Due to their disabilities none of the residents were able provide their views and opinions about the staff however they appeared relaxed and responded positively to them all. Discussion with staff showed that they are interested, motivated and committed to their work. Comments made by staff which supported this included: “I really enjoy my job here”. “We get a lot of training”. “All the staff get on really well this is a really good staff team ”. The acting manager confirmed that new staff complete an induction programme at the start of their employment. He said that the induction lasts for a couple of weeks and covers areas such as the management structure of the company, workers roles and responsibilities, policies and procedures, emergency procedures. Also during induction staff are provided with training in all mandatory areas such as health and safety, protection of vulnerable adults, first aid and medication awareness. The AQAA showed that all staff go through the Learning Disability Award Framework (LDAF) as part of their induction training. The acting manager also said that the worker would be on shift with an experienced member of staff throughout their induction. Induction records, which were seen, showed that staff have followed an induction programme linked to the aims and objectives of the home and the needs of the residents. Each member of staff had a training and development plan, which listed training they have completed as well as future training needs. These records and discussion with a member of staff showed that staff have completed or are due to commence the following training: fire awareness, first aid, health and safety, protection of vulnerable adults, learning disability awareness, medication awareness. The AQAA showed that eight members of staff have achieved a National Vocational Qualification (NVQ) in care level 2 or above and that one member of staff is working towards it. Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 24 Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 25 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 good. This judgement has been made using available evidence including a visit to this service. The home is managed to the benefit of the residents. EVIDENCE: Prior to the inspection visit the Commission was notified in writing of the resignation of the registered manager of the home Mr Nigel Deans. Mr Deans chose to leave the home to further his career. The Commission was also notified in writing of details of an acting manager and the company’s plans to recruit a permanent manager. Discussion with a locality manager Mr Darren Orme who was present during part of the inspection confirmed that a permanent manager has since been appointed to the home and is due to commence work several days following the inspection visit. Recruitment records including all the necessary preemployment checks for the manager were viewed. They showed that the person is well qualified, experienced and fit for the job. Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 26 Mr Orme said that the manager would be advised at the earliest opportunity to obtain, complete and forward onto the Commission an application for their approval as registered manager of the home. The acting manager who was on duty at the time of the inspection visit assisted throughout. The acting manager a senior support worker for the company appeared knowledgeable and showed a good understanding of both residents and staff. Staff spoken with all agreed that he has managed the home very well. They made the following comments: “He knows his Job” “He is approachable” If something is not right you can tell him and he will sort it out right away” “He is very good” Were appropriate residents, relatives and advocates are invited to complete surveys as part of the homes quality monitoring processes. This gives people the opportunity to put forward their views and make comments about aspects of the service for example, the manager and staff, the quality and choice of food, and the environment. The results of surveys are used to make the necessary improvements to the service. Also as part of the homes quality assurance process and in accordance with Regulation 26 of the Care Homes Regulations a representative for the home visits the premises each month. They interview residents and staff, check records and inspect the environment. It is important that this is done to check the standard of care in the home. Following the visit a report is written detailing the outcomes of the visit. Records seen at the home showed that the visits are taking place and the reports written. Details provided in the AQAA, discussion with staff and examination of a selection of training records showed that staff 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. The AQAA showed that all the required heath and safety policies and procedures are available at the home and that more than half of them have been reviewed and updated in the past two years to ensure that they are in line with current legislation and good working practices. The acting manager said that the others are due to be reviewed and updated in the near future. The AQAA also showed that equipment used at the home has been serviced or tested as recommended by the manufacturer or other regulatory body. The AQAA also showed that all the required checks have been carried out on equipment used at the home and at the right time. They include electrical circuits, portable electrical equipment, heating system and gas appliances. A selection of certificates and records, which were seen, supported this information. Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 27 Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 28 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 3 ENVIRONMENT Standard No Score 24 3 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 3 3 X 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 3 X 3 X 3 X X 3 X Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 29 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. Standard Regulation Requirement Timescale for action 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 YA24 Good Practice Recommendations The areas of the home described in the report should be improved to further improve the comfort of the residents living at the home. Rosehedge DS0000021465.V351753.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Waterloo, Liverpool L22 OLG 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.V351753.R01.S.doc Version 5.2 Page 31 - 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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