Inspection on 10/08/05 for Rosewood

This inspection was carried out on 10th August 2005.

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 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

Rosewood 11/05/07

Rosewood 12/05/05

Rosewood 16/11/04

Rosewood 20/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Sutton Lodge Nursing Home

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 Rosewood Farmfield Drive Charlwood Surrey RH6 0BG Lead Inspector Susan McBriarty Unannounced 10 August 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. Rosewood H09 H58 s33902 Rosewood v241424 100805 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Rosewood Address Farmfield Drive, Charlwood, Surrey, RH6 0BG 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) 01883 383838 Peter Kinsey Mrs Rosemary Simpson CRH Care Home 8 Category(ies) of LD Learning disability, 8 registration, with number PD Physical disability, 8 of places SI Sensory Impairment, 8 Rosewood H09 H58 s33902 Rosewood v241424 100805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 The age range of the people that may be accommodated will be 18-55 years. 2 The home may admit one named person who is over the age of 55 years. 3 There will be a registered nurse of level one or above and three health care assistants on the day shift. 4 There will be one registered nurse of level one or above and one health care assistant on the night shift. 5 The registered manager must be in addition to staff for at least two shifts per week,in order to carry out the responsibilities under the Care Standards Act 2000. Date of last inspection 12-May-2005 Brief Description of the Service: osewood is owned and managed by Surrey Oaklands NHS Trust and is registered to accommodate eight service users with learning disabilities and nursing needs. In addition the eight service users may have needs in relation to physical disability and or sensory impairment. The property has been purpose built and is appropriate for those who have needs associated with physical and sensory impairments. The home has a semi-rural location but is in close proximity to several local towns. The communal areas of the home provides a large lounge, sun lounge, kitchen, utility room and a sensory room. A large garden surrounds the home which has been designed for wheelchair users in mind. Rosewood H09 H58 s33902 Rosewood v241424 100805 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the second inspection for 2005-2006. The home prefers to call those living there residents and this is reflected in the report. During the inspection five residents and five staff were seen. The residents have complex needs and are not able to offer their views on the service they receive. This inspection focussed on those standards not assessed at the inspection undertaken on the 12th May 2005 and the requirements made at that inspection. What the service does well: What has improved since the last inspection? What they could do better: The home does need to focus more effort on recording and documenting the work undertaken in particular care plans and risk assessments. In discussion with the manager and other staff and observing conversations and telephones calls it was evident that they were aware of the needs of the residents. However this is not fully evidenced within resident files. Other requirements were made from the evidence found during the inspection and these include: The organisation must ensure that a policy and procedure is in place to ensure that the ageing, illness and death of a resident are handled with respect and Rosewood H09 H58 s33902 Rosewood v241424 100805 stage 4.doc Version 1.40 Page 6 meet the wishes of the resident, family or are in the best interest of the resident. Surrey Oaklands NHS Trust must review its policies and procedures with regard to the recording and storage of Criminal Record Bureau checks. The current liability insurance is out of date with a renewal date of March 31st 2005. The requirements, as stated previously, from the last inspection have not been fully met and these are identified again within the requirement section of the report. 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. Rosewood H09 H58 s33902 Rosewood v241424 100805 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 Rosewood H09 H58 s33902 Rosewood v241424 100805 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) These standards were assessed at the announced inspection of the 12th May 2005. EVIDENCE: Rosewood H09 H58 s33902 Rosewood v241424 100805 stage 4.doc Version 1.40 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 standard(s) 6,9 These standards were assessed at the announced inspection of 12th May 2005. EVIDENCE: The requirement that residents sign and agree their own care plan wherever possible has been met. The manager had written to the CSCI confirming the details of the agreement. The requirements made at the announced inspection of the 12th May that care plans and risk assessment be updated regularly has not been met. The requirement for the care plans has already been carried over from three inspections. A further date has been agreed due to the staffing problems recently experienced by the home. However this date will not be extended further. Rosewood H09 H58 s33902 Rosewood v241424 100805 stage 4.doc Version 1.40 Page 10 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) These standards were assessed at the announced inspection of 12th May 2005. EVIDENCE: Rosewood H09 H58 s33902 Rosewood v241424 100805 stage 4.doc Version 1.40 Page 11 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) 21 Further work is required to ensure that the home meets Standard 21 and the needs and wishes of the residents. Standards 18,19 and 20 were assessed during the announced inspection of the 12th May 2005. EVIDENCE: Surrey Oaklands NHS Trust has a number of policies and procedures to support various stages of resident’s lives. These include dealing with untoward deaths and sudden deaths, however no policy is available regarding the individual wishes of the resident with regard to ageing, illness and dying. The home does enable those who wish to remain at the home until the time of their death and seek to ensure they meet the needs of those residents. The manager has ordered a workbook for staff to enable them to work together as a staff team to support the bereaved and those who are dying. In addition Surrey Oaklands NHS Trust have supplied the home with a leaflet printed by the Home Office. A requirement is made to ensure that the organisation provide a policy and procedure to resolve this matter. Rosewood H09 H58 s33902 Rosewood v241424 100805 stage 4.doc Version 1.40 Page 12 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 These standards were assessed at the announced inspection of 12th May 2005. EVIDENCE: The requirement made at the announced inspection of the 12th May 2005, that all staff receive training in the protection of vulnerable will be met by November 2005. All the staff have been booked to attend one of two courses, the delay has been due to the availability of the course. Rosewood H09 H58 s33902 Rosewood v241424 100805 stage 4.doc Version 1.40 Page 13 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) These standards were assessed at the announced inspection of 12th May 2005. EVIDENCE: Rosewood H09 H58 s33902 Rosewood v241424 100805 stage 4.doc Version 1.40 Page 14 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) 31,34,36 The organisation had policies and procedures in place for the recruitment and selection of staff. Full training records were held at the home. All staff received appropriate training and supervision taking into account the service users needs. However further work is required regarding the management of staff records in order to ensure the safety of vulnerable adults. EVIDENCE: Those staff files sampled during the inspection held copies of the staff members’ job descriptions and ensures that roles and responsibilities of those staff are recognised. There was confusion regarding the recording and storage of Criminal Record Bureau (CRB) checks. Although the registered person, registered managers are not allowed to see the documents and they are kept in a sealed envelope and offered to the Inspector for sampling. However staff files records are not consistent and disclosure numbers were not recorded in all the staff files seen. The Inspector spoke to a representative of Surrey Oaklands NHS Trust Human Resources team who informed the Inspector that the Trust does not keep a record of the disclosure numbers. As the CRB documents must be destroyed within a specified period this is worrying as it may lead to difficulties should a referral be required to the Protection of Vulnerable list. A requirement has been made to ensure that the Trust maintain an accurate, up to date record of all staff members’ disclosure numbers. Rosewood H09 H58 s33902 Rosewood v241424 100805 stage 4.doc Version 1.40 Page 15 The homes supervision runs from January to January, records show that the six supervision sessions required each year would be provided. For some staff members they will need to book dates to ensure that the standard is met. A recommendation that hours for ancillary staff be reviewed had not been actioned. Whilst this standard was not assessed during the inspection it was noted that specified residents within the home have increasing levels of need. The care staff are having to spend an increasing amount of time with those specified residents and where the staff members are also having to complete domestic tasks the Inspector was concerned at the possible impact on the environment and or the residents. A requirement has been made that staffing levels including ancillary staff be reviewed and the CSCI informed of the outcome. The manager reported that the home has six nurse qualified staff and eight care and or ancillary staff. Three out f the five care staff are undertaking NVQ training. The requirement made at the last inspection that a plan of how the home was going to meet the qualifying requirements for 2005 had been met. The manager reported that a plan had been sent to the CSCI although not received, a further copy is being forwarded. Rosewood H09 H58 s33902 Rosewood v241424 100805 stage 4.doc Version 1.40 Page 16 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) 37,42,43 The home had an open and inclusive approach where staff and service users were listened to. The registered manager is undertaking appropriate training. However some parts of the garden and exterior of the home require further work, the requirement from the last inspection had not been fully met. EVIDENCE: The registered manager has been a qualified registered nurse (RNMH) since 1994 and is currently registered for the Registered Managers Award (RMA). The manager is planning to retire next year and it is possible that the RMA may not be completed within that time. The homes business plan is Trust led and the home is waiting for the Business Plan for 2005 as this had not yet been provided. The manager has responsibility for the budgetary management of the home including any overspending. The manager reported that the financial difficulties due to a vacancy and previous staffing problems were supported by their manager. Rosewood H09 H58 s33902 Rosewood v241424 100805 stage 4.doc Version 1.40 Page 17 Regular meetings are held during which any issues may be raised and discussed openly. The manager also holds responsibility for the resident’s finances and on checking the cash available against the records all those sampled were found to e correct by the inspector. The home and organisation have clear auditing processes and the Inspector saw evidence that the organisation monitors resident finances regularly. A requirement that the paved areas of the garden be cleared of moss and weeds had not been fully met. Observations by the Inspector and discussion with the manager noted that the weeds had been trimmed in some areas. However in other areas no work had been completed. A further requirement is made. Some parts of the paved are sinking, cracked or the grouting has gone. To the side of the home where resident bedroom widows overlook the garden are overgrown and the paved areas have weed growth. The external woodwork was faded and in some places coming away. The manager reported that some work to the external areas had been agreed however not all external woodwork was being painted. A requirement has been made to ensure that the external areas of the home receive appropriate treatment and or work. The home’s liability insurance was out of date, displaying a replacement date of March 2005. The recommendation that a full risk assessment of the home be undertaken on the basis of any future addition of resident category had not been completed. Surrey Oaklands NHS Trust had formally withdrawn the application for variation. However the manager and her line manager have been in discussion and both felt that a risk assessment of the home taking into account the residents current needs would be useful. The requirement that paper towels and liquid soap be provided to reduce the risk of cross infection had been met. The recommendation that the bubble tube be repaired has led to the manager negotiating with the League of Friends and Surrey Oaklands NHS Trust management in order to gain agreement that it be replaced with a new one. Rosewood H09 H58 s33902 Rosewood v241424 100805 stage 4.doc Version 1.40 Page 18 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 x x x x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score 2 x x 2 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Rosewood Score x x x 3 Standard No 37 38 39 40 41 42 43 Score 2 x x x x 2 3 H09 H58 s33902 Rosewood v241424 100805 stage 4.doc Version 1.40 Page 19 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 6 Regulation 15(1)(b) (c) Requirement The registered person must ensure that care plans are reviewed and updated regularly and that documents evidence this action. brought forward from three previous inspections. Timscale of 30th June not met. Enforcement action will be taken if this timescale is not met. The registered person must ensure that service users risk assessments are reviewed and updated regularly and that documents evidence this action. Timescale of 31st July not met. The registered person must ensure that a review take place of the staffing levels within the home. The registered person must ensure that the organisations recruitment practice is reviewed in linw with the requirements of the CRB guidance and The Care Homes Regulations 2001 (as amended). The registered person must ensure that the grounds Timescale for action 30th October 2005 2. 9 13(4)(c) 30th October 2005 3. 33 18(1)(a) 30th September 2005 30th September 2005 4. 34 19(1)(a)( b)(c)(4)(a )(b)(i)(ii)( iii) Schedule 2, 18(4) 13(4)(a) (c), 5. 42 30th September Page 20 Rosewood H09 H58 s33902 Rosewood v241424 100805 stage 4.doc Version 1.40 23(2)(b) 6. 37,43 25(e) including the paved areas of the 2005 home are cleaned, repaired and or re-painted as required and the overgrown bushes cut back. The registered person must 30th August ensure that the liability 2005 insurance is kept up to date and displayed. 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 Good Practice Recommendations Rosewood H09 H58 s33902 Rosewood v241424 100805 stage 4.doc Version 1.40 Page 21 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 Rosewood H09 H58 s33902 Rosewood v241424 100805 stage 4.doc Version 1.40 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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