Inspection on 28/07/05 for Rosemere

This inspection was carried out on 28th July 2005.

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

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

Other inspections for this house

Rosemere 13/09/07

Rosemere 25/09/06

Rosemere 30/01/06

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 Brookfield Close Ottershaw Surrey KT16 0JL Lead Inspector Sandra Holland Announced 28 July 2005 10:00 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 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 Stationary 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 H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Rosemere Address Rosemere Brookfield Close Ottershaw Surrey KT16 0JL 01932 872361 Telephone number Fax number Email 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 Byfleet House, 2 Guildford Road, Chertsey, Surrey, KT16 9BJ Mr Appalsamy Goonniah Care Home (CRH) 6 Category(ies) of Learning disability (LD), 6 registration, with number Dementia (DE), 1 of places Rosemere H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 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 Date of last inspection 03 December 2004 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. Rosemere H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was the first to be carried out in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. The inspection was carried out over six and a quarter hours, by Mrs, Sandra Holland, Lead Inspector. Mr. Sam Gooniah, Registered Manager was present representing the service. A tour of the premises was carried out and a number of records and documents were examined, including medication administration records (MAR), staff files and resident’s individual plans. Five residents and four members of staff were spoken with. It was a positive inspection and the inspector wishes to thank the residents, manager and staff for their hospitality, time and assistance. The people living at the home prefer to be known as residents and that is the term that will be used throughout this report. What the service does well: What has improved since the last inspection? The resident’s (service user’s) guide to the home has been updated to make it specific to Rosemere and the residents living there. Records of medication administered are now being made accurately. Any changes to the menu are now recorded on the menu. Rosemere H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 Page 6 A computer has now been provided at the home to enable access to the Internet for research purposes and for ease of record keeping. 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 H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Rosemere H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3 4 and 5. A full assessment of prospective residents is carried out and prospective residents are welcomed to visit the home. EVIDENCE: Since the last inspection a new resident has moved into the home and the manager was able to explain the process that was carried out before the new resident was accepted. The home has a printed resident’s guide (also known as a service user’s guide), which contains information about the home and the services available. The manager advised that this is available in the Makaton system of communication. This is provided to prospective residents or their representatives to help them decide if the home is the right one for them. Most prospective residents are assessed by their care manager to see if the home can meet their needs, and copies of these were seen in resident’s individual plans. The manager advised that he has drawn up a detailed assessment form so that he can record his own discussions or observations of a prospective resident’s needs. A copy of the assessment form was seen. Prospective residents are actively encouraged to make a number of visits to the home to see if they like it, if they are compatible with the existing resident group and for the staff to see if they can meet the resident’s needs. Records Rosemere H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 Page 9 of the visits made, including an overnight stay, were seen for the resident who moved in most recently. The manager advised that contracts of residence at the home are known as Licence Agreements. These detail the terms and conditions of residence and the resident’s financial contribution, but not the contribution of any other parties, such as health authorities. These must also specify the room to be occupied. Wherever possible residents should sign their own licence agreements. If residents are unable to sign to show they have received and understood these agreements because of their needs, it is recommended that their representatives are asked to sign on their behalf. A requirement and a recommendation have been made – please see page 25. Rosemere H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 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 standard(s) 6 and 9. An individual plan is drawn up for each resident. Residents are supported to be independent. EVIDENCE: A comprehensive individual plan is drawn up for each resident, using information from pre-admission assessments and from residents and their representatives. This was seen to detail the level of support that resident’s require in different aspects of their lives, including communication, personal care, behaviours, social skills and relationships. Individual goals and aspirations are also recorded, along with the support needed to achieve them. Staff advised that the individual plans are reviewed at least every three months and changes to a resident’s needs are noted. The manager advised that any risks to the health and welfare of the residents are assessed in order that they are minimised as far as possible. Risks assessed include financial vulnerability, mobility and personal safety. Staff advised that residents are supported to develop their skills with in the scope of the assessed risk. For example, two residents who would need support to go far from the home, have been supported to manage going to the local post box alone. Rosemere H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 Page 11 Rosemere H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 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 standard(s) 15 and 17. 11, 12, 13, 14, The staff team provide support to residents to develop their skills and to lead active and fulfilled lives. EVIDENCE: Residents were seen being supported to carry out household tasks, including making refreshments and snacks, washing up after lunch and setting the dining room table. Meals seen being prepared were appetising and well balanced. Residents take part in a wide variety of activities, including attendance at adult education classes and leisure activities such as yoga, bowling, swimming, bingo, and visits to pubs and restaurants. A programme of each individual resident’s activities is displayed. Two residents have part time jobs with local employers and both were keen to talk about these. Staff advised that residents enjoy their holidays away from the home and three residents had recently returned from a holiday with members of staff. For Rosemere H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 Page 13 those residents who do not wish to go on holiday, staff advised that day trips to places of interest are arranged. The manager advised that all residents have family involvement, some regular and some only on special occasions such as birthdays. A link has been established with an advocacy service and support is requested for residents when required. Most residents hold keys to their bedrooms and a resident who showed me his room was seen to unlock it. Rosemere H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 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 standard(s) 18, 19 and 20. Residents receive appropriate personal support. Their healthcare needs are well met. EVIDENCE: It was clear from observing the residents and staff that support is provided sensitively and discreetly, in a way that promotes resident’s privacy and independence and in the way that the resident’s prefer. Residents were spoken to in a respectful and appropriate manner. From the individual plans and speaking to residents and staff, it was evident that a number of healthcare professionals are involved in the support of residents. These include general practitioners (G.P.’s), chiropodists, dentists and hospital specialists. Medication administration appears to be effectively carried out. Records seen were accurately maintained. The amount of medication held in the home matched the records held. A small number of medications are held in the home for occasional, as required use. The receipt of these medications is recorded on arrival but not carried forward to subsequent record sheets. It is recommended that the stock level is carried forward to enable accurate checking of stock. A recommendation has been made – please see page 25. Rosemere H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 Page 15 Rosemere H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 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 standard(s) 23. Staff are aware of their responsibilities in the protection of residents. Procedures are in place to safeguard resident’s finances. EVIDENCE: From discussions with staff it was clear that they are aware of their responsibilities in the protection of the residents living at the home. The manager advised that he is an appointed person and signatory to some resident’s financial accounts. Access to resident’s accounts is restricted to the appointed person and two signatures are required and recorded for all transactions. This is to safeguard the residents and the staff. A detailed record book is maintained for each resident, in which all financial transactions are recorded. A check of monies held for safekeeping is made three times a day at the handover of staff shifts. This was checked and found to be accurate. Rosemere H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 Page 17 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 standard(s) 24, 25, 26, 27, 28 and 30. The overall décor and furnishings in this home provide a well-cared for and homely environment for residents. EVIDENCE: The home was cheerful, bright and is appropriately furnished and equipped in a domestic, family style, to meet the needs of residents. It was clean, tidy and freshly aired throughout. Residents were proud to show their bedrooms, which had been made individual with personal belongings, including televisions, radio and music facilities, photographs and ornaments. Communal space is provided in a spacious lounge, which also has a dining area. A separate quiet room enables residents to spend time apart from each other if they wish. An enclosed, level garden is available and was attractively equipped with sun umbrellas, tables and chairs. Rosemere H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 Page 18 Rosemere H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 34, 35 and 36. Residents are supported by a stable, effective team of staff, working under the leadership of the manager. EVIDENCE: The manager advised that the home is run by a small team of experienced support staff who support residents with all roles within the home, including shopping, cooking, laundry and domestic tasks. Staff files that were seen contained the required documents and records and Criminal Record Bureau (CRB) clearances are obtained for all staff. In the event that a conviction or caution is identified on a CRB disclosure, it is required that a risk assessment is carried out. This is essential to assess the level of any risk to residents, staff or the service. Job descriptions are provided to staff and were seen for each role held, in the staff file. Members of staff spoken to confirmed that most had worked at the home for a number of years. This has ensured continuity of support and stability for the residents. Staff spoke enthusiastically of the training opportunities they are provided with and encouraged to attend. A member of staff described being initially reluctant to undertake a National Vocational Qualification (NVQ) in care, but now that it is almost completed, feels a sense of achievement. A plan of mandatory training is drawn up and was seen. The manager advised that Rosemere H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 Page 20 other training needs are discussed at supervision meetings and appraisals with staff. The manager stated that supervision meetings are held with staff every two months and an annual appraisal is carried out. Records of both of these were seen. An immediate requirement has been made – please see page 25. Rosemere H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38 and 41. The residents in this home benefit from a well-run home and are supported by an effective staff team and a competent manager. EVIDENCE: The manager advised that he has managed the home for five years and is a qualified nurse for people with learning disabilities and for people with mental health illness. He advised that he has undertaken training for and completed, the National Vocational Qualification (NVQ) Level 4, Registered Manager’s Award (RMA). It was clear that the manager has created an open and inclusive atmosphere. He was seen to be freely available to residents and staff and interacted with them in a relaxed but professional manner. Residents entered the office in a very natural way and sat in the armchair provided, to discuss their day or activities. Rosemere H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 Page 22 Record keeping in the home was seen to be well organised, with records accessible and appropriately stored. Confidential items were seen to be stored in a locked provision, to which only the manager had access. Rosemere H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 2 Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 x 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Rosemere Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x 3 x x H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 Page 24 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 5 Regulation 5 (3) and 17 (2) Schedule 4 12 (1) (a) and 13 (4) (c) Requirement 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. The registered person shall ensure that the care home is conducted so as to promote and make proper provision for the health and wefare of residents. He shall also ensure that unnecessary risks to the health or safety of residents are identified and so far as possible eliminated. Specifically, in the event that a member of staff is found to have a conviction or caution listed on their CRB disclosure, a risk assessment must be carried out in respect of that member of staff. Timescale for action 28th October 2005 2. 34 With immediate effect from 28th July 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Rosemere Refer to Good Practice Recommendations H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 Page 25 1. Standard 5 2. 20 It is good practice that residents sign their contract/ staement of terms and conditions. In the event that residents are unable to sign, it is recommended that their representative is asked to sign on their behalf and the reasons for this to be documented. It is good practice to carry forward the quantity of medication held for administration as required. This enables regular checking to be carried out and an audit trail to be followed. Rosemere H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Rosemere H09 H58 S13773 Rosemere V230327 280705 Stage 4.doc Version 1.40 Page 27 - 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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