Inspection on 13/09/07 for Rosemere

This inspection was carried out on 13th 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 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rosemere 25/09/06

Rosemere 30/01/06

Rosemere 28/07/05

Rosemere 03/12/04

Rosemere 12/10/04

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 Rosemere Rosemere Brookfield Close Ottershaw Surrey KT16 0JL Lead Inspector Lesley Garrett Unannounced Inspection 13th September 2007 11:30 Rosemere DS0000013773.V344000.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 Rosemere DS0000013773.V344000.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. Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosemere Address Rosemere Brookfield Close Ottershaw Surrey KT16 0JL 01932 872361 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) RBeedasee@nsurreypctnhs.uk Welmede Housing Association Ltd Rajen Beedasee Care Home 6 Category(ies) of Dementia (1), Learning disability (6) registration, with number of places Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th September 2006 Brief Description of the Service: Rosemere is a home for up to six young adults who have learning disabilities and who may display challenging behaviour. The home is a purpose built bungalow, situated in a residential area of Ottershaw. It has a level garden and car parking is available in front of the building. Amenities including shops, pubs and public transport are available nearby. Welmede Housing Association, who runs a network of homes in the area, manages the home. The North Surrey Primary Care Trust (NSPCT) employs staff at the home. The building is owned and maintained by the Hyde Housing Group. The fees at this service are £ 1425.00 per week. Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 11:30 and was in the service for three hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. We asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. The manager completed an AQAA which is a self assessment quality document which also assisted with the site visit. We looked at how well the service was meeting the standards set by the government and have in this report made judgements about the standard of the service. We would like to thank the service users and staff for their hospitality during this visit. What the service does well: The documentation, which includes the person centred plans, health plans and risk assessments, is of a good standard and is regularly reviewed and there was evidence of service user involvement. The home benefits from a stable staff team, which has allowed both staff and people who use the service to get to know one another and form good relationships. On the day of the site visit staff were observed to sit and eat lunch with the individuals and then to relax in the lounge afterwards to enjoy a television programme. A variety of activities are available to the people who use the service and on the day of the site visit some individuals had been shopping and another engaged in an aromatherapy session. From the evidence seen by the inspector and comments received, we consider that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 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 Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 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. 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. The arrangements in place for assessing needs are good ensuring prospective individuals needs and aspirations are assessed before admission to the home. EVIDENCE: It was stated that in the past seven years there has only been one new admission. The manager does all pre-admission assessments and we were told that this is a gradual process. Prospective individuals are encouraged to visit the home and stay for a meal. During the last admission the parents were also involved and visited the home prior to admission. Documentation for this process was observed and is a good standard. Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 67&9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has developed good care plans and risk assessments. The documents were current and well recorded to ensure that the people who use the service have their health needs met. Individuals make decisions regarding their lives and participate in the running of their home. EVIDENCE: We sampled two individuals person centred plans (PCP) and they contained evidence that each person that uses the service had been involved in the development of their plan as they were signed by them to confirm agreement. The manager stated in their AQAA that the home involves the individuals with these plans. The plans sampled covered all aspects of personal care, social support and healthcare needs. It was observed and evidenced in the AQAA that all people who muse the service have a Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 Page 10 Keyworker and staff have been at the home for five years and more therefore know the individuals well. All decisions made by the individuals are well documented in their PCP’s. It was observed that one individual has a picture board in place to aid with their communication. Individuals have access to their finances when they need to as their personal allowance is kept in the home. Two accounts were sampled and found to be correct with invoices, withdrawals and deposits all recorded in their individual books. The boxes are checked every day at the beginning of a shift to ensure that they are correct. We were also told that individuals are also able to visit the bank if they wish to do so. We observed in the PCP’s that good risk assessments were in place for day to day activities and also environmental risk assessments for the home. Also in their plans were good notes that were written for when individuals went on holiday. One survey returned to us stated that the home helped their relative to make choices in their daily life to ensure their safety as they were unable to this themselves. Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 Page 11 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. The home promotes and maintains service users involvement in their community, offers appropriate activities and maintains friendships. Service users are encouraged to be involved in the running of the home and improving daily living skills. The available choice of food provided was of a good standard. EVIDENCE: We observed that the people who use the service could attend a variety of activities according to their assessed needs. This includes adult education classes, keep fit, yoga, dancing and drama. On the day of the site visit two individuals were having an aromatherapy session and the deputy manager had taken two individuals shopping that morning. Access to the community is encouraged and the manager stated that some could attend the local church on Sundays. Every month the keyworker spends the day with their individual doing something special for them for example out Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 Page 12 for a meal. Shopping is enjoyed by the individuals both for personal items and shopping for the home. Family links are maintained where possible and visitors are welcome at any time. The home has a small lounge that can be used for private visits or they can use their own bedroom. One survey returned to us stated ‘most importantly to us a room is provided where we can be with or relative for a private visit’. Staff explained to us that every weekend there is a meeting where the people who use the service are involved in planning the meals for the week. At least three of the individuals can prepare lunch for themselves, which usually consists of a sandwich or snack. The main meal of the day is taken in the evening and the staff cooks this with the assistance of the individuals in the home where there is a rota for preparing and cleaning away. We were also told that all meals are health with plenty of fruit and fibre encouraged. The home has the assistance of a dietician when necessary and one individual has a care plan that demonstrated their input to loose weight in a health way. We observed in the individual PCP’s that nutritional risk assessments were in place and weights are monitored regularly. Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 Page 13 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. The home has documentation to evidence that service users receive personal care and attend health care appointments to ensure their wellbeing and welfare. The homes medication procedures are robust to ensure the safety and wellbeing of service users. EVIDENCE: The care plans sampled included clear records to demonstrate that service users receive personal care in the way they prefer and health care appointments were attended, for example visits to the dentist, optician and general practitioner (GP). Records to monitor the service users’ specific health care concerns were also well documented and included weight charts and special diets. The health care records also evidenced that the home had close working relationships with health care professionals such as care managers, dieticians and speech and language therapists. Records indicated that care plan reviews had taken place and the home were active in seeking advice and support from Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 Page 14 healthcare professionals should the need arise to ensure the safety and well being of the service users. The home has a medication policy and all staff that dispenses the medications has training and records were seen. The manager said they use a local pharmacy and medicines are dispensed in bottles in tablet or liquid form. It was observed as good practice that for some individuals protocols were in place for the administration of mood altering medicines. Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a robust complaints procedure to demonstrate that complaints will be acted upon and a Safeguarding Adults policy and procedure to ensure that service users are adequately protected. EVIDENCE: The home has a complaints policy and the acting manager explained that no complaints have been received by the home since the last site visit and no complainant has contacted the Commission with information concerning a complaint either. The complaints policy is also in easy read format and was observed in the people who use the service PCP’s. The home has a safeguarding adults policy and this is in line with the local authorities procedures. All staff has received training and this is carried out every two years. The manager stated that there have been no referrals under these procedures. Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a safe well maintained home which is comfortable, homely, clean and hygienic but in need of some refurbishment. EVIDENCE: A tour of the building took place and it was clean, tidy and the bedrooms had been personalised to reflect the individual’s tastes and preferences. The lounge has been decorated and new settees and chairs have been purchased also a new dining table and chairs. One survey returned to us stated ‘improvements have been made in the living area regarding comfortable seating’. The manager stated that he is aware of further planned refurbishment as the kitchen is about to be replaced this year. A requirement was made at the last site visit in 2006 for consideration to be given for the bathroom to be refurbished. This remains outstanding as the providers were leasing the building. The manager showed us documentation that stated the bathrooms could now be considered, as the building is no longer leased. The home has only one bathroom and the shower in there is not working. The bathroom Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 Page 17 should remain a priority for Welmede, the providers, to address and this has been made a requirement at the end of the report. The home has a laundry room and the manager stated that the staff does all the washing for the individuals. Some of the cupboards in this room need repairing as at least one door was hanging off. There is a garden, which the individuals have safe access to. There is a covered barbeque area and a further patio and lawned area. Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 Page 18 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. A competent and qualified staff team supports the people who use the service, which have undergone training. Recruitment practices at the home protect individuals in the service. EVIDENCE: Staff are supported to undertake all aspects of training and this includes the National Vocational Qualification (NVQ). The manager stated that all members of staff have the level 2 qualifications. The home benefits from a stable staff team and the manager mentions this in the completed AQAA. Two employment folders were sampled and all the necessary checks had been made prior to any member of staff being employed. We observed that the home provides training for members of staff and this included safeguarding adults, first aid and food hygiene. The manager stated that the providers send to the home a list of training courses that is available to all staff which is extra to the mandatory elements. The manager said that Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 Page 19 during supervision session’s staff could choose the courses they would like to participate in. All staff receives induction training, which is linked to a nationally recognised programme. Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 Page 20 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 well run and service users can be confident that their views are listened to. The health and safety of the people who use the service are protected. EVIDENCE: The manager has been registered with the Commission since February of this year and already held his registered managers award. He stated that he has good support from his managers and is able to continue his professional development with regular training courses. The manager stated that quality survey forms are sent to relatives, friends and other healthcare professionals every year. The results of the surveys go to the management team and an action plan is produced from these results. Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 Page 21 The home also completes quality audits for the home and different aspects of home life are looked at. The home has recently completed surveys on the individual PCP’s and individuality and choice. The manager has visits from his line manager every month where all areas of the home are looked at and the information is then stored at the home. We also saw evidence that meetings are held every month and are attended by both staff and the people who use the service and minutes are kept. We observed on the completed AQAA that the manager provided that health and safety checks are carried and the results are documented. Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 Page 22 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 2 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 Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 Page 23 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 Standard YA24 Regulation 23 Requirement The home should now continue its programme of refurbishment to include the bathroom, as the home is now able to do this. Please inform CSCI of the plans for this room to make us aware of when work will now start. Timescale for action 13/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate 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 Rosemere DS0000013773.V344000.R01.S.doc Version 5.2 Page 25 - 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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