Inspection on 30/08/07 for Roseleigh

This inspection was carried out on 30th August 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Roseleigh 08/12/06

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Roseleigh Roseleigh 39 Ringley Avenue Horley Surrey RH6 7EZ Lead Inspector Pat Collins Unannounced Inspection 30th August 2007 12:30 Roseleigh DS0000067409.V346140.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 Roseleigh DS0000067409.V346140.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. Roseleigh DS0000067409.V346140.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Roseleigh Address Roseleigh 39 Ringley Avenue Horley Surrey RH6 7EZ 01883 731547 01883 744721 Roseleighhouse@hotmail.co.uk 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) Cavendish care Ms Susan Kemp Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Roseleigh DS0000067409.V346140.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2006 Brief Description of the Service: Roseleigh is a care home providing accommodation and personal care for up to six adults of mixed gender who have learning disabilities. The property is located in a quiet residential road and within walking distance of Horley town centre which has a good range of shops and other public amenities. Roseleigh is a large Victorian period-detached property with a good-sized enclosed garden to the rear and car parking space at the front. Accommodation is on three floors accessible by stairs. Communal areas are on the ground floor, comprising of a large lounge, fitted kitchen, dining room and WC. The six bedrooms are on the ground and first floor. All are spacious and five bedrooms have en-suite toilets with showers and one has an en suite bathroom. Other facilities include further WCs, a communal bath/shower room, office and meeting room. All area of the home are decorated and furnished to a high standard. The home is owned and managed by Cavendish Care that is a partner company of Gresham Care. These organisations successfully operate a group of similar care homes locally and a small domiciliary care service. Fees range from £1905 to £2733 per week. Roseleigh DS0000067409.V346140.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced and formed part of a key inspection process. Judgements about the home’s management and services are based on a cumulative assessment and knowledge of the home since its last key inspection in December 2006. Information supplied to the Commission for Social Care Inspection (CSCI) by the home manager, has been taken into account. Ms Pat Collins, Regulation Inspector, undertook the inspection visit. This began at 12:30 hrs and concluded the same day at 18:45 hrs. The home manager was present for part of the inspection and the deputy manager facilitated the inspection process. We have looked at how well the home is meeting the national minumum standards set by the Government and judgements made are contained in this report. A partial tour of the premises took place, records were sampled and staff on duty were consulted. There was contact with three of the four people living at the home. As the inspector did not share their communication methods and language skills were very limited, their wellbeing was assessed by observations of facial expressions, body language, and interaction with staff and from their records. The views of relatives of people living in the home, their care managers and general practitioner were actively sought by use of a questionnaire survey. Two questionnaires were received back and both were from relatives. The term ‘residents’ is used hereafter in this report when referring to people using the home’s services. This is in accordance with the preference of management for continuity as this term is used by staff and in internal publications. We were unable to illicit the views of residents in this matter. The inspector would like to thank all who contributed to the inspection process and in particular all residents and staff for their time, hospitality and assistance. Additionally, the responsible individual of the organisation operating the home who visited during the inspection, making herself available for discussions and ensuring staff were supported. What the service does well: The home successfully offers a good level of personal support specific to the individual needs of each resident. Residents were appropriately dressed in respect of their age and culture also well groomed at the time of the visit. They receive support and encouragement to enable independence and autonomy within individual capabilities. They are able to choose the things they enjoy doing within the home. Comments from relatives were, “ The home makes a real effort to get to know residents as individuals. My relative has a personal timetable so does not have to rely on being part of a group. As far as possible my relative is enabled to access everything in the community. He goes to musicals, the gym and has a paper round just as if he did not have a Roseleigh DS0000067409.V346140.R01.S.doc Version 5.2 Page 6 disability”. Another relative commented, “I feel they provide wonderful support and Cavendish Care has completely revolutionised the life of my family. They provide great care and my relative is always clean and tidy and the home environment is so ‘homely’”. Care plans are well written from residents’ point of view and are under continuous review. Residents are supported in being part of their local community. The service actively encourages and provides imaginative and varied opportunities for residents to develop and maintain social, emotional, communication and independent living skills. The focus is on involving residents’ in all areas of their life and actively promote their right to make choices, providing links to specialist support where needed. The home has suitable vehicles’ that enable residents to access the wider community, using mainstream leisure and educational services wherever practicable. A particular strength of the staff team is their skill, in collaboration with speech and language therapists’ in meeting special communication needs. This gives residents a degree of control in their daily lives. Information is displayed in formats that aid understanding, using widget symbols and pictures, and written in easy read English. The home supports and positively encourages residents to keep in contact with friends and family. A relative commented, “ every Wednesday evening we have a call from our relative living in the home, via a web cam”. Another said, “ The home is brilliant in helping my relative keep in touch with us, they send a male carer to support and enable my relative to make home visits”. Residents’ are well supported by a new staff team who are committed to meeting the needs of residents. Members of staff consulted said they considered the home to be well managed. The physical environment has been tastefully upgraded and thought gone into the home’s décor and furnishings to ensure suitability for residents’ needs and lifestyles. What has improved since the last inspection? Admission procedures have been strengthened and care plans and risk assessments are now dated and signed by staff. The staff-training programme is ongoing. Quality assurance systems have been further developed and include use of a quality survey for relatives to give feedback. The dining room has been extended providing additional space, which has benefited residents. An en suite shower room has been modified to include a bath to meet the preference and needs of a resident. Additionally a bedroom adapted and furniture in the lounge has had sharp corners removed to enhance the safety of the environment for a resident who has seizures. Roseleigh DS0000067409.V346140.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Roseleigh DS0000067409.V346140.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 Roseleigh DS0000067409.V346140.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): Regulations: 1, 2 & 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives/representatives receive the information needed to enable an informed decision about the home’s suitability to meet individual needs and aspirations. Competent staff carry out inclusive comprehensive pre-admission assessments to ensure needs can be met. , They use appropriate communication methods to afford prospective residents choice in where they live. Good practice transition procedures enable prospective residents to be introduced to residents and staff and to experience living in the home before moving in. EVIDENCE: The home’s statement of purpose, which is the document describing who the home is for, is prominently displayed in the office. The deputy manager is currently producing a home brochure central to which will be the home’s value base and service objectives. These are the four key principles of the Government’s Valuing People Strategy - Rights, Independence, Choice and Inclusion. It was suggested that these consideration be given to further developing the statement of purpose document to expound how these values relate to residents transition into adulthood. Service users guides, the document that explains how the home works, are written in widget. This is a communication method using pictures and symbols Roseleigh DS0000067409.V346140.R01.S.doc Version 5.2 Page 10 to help residents understand, as far as practicable, what is written. Key workers explain the content of this document to residents after admission, over a period of time, taking this at a gradual pace. The service users guide has been recently updated to reflect changes within the home and the staff team since the home’s registration. The home’s admission policy is underpinned by equal opportunity principles and comprehensive assessments procedures are followed. These include assessment of risk, ensure needs can be met and consider compatibility with existing residents. The home manager and another staff member carry out pre-admission assessments. This is an inclusive process involving the prospective resident, relatives, relevant professionals and other agencies. The resident’s file examined contained evidence of a comprehensive assessment process and records of this individual’s transition from a residential college to the home. There had been three transition visits to the home including an over night stay. Pre-admission assessments are ongoing for a prospective resident and have been completed for another who has been offered a place. This person has visited the home on a number of occasions. He is gradually moving his possessions in and receiving support in personalising his bedroom. His file contained records of a comprehensive assessment of needs, care management assessment and care plan also educational assessments. Roseleigh DS0000067409.V346140.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): Standards: 6, 7, 8 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from person centred care involving them in decisions about their lives and in planning the care and support they receive. EVIDENCE: There were four residents accommodated at the home, two male and two female aged between 18 and 20 years. One resident was on leave staying with a relative at the time of the visit. The care files examined for two residents enabled judgements to be formed about how well the home is meeting these standards. The files contained essential life style plans developed from baseline assessments. It is recommended that these be produced in an easy read widget format for residents who would benefit from the same. Each plan contains aims for developing independent living skills, communication and participation in social and leisure activities. Risk assessments support independence and balance positive reasons for risk-taking against potential harm. Achievable, specific goals have been set aimed to give residents sense of achievement, developing Roseleigh DS0000067409.V346140.R01.S.doc Version 5.2 Page 12 confidence and self-esteem. One to one time is given to each resident on a weekly basis to work on achieving goals. Placement plans cover health needs, methods of communication (with specialist input from speech therapist for three of the four people living at the home) social, personal and educational development. Diversity and lifestyle needs are addressed and contact facilitated with family and friends. The home affords the same opportunities to all residents, irrespective of their gender. Staff are informed of residents’ religion. The manager states in information sent to the CSCI that none of the residents had shown interest in attending chuch and if they wished to do so, this would be accommodated. Care plans were up to date though not all had been signed by relatives on behalf of residents, signifying involvement in the process. Whilst care management reviews were stated to have taken place not all files contained a record of the same. The manager has agreed to contact care management to obtain these records. It was stated that the home intends to convene six monthly reviews involving residents, their relative/representative, managers and key workers, in between annual care management reviews. Notes of agreements and actions will be made and circulated to all participants and to care managers. The notes for residents will be produced in widget form and a copy kept in their files. The management of behaviour and deficits in social skills is supported by care plans and professional guidelines as necessary and underpinned by risk assessments. The local people with learning disabilities team is accessible for support and professional input when needed. The home’s staff training programme is designed to provide staff with the skills and knowledge required including understanding of autism. This enables provision of an appropriate and positive environment for residents, suited to their individual needs. Residents are supported in making choices in their daily lives. The ability to do this has been enhanced by staff’s use of communication tools and aids. Examples of these include PECS, board maker, social stories, basic signing and clear verbal communication. The deputy manager advised of plans for the future use of communication passports when developing health action plans. In the first year of the home’s operation as residents’ gradually moved in, staff have focused on getting to know each individual and on understanding their verbal and non-verbal means of communication. As trust and relationships between residents and staff has grown, opportunities for individuals to make some informed decisions and understand available options has increased. Residents changing needs and aspirations are monitored. Staff are committed to enabling residents’ to make the transition to adulthood and promote age appropriate activities and choices. At weekends or times when residents’ don’t have a structured activity, they have a choice to get up late if they so wish. Mealtimes are flexibly arranged around residents’ individualised activity timetables. Residents’ are encouraged and supported to engage in domestic routines and to share these responsibilities comensurate with levels of ability and understanding. On the Roseleigh DS0000067409.V346140.R01.S.doc Version 5.2 Page 13 day of the inspection a resident was involved in setting and clearing the dining table for the evening meal. Residents are supported and encouraged to choose what they wear and their own hairstyles. On the day of the visit a resident spent the morning buying new clothes with staff support and stayed out for lunch. She appeared very happy about her purchases showing staff what she had bought on her return. The same resident went to the cinema with a support worker, making an informed choice about the film. One resident was at college which is the same one he attended prior to moving into the home. This continuity has been of benefit to this individual’s development and health. Another resident was out all morning with one to one support in using local mainstream leisure centre facilities. They had been for a gym and swim session. Roseleigh DS0000067409.V346140.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): Standards: 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 enabled within individual levels of understanding and capacity to make choices about their lifestyles and to learn and develop life skills. A balanced, healthy diet is promoted with opportunity for choice of food. Residents are encouraged to be involved in the purchase and preparation of food. Opportunity is made for age-appropriate social, educational, cultural and recreational activities and for integration in community life. Residents’ rights and responsibilities are recognised and they are supported in maintaining and developing personal and family relationships. EVIDENCE: Residents each have a nutritional assessment undertaken by a nutritionist. A four weekly rotating menu is in operation with flexibility to accommodate residents’ choice. The menu is varied and stated to have been compiled with input from residents and a dietician Arrangements were being made to accommodate the special dietary needs of one resident. A resident was Roseleigh DS0000067409.V346140.R01.S.doc Version 5.2 Page 15 observed preparing and cooking his evening meal with one to one support. This is part of his goal planning and takes place weekly. A support worker prepared and cooked the evening meal for the remaining residents and staff. A resident was encouraged to be involved in setting and clearing the dining table. The two - course meal was observed to be substantial and wholesome and the presentation of the dining table was good. The dining room has been extended since the last inspection affording additional space to meet the needs of residents in accordance with the home’s stated purpose. Also to accommodate the number of staff and residents at the table when occupancy levels increase. Basic food hygiene training for staff was stated to be ongoing. Currently 40 of staff have undertake this training. The operation and routines of the home promotes individual independence, affording residents choice and respecting individuality. It was good to note staff have developed communication boards for a resident for the purpose of giving this individual better understanding of what is happening in this person’s life The home has made regular changes to residents’ individual activity timetables as interests change. College timetables have been reviewed and new college schedules planned. New activities are also being introduced, an example given was sailing. All residents access mainstream community activities to promote community presence and awareness. They access a wide range of activities which combine fitness, fun and learning new skill. A staff member is designated responsibility for organizing activities, focusing on indentifying needs and aspirations. Opportunities are explored for personal development and independence training, supporting residents to lead fulfilling lives. The organisation employs a staff member whose role includes finding meaningful occupation and opportunities for paid and voluntary work for residents. One resident enjoys doing a paper round once a week with staff support. Another resident is on a waiting list for a paper round. A holiday has been planned for each resident to meets their individual needs. It was stated that holiday venue options were discussed as far as possible with residents within their individual levels of understanding. It was noted one resident may not now be going on holiday on medical advice. Residents are supported in maintaining family relationships. One resident was stated to go home most weekends. To enable another resident to go home for visits staff transport that individual to his parent’s home and one and sometimes two staff remain with this individual to ensure appropriate and safe behaviour management. Feedback from this relative confirmed how much this arrangement is valued. Roseleigh DS0000067409.V346140.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): Standards: 18, 19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health and personal care is based on residents’ individual needs. The principles of respect, dignity and privacy are put into practice. Residents are not able to safely self medicate. They are protected by the home’s medication policies and practices and systems for regular medication audits are in place. It is essential for all medication errors to be notified to the CSCI EVIDENCE: Information provided by management and staff consulted suggests personal care support is managed in a dignified and sensitive manner. As far as practicable, privacy is respected whilst maintaining residents’ safety. Effort is made to support residents with intimate personal care by same gender staff . Residents are encouraged to do as much as they can for themselves within individual levels of ability. Two residents have clear guidance written in boardmaker, relating to their personal care routines, to enable their understanding and promote independence. Medication was securely stored in a metal medicine cupboard in the office and medication keys held by the person in charge. Records of staff training confirmed that with the exception of three bank workers who are university Roseleigh DS0000067409.V346140.R01.S.doc Version 5.2 Page 17 students and don’t work during term time, had undertaken in - house medication training. It was understood they mostly do not engage in medication practices and if they do are directly supervised. The in-house training is a half - day certificated basic medication session. This is designed to provide support workers with knowledge and practical skills to safely select, prepare and give different types of medicine to residents, a process referred to as ‘medication administration’. The deputy manager stated usually he or the manager mentors support staff until they are confident in giving medication and competent to do so. Some staff had completed an advanced medicationtraining course. It was stated that two staff were undertaken medication training provided by the home’s pharmacy supplier. The organisation has a nominated medication officer who provides the internal basic medication training for staff. Recent communication between the organisation’s responsible individual and the CSCI has clarified the medication officer’s qualifications. The medication officer is stated to be qualified to sign off staff undertaking the pharmacy’s medication training, levels one and two, as competent. The medication officer carries out monthly medication audits and these records were sampled. It was noted that occasional medication errors had been identified and remedial action implemented. Residents’ involved were unharmed. Discussed at the time of the visit was the requirement for all medication errors to be in future notified to the CSCI. This does not include medication spoiled but errors of medication omission or administration of wrong dose or wrong drug. It has been agreed that this omission will be rectified. Records of medication received were seen however medication disposal records could not be located. The manager has since confirmed these exist and were locked away. Medication supplies and records were sampled and found to be in order on the day of the inspection visit. Residents are registered with a general practitioner and have health action plans. All support is received to enable residents’ access to NHS healthcare facilities and primary and specialist services. Health care is monitored including nutrition and weights. Records were examined specific to the management of epilepsy. These residents are monitored by specialist epilepsy services. Clear protocols had been developed for the management of seizures and multiple seizures in order for staff to know when to alert paramedics. A resident is currently prescribed medication for administration in the event of multiple seizures. This is held in the home for administration by paramedics. Recommendation has been made by an epilepsy specialist for this individual to be prescribed an emergency drug that is orally administered. The home will first need to source suitable training for team. The staff-training programme includes epilepsy awareness and this is ongoing. Three staff have not had this training. To ensure the safety of residents with epilepsy the home employs one waking night staff who is instructed to directly check these individuals throughout the night every fifteen minutes. There is also a second member of staff sleeping on the premises who is on-call. The deputy manager stated there was at all times at least one staff member of staff on duty who had undertaken epilepsy awareness training Roseleigh DS0000067409.V346140.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): Requirements: 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 an open culture that supports and enables residents to express their views and any concerns. Staff have had safeguarding adults training and know how to respond in the event of an alert. The home’s complaint procedure needs to be developed and the organisation’s abuse procedure amended. EVIDENCE: The CSCI has not received any complaints about the home since its registration. The home’s complaints procedure is available in pictorial and written forms. These are displayed on a notice board just inside the office and in the service users’ guide supplied to all residents. On reviewing the complaint procedure it was recommended this be further developed to include timescales and stages of the complaint process. Also discussed was the need to log all concerns and complaints, action taken and outcome in the complaint record. In circumstances where there may be difficulty in distinguishing between concerns, complaints and disagreements about an individual’s care with a third party, it is important to also briefly log the issues and action taken and cross refer entries to information and correspondence in residents’ files. Complaint record keeping systems must provide an audit trail that can demonstrate complaints are taken seriouslyand an impartial response in trying to resolve problems. Roseleigh DS0000067409.V346140.R01.S.doc Version 5.2 Page 19 Staff consulted about residents’ ability to make a complaint acknowledged the need for advocacy owing to communication barriers. Staff said they would report any obvious indicators of residents being unhappy or in distress to the manager or person in charge. This action would enable appropriate support and any relevant procedures to be followed. As staff have gradually become familiar with residents’ individual ways of communicating staff have become more adept at recognising and interpreting changes in behaviours, the tone and pitch of verbal communication and their non-verbal communication, posture, gestures and facial expressions as signs of concerns and complaints or other problems. They try hard to find out the cause and to put things right, excluding physical illness and pain. There has been safeguarding adults’ referrals since the home’s registration. Staff received safeguarding adults awareness training as part of their LDAF induction. From discussions with individual staff members it was clear that they are aware of their responsibilities relating to safeguarding adults. They said they would report any concerns or suspicions of abuse to the manager or person in charge. If needed, staff knew that they could also refer any concerns to the home’s external management or to other agencies. In the event of an allegation of abuse, the home’s management stated the home would follow the Surrey Multi-Agency Procedure for Safeguarding Adults. A copy of the procedure is kept in the home and the home also has its own policies and procedures, including abuse and whistle blowing. The need for review and amendment of the home’s abuse procedure was discussed to ensure this is compatible with the multi-agency procedures. Residents personal money is safeguarded by the home’s financial procedures and checks and balances. The staff vetting procedures safeguard residents from harm. Roseleigh DS0000067409.V346140.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): Requirements: 24 & 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The physical environment is of a high standard and fit for purpose. It is domestic in scale and character, comfortable and well maintained. The home is clean and hygienic. EVIDENCE: The home is attractively decorated and furnished to a high standard and is domestic in style and character. The living environment is appropriate for residents’ lifestyle and needs and is clean, secure and well maintained. The organisation is prepared to go that ‘extra mile’ to ensure needs are met and residents happy and comfortable in their environment. Since the last inspection work has been completed on an extension, increasing dining space, which is of benefit to residents. An en suite facility has been adapted and a bath installed to meet the individual preference of a resident. A bedroom of a resident who has seizures has been modified to ensure his safety and furniture in the lounge had sharp corners removed. Roseleigh DS0000067409.V346140.R01.S.doc Version 5.2 Page 21 Residents were stated to be encouraged to bring furniture and personal belongings with them on moving into the home. Staff stated all residents’ had personalised their own rooms, reflecting individual tastes and interests. Staff adhere to a strict policy of not going into residents bedrooms when they are not present. They were also observed to knock on bedroom doors and to respect residents’ privacy. The only bedroom viewed was a ground floor vacant bedroom, which was stated to be typical of all bedroom provision. This was spacious and well furnished with sturdy, good quality furniture. Liquid soap and paper towels were provided in communal toilets and bathroom. The utility room is sited on the second floor and staff stated to support residents in carrying laundry up and down stairs. Products that may be hazardous to health have been risk assessed and COSHH products stored in locked provisions. There is a spacious, well maintained garden with a trampoline and a barbeque which have both been risk assessed in their use. The garden is not wheelchair accessible from the house but wheelchair user visitors can access the garden from the car park. Discussion took place with the deputy manager regarding the potential hazard of some steps without handrails, leading from a ground floor bedroom door opening onto the garden. It was stated the propective resident imminently due to occupy this room will be requested not to use this door to access the garden. It was also stated this was not a fire evacuation route. Roseleigh DS0000067409.V346140.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): Requirements: 32, 33, 34 & 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst staffing levels met the needs of residents the management of staff time and activities should be reviewed to ensure staff are able to take breaks. Staff recruitment practices must ensure a full employment history is obtained for prospective staff. Also Criminal Records Bureau (CRB) records and disposal must be in accordance with CRB policy. Progress is ongoing to ensure staff are fully trained and competent. Bank staff must have all statutory training and updates. EVIDENCE: The home has been operating since June 2006 and the staff team gradually built up in accordance with occupancy levels. Five full time and five part-time staff were employed at the time of the inspection visit, including the manager and deputy manager. It was stated the organisation employs three bank support workers who work during their holidays. The staff rota was sampled. Staffing levels are three support workers plus the manager during the week, on early shift and four support workers on late shifts throughout the week. This is adjusted dependent on occupancy. At night the home has one waking support worker and one member of staff sleeping in, Roseleigh DS0000067409.V346140.R01.S.doc Version 5.2 Page 23 who is on call. The manager stated that four staff on duty every evening for the four residents currently living at the home enables an individualised approach to activities. One resident generally has a two to one staffing ratio when out in the community. Residents also have one to one staff time to focus on their goals. The home manager was on duty at the outset of the inspection and planned to go off duty at 14.00 hrs, though on this occasion remained on duty until 15.30 hrs. Currently staffing shortfalls are covered from within the team and by use of bank staff. The home is able to draw on staff from other homes within the company if needed; conversely if too many staff are on duty owing to low occupancy levels staff may work in other homes within the group, if needed. The deputy manager is included in the home’s staffing levels and was on duty. at the time of the visit until 22 hrs; he was then undertaking a sleeping in/on call duty. The home operates shift patterns in which staff work 36 hours consecutively. This includes a mix of long days and early and late shifts also sleep in duties. The potential for staff fatigue working this type of shift pattern was discussed with the deputy manager. Though the home is not yet operating at full occupancy the dynamic activities programme for residents living at the home can sometimes pose difficulties for staff to take a break. This was understood to be more of an issue at weekends when three staff are on during the day and the manager off duty. At times when the two to one staffing ratio is necessary when using community facilities this leaves one staff to supervise and support those who do not want to go out. Staff contracts were stated to not specify staff break entitlements. Discussion with the responsible individual for the organisation following the visit clarified the expectation for managers to factor in time for staff to take breaks as part of the shift planning process. It is recommended this be reviewed. All staff on duty were friendly yet professional in their approach to residents, demonstrated understanding of their needs and awareness of each individual’s way of communicating. The organisation has a human resources manager. A review of staff recruitment procedures took place and two personnel files were examined. The home had just successfully recruited to a full time support worker vacancy. It was anticipated the new employee would be able to take up post in October or November on completion of the recruitment vetting process. Recruitment practices were overall in accordance with statutory requirements. Discussion had previously taken place with the responsible individual who is aware and has agreed to amend the job application forms to include requirement for a full employment history to be supplied. The manager was advised she must maintain a record for the team evidencing Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks have been carried out in accordance with CRB Policy; also for CRB Disclosures to be removed from personnel files and destroyed. It was agreed this would be Roseleigh DS0000067409.V346140.R01.S.doc Version 5.2 Page 24 carried out. Personnel files were confidentially stored and access restricted to the manager. The manager reported the team to be very dynamic and enthusiastic. The first eighteen months since registration has been spent heavily investing time and finances into staff training and development. The home purchases training from another source that do all relevant training which includes training under the Learning Disability Award Framework. An NVQ programme is ongoing to provide staff with a qualification in health and social care, using paperless course work. Four staff was stated to have NVQ qualifications also one bank worker. The support worker just appointed was stated to have the NVQ Level3 qualification in health and social care. Training records are kept for all staff and training certificates. The team training matrix was examined also the induction records of two staff. Staff employed on the bank who attend university had received some training but were not always available to take up the training opportunities available to the team. A record identifying staff training needs and of training planned was viewed. This demonstrated the homes’ management to be striving to ensure staff receive the required statutory and service specific training needed. Five staff had not yet undertaken basic food hygiene training and it was understood this was being arranged. Roseleigh DS0000067409.V346140.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): Requirements: 37, 39, 41 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s management and administration is based on sound policies and procedures. Quality assurance systems enable management to evaluate the quality of the services provided. The home works to a clear health and safety policy. Overall the health, safety and welfare of residents is promoted. EVIDENCE: The manager is registered with the CSCI and has relevant, extensive experience, an NVQ Level 4 qualification in management and has completed the registered managers award certificated training. Discussions with the manager confirmed her enthusiasm for shaping and developing this new service. Also a strong commitment to the provision of a quality service and highest standards of care and support at the home. The manager works Monday to Fridays and is supernumerary to staffing levels. Two support workers consulted expressed the view the home was well managed. They Roseleigh DS0000067409.V346140.R01.S.doc Version 5.2 Page 26 stated they were encouraged to make constructive contributions to how the home operates. The deputy manager has been in post one year and has worked with the manager in the past. He has relevant experience and an NVQ Level 3 qualification in health & social care. He is currently undertaking the registered managers award training. The deputy manager competently facilitated the inspection process throughout the visit. Discussions with the manager and deputy manager indicated they work well together and each has defined areas of responsibility. The deputy manager is part of the home’s staffing levels. When the manager is on leave and he assumes responsibility for the home’s management it was noted there can be days when he is not in touch with what is happening at the home owing to the shift pattern. He acknowledged this can sometimes detract from the home’s management. It is suggested that this be reviewed and the deputy manager works the manager’s duties in her absence. The office is well located on the ground floor to enable unobtrusive monitoring of practice and residents’ well being. Records were well organised and residents’ personal records were confidentially stored. There is another office on the second floor which is the office base of the organisation’s general manager. Though not ideal to have an office for an external manager in the residents’ home it was stated this was infrequently used and the privacy of the residents’ home respected by the general manager. Staff can access this office for meetings. Examination was made of a number of systems and records relating to the health, safety and welfare of residents and for safe working practices. Whilst generally these were considered satisfactory it is recommended that the local Surrey Fire & Rescue Fire Safety office be consulted in the current practice of key locking the front door. Consideration could be given to providing a spare key in a break glass box by this door; as an alternative a door lock could be fitted which is integral to the fire system that automatically releases if the fire alarm is activated. The home has a no smoking policy and none of the residents are smokers. A health and safety and fire safety risk assessment was seen. Systems appeared adequate to safeguard residents finances and arrangements reported for daily checks of records and cash tins. Accident records are maintained and staff training is ongoing to ensure appropriate completion of risk asessments and incident forms. Various systems are in place for self-monitoring and review of the home’s services. The quality assurance system includes a recent survey of residents’ relatives. It was not clear what mechanism had been used to communicate the outcomes of this survey to residents within individual levels of understanding, Roseleigh DS0000067409.V346140.R01.S.doc Version 5.2 Page 27 their relatives and professional stakeholders. There is a need to ensure this takes place. The audit identified some shortfalls and the team and the organisation has worked hard to improve these areas. A relative who responded to the CSCI survey identied the need for improvement in the home’s communication systems. It was noted that the home’s management is aware of this. It was stated they continue work on this through constant reminders to staff of the importance of communication at staff meetings and through one to one staff support arrangements. This same relative also stated the home makes a real effort to get to know residents’ as individuals and enabling residents to use mainstream services. Comments from a second relative included “are wonderful, they provide great care, the home is always clean and tidy and this organisation has completely revolutionised our lives”. Roseleigh DS0000067409.V346140.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 3 2 3 3 x 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 4 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 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 3 x 3 x 3 x 2 2 x Roseleigh DS0000067409.V346140.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? Yes 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. Standard YA22 YA23 Regulation 17(2) 13(6) Requirement For a record of all complaints and include the action taken in respect of the complaint. For the homes safeguarding policy and procedure to be amended to ensure this is compatible with local multiagency guidance and procedures. For staff recruitment procedures to include obtaining a full employment history and job applications amended. All staff including bank staff must receive all statutory training. The previous timescale for all staff to receive basic food hygiene training has not been met. CRB record keeping and disposal must be in accordance with CRB policy. Timescale for action 30/09/07 30/09/07 3. YA34 19 (1)(a) 07/09/07 4. YA35 18 (1)(a) 30/10/07 5. YA41 10(1) 30/10/09 Roseleigh DS0000067409.V346140.R01.S.doc Version 5.2 Page 30 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 YA6 YA6 Good Practice Recommendations For care plans and goal to be produced in a format suitable to aid residents’ understanding. It is recommended that the home maintain its own record of discussions and agreed actions arising from care management reviews for reference in the event that a copy is not received from purchasing ‘authorities’. For the complaint procedure to be further developed. For review of shift planning, activity timetables and weekend staffing levels to ensure time for staff breaks is built into each shift. For contact to be made with a Surrey Fire & Rescue Adviser in respect of the fire safety matter practice detailed in the body of this report. 3. 4. 5. YA22 YA42 YA42 Roseleigh DS0000067409.V346140.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Roseleigh DS0000067409.V346140.R01.S.doc Version 5.2 Page 32 - 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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