Inspection on 09/03/06 for Rosehedge

This inspection was carried out on 9th March 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 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 14/03/07

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 9th March 2006 10:30 Rosehedge DS0000021465.V287461.R01.S.doc Version 5.1 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.V287461.R01.S.doc Version 5.1 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.V287461.R01.S.doc Version 5.1 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.V287461.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 4 LD Date of last inspection 4th November 2005 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. Rosehedge DS0000021465.V287461.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second of two inspection visits that are required at the home each year. The inspection was unannounced and took place over 3 hours. The inspection was conducted with the manager who was on duty at the time of the visit. Four residents were at home throughout the inspection. The requirements raised as part of the last inspection report were discussed and checked with the manager. The services responses to those are described within this report. A partial tour of the home was conducted. Care records and other required records were inspected. Records that were examined included a selection of residents care plans, daily diaries, medical notes, medication and records, staff rotas and certificates of health and safety checks. Staff and the manager were spoken with and their views obtained. It was not possible to obtain the direct views of the residents due to the nature of their disabilities however, their experiences were obtained through discussion with the manager, general observations and compliance with standards. What the service does well: What has improved since the last inspection? The rusted radiator cover in the ground floor bathroom has been replaced. The hoist in the downstairs bathroom has been repaired. Residents Learning Logs are now fully completed. The wall over the sink in the ground floor bathroom has been plastered. Rosehedge DS0000021465.V287461.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Rosehedge DS0000021465.V287461.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rosehedge DS0000021465.V287461.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5. Key Standard 2 was assessed at the last inspection and was met. Contracts were available for each resident but some did not show that residents agree to the terms and conditions of the home. EVIDENCE: A contract of terms and conditions was seen for all residents, which included all the elements for this standard. Not all contracts were signed, although there was evidence that the manager has made arrangements for this to be done. Contracts must be signed and dated by the resident and/or their representative to show that they agree with the Terms and Conditions of the home. Rosehedge DS0000021465.V287461.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7. Key Standards 6 & 9 were assessed at the last inspection and were met. In practice residents are encouraged to make decisions with the assistance that they need, however some decisions made by others are not recorded as well as they need to be. EVIDENCE: The manager said residents are supported and encouraged to take part in aspects of live in the home in accordance to their ability and understanding. Details of their ability and support required in most areas were recorded in their individual ELPs. Through discussion and on observation the manager and staff showed that they respect resident’s rights to make decisions. Some choices and decisions made for residents by others and why were not recorded and agreed in their ELPs. Details of this are explained further on in the report (Standard 16). Rosehedge DS0000021465.V287461.R01.S.doc Version 5.1 Page 10 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): 16. Key Standards 12, 13, 15 & 17 were assessed at the last inspection and were met. In practice residents rights are respected and their responsibilities recognised in their daily lives, however, their right to make certain decisions is not recorded and agreed. EVIDENCE: A requirement was raised as part of the last inspection report for records to be kept up to date to show that residents are given opportunities for personal development. This was because Learning Logs that were kept for each resident had not been completed on a number of days. Learning Logs that were examined were fully complete. Details of activities, interests and hobbies that residents are offered and take part in at home were recorded in good detail. Residents were seen using all parts of the home. Staff provided the help and assistance that is required to enable residents move around the home. Information in Essential Lifestyle Plans (ELPs) provide staff with clear information about how best to support residents to move about the home freely and safely whilst respecting their right to do so. Rosehedge DS0000021465.V287461.R01.S.doc Version 5.1 Page 11 Staff were seen offering residents with choices, which were respected and supported appropriately. There are some restrictions placed upon residents because of their limitations. Restrictions include residents not being given a key to their own rooms and a key to the front door, having restricted access to parts of the home and opening their own mail. This is because of the persons lack of understanding and/or because it poses a risk to their safety. They therefore depend on others to make decisions for them. ELPs did not include all the information about decisions that other people need to make and why. This information must be recorded and agreed for each person. Several good-sized communal areas provide residents with a good amount of shared and private space apart from their own bedrooms. Rosehedge DS0000021465.V287461.R01.S.doc Version 5.1 Page 12 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. Key Standards 19 & 20 were assessed at the last inspection and were met. Residents receive personal support according to their wishes. EVIDENCE: All residents require some assistance with personal care including advice, guidance & support. ELPs that were examined had a detailed and agreed routine, which showed a great deal of staff input & guidance and the importance of the routine for the residents. Regular ELP reviews allow staff to address any issues or changes to care that may be necessary. These records were seen and were detailed and satisfactory. Rosehedge DS0000021465.V287461.R01.S.doc Version 5.1 Page 13 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. Key Standard 23 was assessed at the last inspection and was met. People are confident about making complaints, which are acted upon promptly. The homes policies and procedures ensure that residents are protected from abuse. EVIDENCE: A complaints procedure was viewed at the home. The procedure includes details about the action and timescales involved in the process, and it also included details of the Commission for Social Care and Inspection (CSCI). Due to limitations none of the residents are able to access a complaints procedure, however the manager confirmed that their families/representatives are given a copy of the procedure. Records sent to the Commission show that the home have received two complaints made by staff who work there. These were in relation to protection issues, which were dealt with by the home promptly and appropriately. None of the residents are financially independent. Their money is managed by staff that work at the home. The home operates a strict procedure for checking and recording residents money. Records were well maintained, monies were securely stored. The system was accountable and monies were individually stored as opposed to being pooled. Information about advocacy services was displayed on a notice board in the office. Rosehedge DS0000021465.V287461.R01.S.doc Version 5.1 Page 14 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, 25, 28 & 30. The home was clean, tidy and maintained to a good standard providing a comfortable and safe environment for the people who live there, however the condition of some areas compromise the comfort and dignity of residents. EVIDENCE: The standard of décor in the home is good although it remains bland in places. Residents would benefit from a more stimulating environment. For example colourful wall coverings and pictures that would create a more homely feel. Positive steps towards achieving this have already taken place by the introduction of a sensory room. Staff recognise that residents often get anxious and frustrated, which lead to behavioural problems, so have created a room for residents to ‘chill out’. A ground floor lounge has been equipped with lights and other equipment aimed at providing a relaxing and stimulating area for residents. Easy chairs have been purchased for the room since the last inspection. Bedrooms on the first floor are decorated and furnished to a good standard. A range of personal items including TVs, music centres and colourful lights are displayed around residents rooms. Following the last inspection a number of requirements and recommendations were given in relation to the environment. In response to them the following Rosehedge DS0000021465.V287461.R01.S.doc Version 5.1 Page 15 repairs have been carried out which ensures the safety, comfort and dignity of residents: • The radiator in the ground floor bathroom, which is badly rusted, has been replaced. • The hoist in the ground floor bathroom has been repaired and is now in full use. • A shower hose has been fitted to the shower over the bath. • The wall over the sink in the ground floor bathroom has been plastered. The décor in the ground floor bedroom still needs attention as it is becoming tatty with wallpaper peeling off in parts and stains on the ceiling. All parts of the home were clean and tidy. Rosehedge DS0000021465.V287461.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 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): 34. Key Standards 32 & 35 were assessed at the last inspection and were met. The homes recruitment procedures ensure the protection of residents. EVIDENCE: Two staff files were examined. They contained the required identification evidence, reference copies, Criminal Record Bureau (CRB) checks and proof of qualifications. The recruitment policy is robust and meets the minimum standards. Staff files that were examined showed evidence that staff have undertaken periodic training which is required by regulation and enables them to meet the needs of the resident group. Rosehedge DS0000021465.V287461.R01.S.doc Version 5.1 Page 17 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. The appointed manager has not yet been approved by the commission as the registered manager of the home. EVIDENCE: A manager has recently been appointed to the home following the resignation of the previous manager. The manager has been advised of the process that she needs to follow to become the Registered Manager of the home. The manager who has NVQ Level 4 in Care and Management showed good knowledge and understanding of all the residents needs. A detailed health and safety manual is available for staff to refer to. It includes policies and procedures, which ensure the health and safety of residents and staff. Information on cleaning products and substances that are potentially hazardous to health were also seen. Records show that Provider visits, which are required under Regulation 26 of The Care Home Regulations, are being carried out at the required intervals. Rosehedge DS0000021465.V287461.R01.S.doc Version 5.1 Page 18 Rosehedge DS0000021465.V287461.R01.S.doc Version 5.1 Page 19 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 X 3 X 4 X 5 2 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 3 26 X 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 2 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 2 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X X 3 X 3 X X X X Rosehedge DS0000021465.V287461.R01.S.doc Version 5.1 Page 20 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. 2. 3. Standard YA5 YA16 YA38 Regulation 5 15(1) 9(1)(2) Requirement Residents contracts must be signed and dated by them and/or their representative. Care Plans must include all the required information The manager must ensure that she makes an application to the Commission for approval of registered manager of the home. Timescale for action 08/05/06 08/06/06 08/04/06 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. Refer to Standard YA25 YA28 Good Practice Recommendations The decoration in the ground floor bedroom should be repaired. Consideration should be given to the redecoration of communal areas of the home. Rosehedge DS0000021465.V287461.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Rosehedge DS0000021465.V287461.R01.S.doc Version 5.1 Page 22 - 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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