Inspection on 25/09/06 for Rosemere

This inspection was carried out on 25th September 2006.

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

Rosemere 13/09/07

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 Sandra Holland 25 th Unannounced Inspection September 2006 10:00 Rosemere DS0000013773.V312810.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.V312810.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.V312810.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) Welmede Housing Association Ltd To be confirmed Care Home 6 Category(ies) of Dementia (1), Learning disability (6) registration, with number of places Rosemere DS0000013773.V312810.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: UNDER 65 YEARS OF AGE 30th January 2006 Date of last inspection 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. The home is managed by Welmede Housing Association, who run a network of homes in the area. Staff at the home are employed by the North Surrey Primary Care Trust (NSPCT). The building is owned and maintained by the Hyde Housing Group. The fees at this service are £ 1395.00 per week. Rosemere DS0000013773.V312810.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was the first to be carried out in the Commission for Social Care Inspection year, April 2006 to June 2007 and was carried out under the “Inspecting for Better Lives” programme. Mrs Sandra Holland, Lead Inspector carried out the inspection over seven hours. Mrs Patma Hurst, Senior Support Worker and shift leader was present representing the service. The Manager, Mr Rajan Beedasee arrived later for the afternoon shift. Areas of the home were seen and a number of records and documents were sampled, including residents’ contracts and individual plans, medication administration record (MAR) charts and staff files. During the course of the day, all six residents, three staff and a visiting “floating” support worker were spoken with. A pre-inspection questionnaire was supplied to the home at the time of the inspection and this was completed and returned within the requested timescale. Some of the information supplied in the questionnaire will be referred to in this report. The people living at the home prefer to be known as residents and that is the term that will be used throughout this report. The inspector would like to thank the residents and staff for their hospitality and support. What the service does well: The service is run as a home, with residents being involved as fully as possible in the day-to-day activities and tasks. Staff members and residents were observed to have a relaxed, friendly relationship and the atmosphere in the home was warm and homely. The residents are supported by the home to be active members of the local community. There is a timetable of work and leisure activities in place and the home has a vehicle for transporting residents to and from these. Residents appeared to be very well supported, with staff encouraging residents to be independent as much as possible and to make their own choices. A resident was happy and proud to show his bedroom to the inspector. Rosemere DS0000013773.V312810.R01.S.doc Version 5.2 Page 6 Members of staff spoken with said that they are happy working at the home. Most of the staff have worked there for many years and demonstrate a high level of understanding and knowledge of the residents’ individual needs. 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. Rosemere DS0000013773.V312810.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.V312810.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes statement of purpose and service user guide are to be updated. Residents must be supplied with all the required information regarding the terms and conditions for living at the home. Thorough assessments of the needs of any prospective resident are carried out, before they are admitted to the home. EVIDENCE: The home holds a detailed Statement of Purpose and Service User Guide, which would be made available to any prospective residents, to provide information about living at the home and the service provided. It was noted that this was outdated and referred to the previous manager, to the National Care Standards Commission (NCSC), not CSCI, and the annual fees specified were no longer accurate. The manager stated that these would be updated and new copies of these documents (or the relevant pages), would be supplied to CSCI. Each resident is supplied with a Welmede Licence Agreement, stating the terms of living at the home. These specify the residents’ contributions to the fees for living at the home, and all had been signed by the resident or their representative. The licence agreements do not state who pays the balance of the fees. The manager advised that all the residents are financially supported by local authorities, but the names of the local authorities, the amounts paid or Rosemere DS0000013773.V312810.R01.S.doc Version 5.2 Page 9 how these are paid, are not recorded in the home. This information and a copy of the agreement held with the relevant local authority must be made available to residents. A requirement was made at the inspection carried out on 30th January 2006, that this information must be supplied to the resident, and a timescale of 21st April 2006 was given, but this has not been met. There have been no new residents admitted to the home since the last inspection, but staff were able to advise of the thorough assessment procedure that is undertaken before a new resident would be accepted to live at the home. As most applicants to live at the home are supported financially by local authorities, a detailed assessment of their needs would be carried out under the care management process and a copy of the assessment would be obtained. Staff advised that any new or prospective resident would be introduced very gradually to the existing residents, to ensure that they were not unsettled or disturbed by a new member of the household. Requirements have been made regarding Standards 1 and 5. Rosemere DS0000013773.V312810.R01.S.doc Version 5.2 Page 10 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): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The support requirements and needs of residents are detailed in their individual plans and are regularly reviewed. Residents are supported to make their own decisions and choices. Any risks to residents are identified, assessed and monitored. EVIDENCE: From the residents’ individual plans, it was clear that their assessed and changing needs have been recorded in detail to ensure that staff have comprehensive guidance as to the support needs of each resident. These include social and occupational needs, personal care needs, behavioural and communication needs and the support required to be involved or to develop, household skills. It was pleasing to see that daily notes record progress or activity against the numbered areas of the individual plan. This ensures that staff can see at a glance which areas have been recently assessed, or where changes have occurred. The manager advised that individual plans are reviewed every three Rosemere DS0000013773.V312810.R01.S.doc Version 5.2 Page 11 months to ensure they accurately reflect the needs of residents and records of this were seen. Staff were observed to enable residents to make their own decisions, offering choices and providing residents with time to decide and to respond. Residents were seen to have free access to all parts of the home and to move around the premises as they wished. To assist one resident in decision making, staff advised that pictures of daily activities are offered and the resident then makes a choice from these. This format is also used to guide a resident to acceptable behaviours when taking part in social activities, as challenging behaviour has been displayed from time to time. Residents are encouraged to be independent in as many aspects of their lives as possible staff advised. Where this involves any element of risk this has been assessed to ensure that the risk can be minimised if possible, or managed with support from staff, for example. One resident was having a bath alone during the inspection period. Staff advised that the resident could manage independently once the bath water was prepared and had been checked to ensure it was the correct temperature. A member of staff then maintained the resident’s privacy and safety, by knocking and asking through the door, if the resident required any help. A new risk assessment has been drawn up for a resident who recently left the premises without the knowledge of staff and was found unharmed at a local shop. Staff stated that this had not happened before and is an indication of a changing need. Further measures have been put in place to safeguard residents. Rosemere DS0000013773.V312810.R01.S.doc Version 5.2 Page 12 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): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents take part in a range of activities and are active members of their community. Residents are well supported to maintain appropriate relationships and are offered a well-balanced diet. EVIDENCE: A comprehensive programme of activities is in place and a large wall chart in the office displays this and is accessible to residents and staff. Resident’s individual activities are recorded in their support plans and a record is kept in the daily notes for each resident as to the activities, both inside and outside of the home, that residents take part in. These activities include yoga, going out for meals or to the pub, bingo at a local centre, shopping, swimming and bowling. One resident was going out at the time of the inspector’s arrival and told of going bowling and out for lunch afterwards. It was clear that the resident was looking forward to this and to the company of the one-to-one “floating” support worker who was to accompany him. The support worker advised that Rosemere DS0000013773.V312810.R01.S.doc Version 5.2 Page 13 he provides additional support to residents, over and above that provided by staff in the home, and this is provided twice a week for one resident at Rosemere. It was clear that residents are encouraged to be active members of their local community. Three residents went for a drive with a member of staff during the morning and chatted happily on their return. Residents spoke of their holidays and of being happy at the home. Two residents spoke of the jobs they carry out and staff confirmed that three residents work part-time at a local day centre. Residents were seen to be at ease in the company of staff and were very much “at home” in all parts of the premises. Staff advised that five of the six residents have active family relationships and that visitors are welcomed. The brother of a resident was due to visit on the day of inspection, but telephoned to advise that he could not attend due to transport problems. One resident has a boyfriend who lives in another local home and staff advised that they provide support to the resident to enable her to visit him and to keep in touch. Residents were seen carrying out their household tasks which were undertaken willingly and with confidence, and preparing drinks and snacks for themselves. Staff advised that meals are planned to enable effective shopping to take place, but residents can choose alternatives if preferred. From the record of food served and the two week menu supplied with the pre-inspection questionnaire, it was clear that residents receive a well-balanced and healthy diet. Rosemere DS0000013773.V312810.R01.S.doc Version 5.2 Page 14 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, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive support in the way they prefer and their healthcare needs are well met. Medication administration appears to be effectively managed. EVIDENCE: Staff were observed to speak to residents in a friendly, informal, but appropriate manner, which showed respect to residents. It was clear that residents’ individual preferences were accommodated, with one resident having a bath at a time of their choosing, followed by their mid-morning breakfast. Support with these activities was given discreetly and was kept to the minimum required, to promote the resident’s independence. It was pleasing to hear from staff that a key-worker system is in place, with each resident allocated a key-worker and a co-key-worker. This ensures that residents benefit from continuity and consistency of support, even if their keyworker is away from the home, such as on leave or sickness absence. It was clear from speaking to staff and from the records seen, that the healthcare needs of residents are well met. A record is maintained in the residents’ individual plans of the support provided by healthcare professionals, including general practitioners (GP’s), community nurses, dentist, optician, and Rosemere DS0000013773.V312810.R01.S.doc Version 5.2 Page 15 chiropodist. If required, referrals are made to specialists such as psychiatrists and speech and language therapists by residents’ GP’s. The administration of medication appears to be effectively managed. Staff advised that medication is supplied to the home by a local pharmacy, and staff who administer medication have received training provided by the pharmacy. A record was seen of the last monitoring visit carried out by the pharmacist in June 2005. As this was more than a year ago, it is recommended that an updated visit is arranged, to ensure that the home’s medication procedures, practice and storage meet current requirements. Medication was seen to be appropriately stored and when the stock of medication held in the home was checked, this accurately matched the record held. A record had been signed by staff, to show that they had read and understood the Royal Pharmaceutical Society policy regarding the administration of medicines in care homes. A recommendation has been made regarding Standard 20. Rosemere DS0000013773.V312810.R01.S.doc Version 5.2 Page 16 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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. No complaints have been received since the last inspection. Staff are aware of the changes in residents behaviours which would indicate that they were unhappy. Most staff are aware of their responsibilities in the protection of residents. EVIDENCE: The home’s complaints procedure is made available in written or pictorial format and is included with each resident’s licence agreement. A complaints and compliments record is maintained but it is pleasing to see from the preinspection questionnaire, that no complaints have been received since the last inspection. The shift leader advised that some residents are able to make a complaint verbally, but that staff would be aware of any resident’s unhappiness, by changes in the resident’s behaviours, facial expressions or body language. If these were observed or noted, staff would immediately look into the reasons for the changes. The manager stated that in the event of any incident or suspicion of abuse, the home would follow the Surrey Multi-Agency procedure for the safeguarding of vulnerable adults. A copy of the procedure is kept in the home and was seen to be the most recent version. The Welmede policy and procedure regarding abuse links with and refers to, the Surrey policy. A Whistle-blowing policy and procedure and the Department of Health document “No Secrets” are also available in the home, to guide staff in the event of any concerns regarding abuse. Rosemere DS0000013773.V312810.R01.S.doc Version 5.2 Page 17 It was of concern that a member of “bank” staff working in the home, but who usually works in another Welmede home, stated that he had not received any training in the safeguarding of vulnerable adults. The staff member was aware that any concerns or allegations of abuse must be reported to the manager or person in charge, but was not aware of the types of abuse that may occur. During the morning of the inspection, the staff member had taken three residents out for a drive in the home’s vehicle. From the training records seen, it was evident that the home’s directly employed staff had received training in the safeguarding of vulnerable adults, but no records are held for bank staff. As it is required that all staff working in the home must receive training appropriate to the role they carry out, it is recommended that a system is established to ensure that any additional staff supplied to work at the home are appropriately trained, and that their training is kept up to date. A recommendation has been made regarding Standard 23. Rosemere DS0000013773.V312810.R01.S.doc Version 5.2 Page 18 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, 26, 27 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is suited to their needs with attractive individual bedrooms and sufficient communal space. Three areas requiring attention have been reported to the owners of the building. The home is clean, fresh and appears hygienic. EVIDENCE: The home is a detached bungalow set in its own enclosed gardens and is well suited to the needs of residents. It has been decorated and furnished in a comfortable and homely style, is light and freshly aired and generally well maintained with just three shortfalls observed. It was noted that the bathroom appeared worn and tired and does not present as an attractive place to bathe. The bath surface is very worn and marked, the sealant around the bath where it meets the tiles, has discoloured and looks very unappealing and the non-slip flooring has also discoloured through wear. Although the window is high and does not present a problem with privacy, there is no curtain or blind to soften the appearance of the window. Rosemere DS0000013773.V312810.R01.S.doc Version 5.2 Page 19 The top of the radiator cover in the dining area of the lounge has been broken off and removed, but this leaves the radiator accessible. Whilst this is not currently a risk to residents, because the radiators are not in use, this could present a burning risk, if and when the heating is turned on. As the weather is becoming autumnal and colder, the heating may need to be turned on in the very near future. The office carpet is very marked and needs to be cleaned or replaced. The manager and staff stated that they have reported these matters to the housing association which owns and manages the premises and are waiting for them to be attended to. Estimates of the price for having all the carpets in the home cleaned, are being obtained the manager advised. Contract gardeners were attending to the gardens on the day of inspection. Each resident has an individual bedroom with basin which is well furnished and equipped to meet the needs of residents. Residents are provided with keys to their bedrooms and a resident unlocked his door and proudly showed his room. It was decorated in cheerful colours and contained the resident’s own belongings including a music centre, television and pictures. As all the residents are fully mobile, no physical adaptations have been required to the home. All areas of the home that were seen were clean and tidy and appeared hygienic. Hand-washing facilities are provided in appropriate places and are supplied with liquid soap and paper towels. A requirement has been made regarding Standard 27. Rosemere DS0000013773.V312810.R01.S.doc Version 5.2 Page 20 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): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a small and stable team of staff who receive training appropriate to their role. Recruitment of staff appears to be effectively carried out. EVIDENCE: From the information supplied with the pre-inspection questionnaire it was clear that residents are effectively supported by a small and stable team of staff. There have been no changes within the staff team since the last inspection which ensures continuity and consistency of support for residents. The shift leader advised that a small number of bank staff are used to supplement the staff team when the home’s own staff take annual leave or have sickness absence and that no agency staff are used. It was pleasing to hear that the shift leader and two other staff have achieved NVQ Level 3 in care and two other members of staff are undertaking this or level 2 in care. The manager stated that he is an NVQ assessor and that only two staff have yet to undertake this training. Rosemere DS0000013773.V312810.R01.S.doc Version 5.2 Page 21 The recruitment of staff appears to be effectively carried out. The files of a number of staff were seen and for these staff, all the required information and documents had been obtained. The manager advised that the deputy manager takes the lead in organising staff training and maintaining a training record for each member of staff. A recent review of staff training records had been carried out the manager stated, to establish what training was required. From the records seen , it was clear that staff undertake training required by law, including fire safety, food hygiene and first aid, as well as training to develop knowledge and skills such as conflict management, infection control and Control of Substances Hazardous to Health (COSHH). The resident group and the staff team are both of mixed gender, and there is cultural and racial diversity amongst the staff team, although this is not reflected in the resident group. Rosemere DS0000013773.V312810.R01.S.doc Version 5.2 Page 22 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 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager needs to submit his application for registration with CSCI. A survey of the quality of the service offered has been carried out but needs to be extended to all those involved in the support residents. Products hazardous to health must be stored in locked provisions. EVIDENCE: The manager advised that he was appointed in January this year, that he is a qualified nurse (RMN), has undertaken and completed NVQ level 4 and is an NVQ assessor. The manager had previously managed another local Welmede care home that had closed. An application for registration by CSCI was submitted by the manager but was returned to him because the documentation was not correct. This must be re-submitted without delay with the correct documentation. A quality survey using previously supplied pictorial, CSCI, forms was supplied to all residents earlier this year the manager stated, and these were completed Rosemere DS0000013773.V312810.R01.S.doc Version 5.2 Page 23 with the support of key-workers. A number of these were seen to contain positive responses in the main. One resident responded that they liked the activities that are carried out and being able to help themselves to drinks and snacks. It is recommended that any future quality surveys are supplied to all those involved in the support of residents, to obtain a wider and more independent view as to how the home is meeting the needs of residents. This should include residents’ families, friends and representatives, GP’s, day service staff, and any visitors such as hairdresser or chiropodist. A number of records relating to health and safety matters were sampled. These records were seen to be carried out to the required frequency and checks, such as those of the temperatures of fridges and freezers and of hot food served, were observed to be within appropriate ranges. During a tour of areas of the home, products hazardous to health were found to be stored in unlocked cupboards. Two bottles of bathroom cleaning liquids were stored in the bathroom cabinet which is not fitted with a lock. Dishwasher powder was stored in an unlocked kitchen cupboard, although it was fitted with a lock. Action was taken immediately to safeguard residents. The bathroom products were removed by the shift leader to the appropriate locked cupboard and the cupboard in the kitchen was locked. Requirements have been made regarding Standard 37 and 42. recommendation has been made regarding Standard 39. A Rosemere DS0000013773.V312810.R01.S.doc Version 5.2 Page 24 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 2 2 3 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 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 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 2 X 2 X 2 X X 2 x Rosemere DS0000013773.V312810.R01.S.doc Version 5.2 Page 25 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 Standard YA1 Regulation 4 and 5 Requirement The home’s statement of purpose and service user’s guide must be updated and a copy of these must supplied to CSCI. The registered person must develop and agree with each resident, a written and costed contract / statement of terms and conditions between the home and the service. Where a local authority has made arrangements for the provision of accommodation or personal care to a service user, a copy of the agreement specifying the arrangements made must be supplied to the service user. Timescale of 28/07/05 and 21/04/06 not met. The premises of the home must be kept in a good state of repair. Specifically the bathroom needs to be refurbished, the lounge radiator needs to be repaired and the office carpet needs to be cleaned or repaired. The manager must apply for registration with CSCI. DS0000013773.V312810.R01.S.doc Timescale for action 22/12/06 2 YA5 5(3) & 17 (2)Sch. 4 22/12/06 3 YA24 23 22/12/06 4 YA37 9 (1 & 2) 22/12/06 Rosemere Version 5.2 Page 26 Timescale of 21/04/06 not met. 5 YA42 13 (4)(c) All areas of the home to which service users have access must be, as far as reasonably practicable, free from hazards to their safety. Specifically, products hazardous to health must be stored in a locked provision and the radiator in the lounge must be covered. 25/09/06 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 YA20 YA21 Good Practice Recommendations It is good practice to ensure that pharmacy monitoring visits are carried out at regular intervals. The policy regarding the dying or death of a resident should be reviewed and revised to include support for residents and staff. It is good practice to ensure that any bank or agency staff used are appropriately trained and that their training is up to date. The system for reviewing the standard of the service offered should be extended to all those involved in the support of residents. 3 4 YA35 YA39 Rosemere DS0000013773.V312810.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. 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