Inspection on 30/01/06 for Rosemere

This inspection was carried out on 30th January 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rosemere 13/09/07

Rosemere 25/09/06

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 Unannounced Inspection 30th January 2006 11:50 Rosemere DS0000013773.V277440.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rosemere DS0000013773.V277440.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Rosemere DS0000013773.V277440.R01.S.doc Version 5.1 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 Mr Appalsamy Goonniah Care Home 6 Category(ies) of Dementia (1), Learning disability (6) registration, with number of places Rosemere DS0000013773.V277440.R01.S.doc Version 5.1 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 28th July 2005 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. Rosemere DS0000013773.V277440.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the second inspection to be carried out in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. Mrs Sandra Holland, Lead Inspector for the service carried out the inspection over a period of three and a half hours. Mrs Patma Hurst, senior support worker and shift leader was present representing the service. A number of records and documents were examined, including resident contracts, policies and procedures and health and safety checks. All six residents and four members of staff were spoken with. The inspector wishes to thank the residents and staff for their hospitality, time and assistance. To fully assess how the home is meting the National Minimum Standards (NMS) for Care Homes for Adults, it will be necessary to read the reports of both inspections. 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? Amendments to resident contracts, known as Licence Agreements, have been issued to state the number of the room to be occupied. Residents sign their licence agreement if they are able to. Rosemere DS0000013773.V277440.R01.S.doc Version 5.1 Page 6 The amount of any medication held in stock is carried forward from previous medication administration record (MAR) sheets, to enable a checking trail to be followed. 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.V277440.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rosemere DS0000013773.V277440.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5. Each resident has a contract, known as a Licence Agreement. These contain most but not all of the required information. EVIDENCE: The shift leader advised that contracts of residence at the home are known as Licence Agreements. These were seen to detail the terms and conditions of residence and the resident’s financial contributions. The contribution of any other parties, such as local authorities or health authorities, are not included. Where the arrangements for the accommodation and support of residents have been organised by other parties (as noted above), a copy of the agreement, confirming the arrangements made, must be supplied to residents. It is required that all of this information is provided to residents and is to be included in their service user’s guide. A requirement was made at the inspection carried out on 28th July 2005 that this information must be supplied. This requirement remains unmet. The timescale for this requirement has been extended to enable the newly appointed manager to meet it. A requirement has been made. Rosemere DS0000013773.V277440.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 10. Residents are supported to make decisions and their confidentiality is respected. EVIDENCE: Staff advised that meetings are held in the home every two weeks to enable residents and staff to discuss household issues, food choices and arrangements for activities. Residents are supported in this by their key worker, a member of staff who is allocated to provide close, personal support to a resident, often on a one to one basis. Individual likes and dislikes are taken into consideration when plans are being made. To assist residents with their decision making, a selection of items, such as holidays or places of interest for a day out, are offered. These would be discussed and individuals or the group are supported to come to a decision. It was clear that staff respect the residents’ confidentiality. Any discussions regarding residents were carried out in the office and are stopped if a resident or visitor enters. The shift handover was observed in progress, with all discussions taking place discreetly. Staff stated that they are trained from their induction, not to discuss residents’ affairs except with others who are entitled to the information. Staff said that if they are unsure if a telephone Rosemere DS0000013773.V277440.R01.S.doc Version 5.1 Page 10 caller is who they say they are, they would take the caller’s number and ring them back, or refer them to the manager or deputy manager. Rosemere DS0000013773.V277440.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. The rights of residents are respected and their responsibilities in their daily lives are recognised. EVIDENCE: It was pleasing to see residents busy with their household tasks and freely and independently going about their daily activities. Most of the residents are able to help themselves to drinks and snacks and willingly offered hot drinks to staff and visitors. Staff advised that residents are encouraged to attend their activities, (and work for three residents), but that if residents are not keen, they are given time and space to consider their options. Staff would then go back to the resident a short while later to ask them what they would like to do. Whilst a programme of activity is in place on weekdays, staff advised that weekends are not structured, to allow residents to choose their preferred activities. A takeaway meal of their own choice was a popular option at weekends, residents advised. Rosemere DS0000013773.V277440.R01.S.doc Version 5.1 Page 12 Staff were seen to interact with residents in a relaxed and friendly but appropriate way. Resident’s rooms were not entered without the resident being present or their agreement being obtained. Most residents hold a key to their bedroom and a resident was seen to collect his key from the secure storage place in the office. Rosemere DS0000013773.V277440.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21. The home has a policy regarding the death of a resident, but it needs to be reviewed and updated. EVIDENCE: The home has a policy for the care of residents in their last days and staff had signed to show they had read and understood it. It was noted that the policy was dated for review in 2002 but this had not taken place. The policy provided guidance as to the practical aspects of dealing with a death but made only a brief reference to support for staff and no reference to support for residents. It is recommended that the policy is reviewed and revised, and should include details of the support services available to residents and staff. The shift leader stated that she was aware that residents had been asked about their end of life wishes, but this had not been recorded in their individual plans. Rosemere DS0000013773.V277440.R01.S.doc Version 5.1 Page 14 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. A complaints policy is available in written or pictorial form. EVIDENCE: The complaints policy was revised last year and staff have signed to show they have read and understood it. It has been made available in both written and pictorial formats to suit the differing needs of residents. A complaints and compliments record is maintained, but no complaints had been recorded. The shift leader stated that any verbal comments or complaints by residents would be dealt with immediately. Staff advised that they would be aware if some residents were unhappy, by observing changes in their body language or by changed facial expressions or actions. Rosemere DS0000013773.V277440.R01.S.doc Version 5.1 Page 15 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): These standards were not assessed at this inspection. EVIDENCE: Rosemere DS0000013773.V277440.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 33. The needs of the residents are met by a committed and effective staff team. EVIDENCE: A small team of experienced staff are employed to support residents and to assist them to carry out all roles within the home, the shift leader stated. This includes personal care, shopping, cooking, laundry, domestic tasks, transport and activities. Staff support service users who are able, to carry out their allocated household tasks. It was clear that staff are interested and committed to the residents they support. They displayed a good understanding of residents’ needs and were seen to readily engage residents in conversations. Residents were seen to be comfortable in the company of staff. The shift leader stated that a number of staff have undertaken a National Vocational Qualification (NVQ) in care. One member of staff has completed NVQ level 3 in care and is now undertaking NVQ level 3 in management. Two further staff are currently undertaking NVQ level 3 in care. Rosemere DS0000013773.V277440.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 39 and 42. A new manager has recently been appointed to the home but has not yet registered with CSCI. Closer attention is required to some aspects of health and safety in the home. EVIDENCE: The shift leader stated that a new manager had been appointed to the home, but had not yet started work, as he was on annual leave. She advised that staff and residents had arranged a party for the previous manager who had recently left, which everyone had enjoyed. A new deputy manager had also been appointed just before the manager left, to enable a period of handover. Staff reported that the deputy manager was settling in and adapting to the home, having moved from another home within the Welmede organisation, which had closed down. Residents had recently completed a service user satisfaction questionnaire, a member of staff stated. These had been completed with the assistance of staff and the responses were seen to be positive. It is recommended that any Rosemere DS0000013773.V277440.R01.S.doc Version 5.1 Page 18 future surveys of the quality of the service offered, are also provided to others involved in the support of residents. These can be circulated to residents’ families and friends, general practitioners (G.P.’s), day service staff and visiting hairdressers for example, to obtain an independent view as to how the home meets the resident’s needs. A number of records (but not all), relating to health and safety were seen, including fire prevention measures. Testing of the fire alarm, fire drills and servicing of fire detection equipment have all been carried out to the required frequencies. It was noted that two fire doors, which are fitted with automatic closing devices, to ensure they close if the fire alarm is activated, were propped open. An upturned stool was used to prop open the laundry room door and a decorative door stop was being used to keep a resident’s bedroom door open, although a sign fixed to the door stated that it was a fire door and was to be kept shut. The certificate of safety for the gas supply was seen, but the shift leader stated that the certificate to confirm the safety of the electrical services could not be found. It is required that this is obtained and kept in the home. The temperature of the hot water supply is tested weekly and was seen to be within the normal range. The call system in the home has been serviced to the required frequency. Regular checks are also made on the home’s vehicle and appropriate action taken. The record showed that two new tyres had been fitted earlier this month. It was noted that some items of food stored in the kitchen fridge were out of date and one item had no label to identify it. Other items had not been labelled and dated when opened, so it would not be possible to know how old they were or when they would no longer be fit to eat. The out of date items were discarded immediately. Requirements and a recommendation have been made. Rosemere DS0000013773.V277440.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 x 3 x 4 x 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 x ENVIRONMENT Standard No Score 24 x 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 3 33 3 34 x 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x 3 x x 3 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x x 2 2 x 2 x x 2 x Rosemere DS0000013773.V277440.R01.S.doc Version 5.1 Page 20 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA5 Regulation 5(3) & 17 (2)Sch 4 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. 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. UNMET FROM 28/07/05. The manager must apply for registration with CSCI. Unnecessary risks to the health or safety of service users must be identified and so far as possible eliminated. Timescale for action 21/04/06 2 3 YA37 YA42 9 (1 & 2) 13 (4)(c) 21/04/06 30/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Rosemere Refer to Good Practice Recommendations DS0000013773.V277440.R01.S.doc Version 5.1 Page 21 1 2 Standard YA21 YA39 The policy regarding the dying or death of a resident should be reviewed and revised. The system for reviewing the standard of the service offered should be extended to all those involved in the support of residents. Rosemere DS0000013773.V277440.R01.S.doc Version 5.1 Page 22 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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