Inspection on 20/11/07 for Rosemerryn

This inspection was carried out on 20th November 2007.

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

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

Other inspections for this house

Rosemerryn 19/02/09

Rosemerryn 22/08/07

Rosemerryn 13/06/06

Rosemerryn 10/02/06

Rosemerryn 06/09/05

Rosemerryn 29/11/04

Rosemerryn 07/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Rosemerryn 2a Cadogan Road Camborne Cornwall TR14 7RS Lead Inspector Lynda Kirtland Unannounced Inspection 20th November 2007 11:00 Rosemerryn DS0000009117.V355814.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 Rosemerryn DS0000009117.V355814.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. Rosemerryn DS0000009117.V355814.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosemerryn Address 2a Cadogan Road Camborne Cornwall TR14 7RS 01209 610210 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) mail@dcact.org Spectrum ****Post Vacant**** Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Rosemerryn DS0000009117.V355814.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd August 2007 Brief Description of the Service: Rosemerryn is a home providing accommodation and personal care for up to three adults with a learning disability. It is run by Spectrum, an organisation that provides specialist care in small units for adults with autistic spectrum disorders. Spectrum aims to provide its service users with appropriate support in a domestic style environment in a community setting. Spectrum employs management and care staff to work directly with service users in the home. Senior managers from within the Spectrum organisation visit the home as necessary and provide additional support. The home is a two-storey, detached house, located in the town of Camborne. It is within easy reach of all the towns amenities and is set in spacious grounds, slightly off the street. Service users are provided with single rooms. They have access to a lounge and dining/ kitchen area. The home has a laundry room, three bathrooms and office accommodation for staff. There are no specific adaptations for people with physical or sensory disabilities and not all parts of the home are wheelchair accessible, but the home has two bedrooms on the ground floor and some adaptations could be made if required. Fees range from £1045.00 - £3374.00 per week according the home’s manager at the time of the inspection. Service users are charged extra for certain activities, such as massage and trampolines, private chiropody, hair dressing, alcoholic drinks and are expected to pay some contributions towards leisure activities outside of the home. Rosemerryn DS0000009117.V355814.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, which took place on 20 November 2007. It lasted for approximately six hours. Information about the home received by the Commission since the previous inspection (22/08/07) was taken into account when planning the inspection. The purpose of the inspection was to ensure that the needs of people who use the service are appropriately met in the home, with particular regard for ensuring good outcomes for them. People who use the service were met and observation of their daily life and care provided occurred. There was an inspection of the home’s premises and of written documents concerning the care and protection of the people who use the service and the ongoing management of the home. Discussions with staff and observations in relation to their care practices occurred as well as discussions with the home’s acting manager. The principle method used was case tracking. This involves examining the care notes and documents for a select number of people who use the service and following this through with interviews with them and/or their relatives and staff working with them. This provides a useful, in-depth insight as to how their needs are being met in the home. At this inspection, one person who uses the service users was case tracked. This inspection has occurred within a quick timescale, as CSCI was aware that the manager has addressed the concerns raised in the last inspection report dated 22/08/07. It was confirmed during this inspection that the manager has addressed six out of eight statutory requirements and four out of six recommendations. Therefore the rating of this service has risen. What the service does well: People who use the service have lived at Rosemerryn for sometime and know each other and the facilities that the home offers well. It is not anticipated that there will be a change of resident group at Rosemerryn. However if there were any new admissions to the home a detailed assessment of individual care needs would be undertaken. People who use the service have detailed written care plans, which set out how the home will meet their personal, health and social care needs, including needs relating to their individual backgrounds and culture, age, sex, religion, individual abilities and sexual orientation. These are regularly reviewed and shared with their representatives so that they can be kept informed of their progress in the home. Staff help them to make important decisions about their lives and enjoy a good quality of life. They are supported and encouraged to take risks to develop their skills, independence and confidence, but in ways which are safe for them and other people. Rosemerryn DS0000009117.V355814.R01.S.doc Version 5.2 Page 6 People who use the service enjoy a good quality of life in the home. Staff support them to take part in a wide range of activities in the community. They are encouraged to go out to a local social club and to maintain valued relationships with their friends and families outside of the home. Staff support people who use the service with their personal care so that they look smart and fashionably dressed, which they appreciate. They are helped to access a range of NHS healthcare providers, such as doctors, opticians and community nurses so that they maintain good general health and receive any specialist services they need. It was observed that the people who use the service appeared relaxed and comfortable in staff presence. It was observed that there is a genuine commitment among the staff team to ensure their welfare and protection from abuse is paramount. The staff team is selected fairly and on the basis that people employed to work in the home are fit and suitable to work with vulnerable adults in a care setting so that service users and their representatives can have confidence in the people caring for them. What has improved since the last inspection? Since the previous inspection the manager has worked hard to comply with the majority of statutory requirements and recommendations. She has ensured that: The medication system is more robust. From inspection of this area it was noted that medication in store now tallies with medication records. Medication records are accurate and the manager is monitoring the temperature of the storage of medication. The medication cupboard is attached to the wall for extra security. The manager is also arranging for Boots pharmacy medication training for her staff team – as this remains in progress a recommendation to this effect will be made. Areas of improvement have occurred to the environment. Ventilation has been improved in one of the ground floor bedrooms and has since been redecorated and refurbished. The stair way was repaired within 24 hours of the last inspection for the safety of people who use the service and staff use. The décor of the home has been reviewed and redecorated where felt necessary; the carpeting downstairs was being cleaned on the day of inspection. The home’s manager and some staff have gained places on the multi-agency training on the protection of vulnerable adults from abuse and will cascade this to staff working at the home. Rosemerryn DS0000009117.V355814.R01.S.doc Version 5.2 Page 7 Staffing levels have been reviewed and staff commented that they felt there was sufficient staff on duty at all times. The manager is in the process of risk assessing and reviewing staff levels on group activities so that sufficient staff are with people who use the service at all times which correspond to their risk assessments. New staff have been appointed since the previous inspection and all necessary checks were made prior to their employment. Care staff are receiving regular individual/ formal supervision, with records maintained. The manager has forwarded her application to be registered with the Commission. The Commission contacted the Fire Authority following the last inspection due to concerns around fire routes/ exits in the home. The Fire Authority visited the property on two occasions and on the first visit identified works that needed to be carried out immediately to ensure there was appropriate fire precautions on site. Spectrum responded to this immediately, which resulted in the Fire Authority being satisfied on their follow up visit that fire precautions are now satisfactory. What they could do better: The manager is currently updating the homes Statement Of Purpose and Service Users guide so that it accurately reflects the services that Rosemerryn provides. This should be presented in an appropriate format. The proportion of staff qualified to NVQ level 2 should be increased towards achieving the 50 level indicated in the National Minimum Standards. The homes manager is aware and has arranged that for some staff mandatory training in the areas of medication, infection control, manual handling, fire and first aid need to be carried out. She is in the process of organising this; hence a recommendation to this effect has been made. New fire doors have been installed but they have no handles on them and they shut by a Yale lock which means that the door automatically locks when it closes. As these are fire doors they must be closed. However this results in that people who use the service are unable to freely access the communal areas, for example the lounge or their private bedrooms, as they have to ask staff to unlock the rooms to gain entry. The manager consulted with Spectrums management team during the inspection that stated this would be addressed as they acknowledged this is restricting freedom of movement in the home for the people who use the service. The homes manager has applied to the Commission for the registered manager post. This is now in process to assess her competence and fitness to manage the home. Rosemerryn DS0000009117.V355814.R01.S.doc Version 5.2 Page 8 The homes fire risk assessment has highlighted some areas that need to be actioned: such as ensuring door handle fittings meet fire regulations, and that fire training needs to be undertaken. The manager must ensure that the actions identified in the homes fire risk assessment are addressed. The manager should review the garden area and take appropriate actions, to ensure that it is safe for people who use the service to use. Currently people who use the service access this area with staff support and need to be supervised at all times. The inspector would like to thank the People who use the service, staff and manager for their kind assistance and cooperation during this inspection. 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. Rosemerryn DS0000009117.V355814.R01.S.doc Version 5.2 Page 9 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 Rosemerryn DS0000009117.V355814.R01.S.doc Version 5.2 Page 10 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): 1,2, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Statement of purpose needs to be reviewed and updated so that it accurately reflects the service that Rosemerryn provides for service users and their representatives information People who use the service are assessed prior to their admission so that they can be confident it will meet their health, personal and social care needs, including needs relating to their age, religion, cultural and ethnic backgrounds, abilities, gender and sexual orientation. EVIDENCE: There have been no changes to the service user group since the previous inspection. From observations and talking with people who use the service it was evident that they are settled in the home, and that they get on well with each other and with the staff. The homes managing is currently updating the Statement Of Purpose and Service Users Guide to reflect accurately the services, facilities and staffing arrangements of the home. People who use the service and their representatives can then have accurate information on what Rosemerryn provides. From documentation inspected it was evident that admissions are made following a full assessment and in consultation with the service user, their family or advocate, and relevant professionals. Rosemerryn DS0000009117.V355814.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans fully address the person’s health, personal and social care needs, including needs relating to their individual and diverse backgrounds. They are able to take safely managed risks and make important decisions about their lives so that they develop their skills and independence. EVIDENCE: People who use the service their family, advocate and relevant professionals are involved in the development of individual care plans and their subsequent reviews. The reviews record their views so that they are aware of the purpose of their placements in the home and are able to contribute to the ongoing care planning process. The care plan has specific headings to address the individual’s health, personal and social care needs, including their diverse needs. These are in written form plus in Widget (pictorial) form. Personal Care plans provide service users with specific goals to work towards, and inform and direct staff in how to support the person to achieve this goal to encourage them to fully maximise their skills for independent living. Staff confirmed they Rosemerryn DS0000009117.V355814.R01.S.doc Version 5.2 Page 12 were able to understand the care plans and that the detail of how to assist in a particular task allowed consistency of care. People who use the service participate in making decisions about important aspects of their daily lives, according to their individual abilities and this was observed during the inspection. Staff were observed supporting people who required it, to make decisions about what to do during the day. People who use the service can choose the level of privacy they wish to enjoy in their private accommodation. People who use the service are able to take managed risks, backed up with written risk assessments and risk management plans, particularly with regard to their engagement in higher risk activities. Service users monies are audited at Spectrum Headquarters and from documentation seen they appeared to be no concerns regarding the management of monies at his time. The Commission is aware that Spectrum is reviewing the policy and procedure of the management of monies. Rosemerryn DS0000009117.V355814.R01.S.doc Version 5.2 Page 13 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): 12,13,14,15, Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use the service are able to take part in a wide range of activities in and out of the home, which are appropriate to their ages, individual needs, interests and cultural backgrounds so that they develop their skills and confidence. They are supported to maintain valued social and family relationships so that they are not isolated or institutionalised. EVIDENCE: At the time of the inspection, people who use the service were engaged in a range of different individual activities. Their individual needs and preferences are considered as part of the assessment and/or care planning process so that they can be provided with activities that are appropriate for them. They have information, in pictorial formats about the different activities available to them so that they can plan and choose what they will do each week with staff. Their daily care records confirm that they make use of a wide range of community resources, including local fairs, cafes, pubs and shops. Rosemerryn DS0000009117.V355814.R01.S.doc Version 5.2 Page 14 The people who use the service attend a social club in the community once a week, so that they have opportunities to meet people from outside of Spectrum. There are records of their contact with their families, including regular visits home, or visits from relatives to them at Rosemerryn. Needs in relation to their developing personal relationships are considered as part of the ongoing assessment and care planning process, including specific risks. Access to independent advocacy services, particularly where an individual does not have close relatives to support them on a regular basis is available. People who use the service did not highlight any issues regarding food at the last inspection; therefore this was not inspected on this occasion. However it was noted that the dining facilities have been improved so that all the people who use the service can now eat together with staff. Rosemerryn DS0000009117.V355814.R01.S.doc Version 5.2 Page 15 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. People who use the service personal and healthcare needs are well met so that they are able to live full and active lives in and out of the home. Medication systems are robust to ensure that medication errors are prevented. EVIDENCE: Care plans are individualised and address their personal care needs. People who use the service appeared to be attractively and fashionably dressed and were well groomed so that they can comfortably take part in community life. The home has suitable bathroom facilities so that they can attend to their personal care in private. People who use the service healthcare needs are considered as part of the care planning process and regularly reviewed. Documentation showed that access to external healthcare providers, including specialists, occurs when needed. There are suitable medication storage facilities and the cabinet has been secured to the wall for extra security. People who use the service do not currently self-administer medication. Spectrum has a medication policy that was present in the home. Rosemerryn DS0000009117.V355814.R01.S.doc Version 5.2 Page 16 From inspecting medication improvements had been made in this area. The MAR sheets were completed accurately and all medication was accounted for and tallied with documentation. From a count of PRN medication this tallied with the documentation. The manager is currently arranging for all staff to attend medication training by Boots pharmacy. Rosemerryn DS0000009117.V355814.R01.S.doc Version 5.2 Page 17 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. People who use the service are listened to and respected so that their views, concerns and complaints are taken seriously and acted upon. There are formal and informal systems in place to ensure that they are able to feel safe in the home. EVIDENCE: People who use the service were encouraged to speak to the inspector if they wished in private or with staff present so that they could make their views known or raise any concerns. No concerns were raised and the home or the Commission has received no complaints. People who use the service are provided with written copies of the home’s formal complaints procedure and have formal and informal opportunities to raise any concerns with staff before they become serious complaints. The home has written procedures to guide staff on what to do if they suspect a person is at risk of abuse. There are records to show that staff are recruited on the basis that they are suitable to work with vulnerable adults in a care setting and appropriate checks are made. Residents are not isolated in the home, but take part in a range of activities in the local community and have relationships with people from outside of the home that they can communicate serious concerns to. Spectrum has a whistle blowing policy. The manager and two staff are booked to attend the Multi Disciplinary Adult Protection course. The home does have a copy of the Cornwall Multi agency adult protection procedure. Rosemerryn DS0000009117.V355814.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,30 Quality in this outcome area is adequate. The manager has ensured that improvements to the décor, furnishings facilities to the home have improved. The home is in the main kept clean tidy and good hygiene is maintained so that people who use the service staff are protected from infection risks. The manager needs to review access to the lounge and safety in the garden area. EVIDENCE: People who use the service appeared to be comfortable and happy in the home. It is well located so that it offers privacy as well as good access to the local town. It is an ordinary, domestic building so that they live in a noninstitutionalised environment in which they can develop their skills and become more independent. Since the previous inspection the manager has arranged for some parts of the home to be redecorated and is planning for other parts of the home to be redecorated in the near future. It was evidenced that people who use the service choose the colours of their room and its furnishings. One room where there were problems with condensation/ damp has been addressed and the room has been redecorated and refurbished. The lounge Rosemerryn DS0000009117.V355814.R01.S.doc Version 5.2 Page 19 and and and free area has also been freshened up. On the day of inspection the carpets were being cleaned throughout the home. The conservatory is no longer in use because it requires major refurbishment, but people who use the service have sufficient communal space without it. The dining facilities have improved thus allowing all people to be able to sit together for lunch, if they wish. The temperature in the attic rooms are being monitored to ensure that there is a comfortable temperature in these rooms at all times. Following the previous inspection CSCI contacted the Fire Authority due to concerns regarding fire systems – new fire doors have been installed but it was observed that the fire doors have no handles on them and when they close they lock immediately. This means that if a person wanted to enter the lounge they would have to ask a member of staff to open the door for them. This is restricting their rights to accessing communal space. The manger contacted a line manager during the inspection and it was agreed this area was being addressed. Therefore a recommendation at this time has been identified as the manager has assured the Commission that people who use the service will be able to access this room freely in the next few weeks. There had been a recent incident of a person who uses the service finding glass in the garden area. The manager said she is aware that the garden is not a safe area for people who use the service to spend time in without staff support, as the garden area is not secure. The manager feels that installing a fence would prevent items coming into the garden area and make it safer for use. She will look into this further so that the garden can be more accessible. The home appeared clean and tidy throughout at the time of the inspection, which was unannounced. There are systems in place to ensure good hygiene and staff were observed using hygiene equipment provided. There are satisfactory systems in place to manage heavily soiled materials, which may represent an infection risk. It is recommended that paper towels are available in the kitchen to promote infection control further. Rosemerryn DS0000009117.V355814.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff are employed in sufficient numbers at all times. Less than half of the staff team are qualified to the level recommended in the National Minimum Standards so that service users can have confidence that people working with them are competent to do so. Staff are recruited fairly, safely and effectively on the basis that they are suitable to work with vulnerable adults in a care setting. They have access to ongoing training. Staff are well supported and receive regular, formal supervision. EVIDENCE: Since the previous inspection the manager has reviewed staffing levels in the home. The staff team comprises of 11 care staff plus two waking night staff, this means that on the day shift there are five care staff available, in the evenings up to 9pm, after which till 10pm the staff team reduce to two. At night there is one staff member who is awake and the other sleeps in. Rotas confirmed this and staff spoken with felt this was sufficient staffing levels at this time. Rosemerryn DS0000009117.V355814.R01.S.doc Version 5.2 Page 21 The manager is aware that when looking at the individual people who use the service risks assessments there were insufficient staffing levels at times to take them out safely as the risk assessment identifies a higher level of staffing. The manager is in the process of risk assessing and reviewing staff levels on group activities so that sufficient staff are with people who use the service at all times which correspond to their risk assessments. According to the manager and records held in the home, slightly less than the recommended 50 of care staff are qualified to NVQ level 2, although this situation should improve as more staff are due to complete it in the near future. Staff recruitment records inspected evidenced that staff have undergone the necessary clearances before they commenced employment at the home. An induction programme for new staff is implemented. Care staff have individual training records and those interviewed during the inspection confirmed that the training has been beneficial to their work. The manager is aware that certain training such as food hygiene, infection control, first aid are needing to be updated and is addressing this. The manager is in the process of ensuring that all staff receives supervision approximately every 6 weeks. Supervision records confirmed this. Rosemerryn DS0000009117.V355814.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The homes manager has applied to the Commission to be registered so that an assessment of her fitness to provide this role is assessed. The home is mainly well managed for the benefit of people who live there. There are formal and informal systems in place to ensure that views from people who use the service are accounted for in the day-to-day running and ongoing development of the home. There are systems in place to protect those who live, work or visit the home from avoidable harm and injury. EVIDENCE: The registered manager Mr Williams resigned in March 2007. Since which there has been two mangers appointed to the home. Hayley Griffins the current manager commenced the managers’ post in August 2007. She has now officially been appointed as manager to the home by Spectrum and has forwarded her application to be the registered manager with the Commission. Rosemerryn DS0000009117.V355814.R01.S.doc Version 5.2 Page 23 She is completing her NVQ 4 in care and registered manager award. She aims to do the NVQ 4 in management. Staff spoke highly of Ms Griffins skills and felt that she was approachable and listened to their ideas or concerns. From observations People who use the service were comfortable in her presence. Ms Griffin has twelve hours dedicated administration time. Due to her recent post as manager the quality assurance process has not commenced however views from residents, family and staff plus regulation 26 visits are in the process of being sought. Records are stored confidentially, staff need to be conscious of their recordings to ensure that it adheres to the data protection act i.e. communications book. The home’s environment in the main appeared safe and there are written individual and environmental risk assessments in place to minimise risks to People who use the service and staff working in the home. Maintenance of the home and its equipment are satisfactory. Since the last inspection the Fire Authority have inspected the premises on two occasions. On the first occasion work was identified to ensure that fire precautions were safe. This work has been completed and the Fire Authority has concluded that they are satisfied with the current fire arrangements in the home. From the homes independent fire risk assessment some elements of work remain outstanding i.e. replacing door handles and ensuring that regular fire training occurs, the recommendations as identified in this report must be actioned. Rosemerryn DS0000009117.V355814.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 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 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 3 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 3 12 3 13 3 14 3 15 4 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 2 X Rosemerryn DS0000009117.V355814.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 4,5 Requirement The homes Statement Of Purpose and Service Users guide must be updated to accurately reflect the services that Rosemerryn provides. This should be presented in an appropriate format for Service users use. Service users must be provided with a comfortable and homely environment, which meets their needs and encourages privacy, dignity, choice and freedom of movement. Timescale for action 29/03/08 2 YA24 12(1) 12(2) 12 (4) 16(2) 23 30/01/08 3 YA42 YA20 23 (4)(a) (C)(v) (d)(e) 4 YA37 8(1)(2) The registered person must 30/01/08 ensure that the issues highlighted in the homes fire risk assessment are actioned: for example ensuring door handle fittings meet fire regulations, and that fire training is undertaken The homes manager application 30/03/08 for the registered manager post must be completed. Rosemerryn DS0000009117.V355814.R01.S.doc Version 5.2 Page 26 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. Refer to Standard YA23 Good Practice Recommendations The home’s manager should undertake multi-agency training on the protection of vulnerable adults from abuse and cascade this to staff working at the home. The homes manger should review the garden area and take appropriate actions to ensure that is a safe area for People who use the service to use. The proportion of staff qualified to NVQ level 2 should be increased towards achieving the 50 level indicated in the National Minimum Standards. The manager should arrange for staff training on mandatory courses such as first aid, medication, manual handling, fire, food hygiene and infection control, which staff should attend. 2 3. YA24 YA32 4 YA35 Rosemerryn DS0000009117.V355814.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. 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