Inspection on 12/04/07 for Roslin

This inspection was carried out on 12th April 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Roslin 28/07/09

Roslin 06/04/09

Roslin 14/02/06

Roslin 08/08/05

Roslin 16/12/04

Roslin 24/06/04

Roslin 04/03/04

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

CARE HOME ADULTS 18-65 Roslin 1 The Chesters Low Fell Gateshead Tyne & Wear NE9 5PB Lead Inspector Mr Lee Bennett Key Unannounced Inspection 12 and 13th April 2007 10:00 th Roslin DS0000007405.V336155.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 Roslin DS0000007405.V336155.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. Roslin DS0000007405.V336155.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Roslin Address 1 The Chesters Low Fell Gateshead Tyne & Wear NE9 5PB 0191 487 3191 0191 487 3191 ntawnt.roslin@nhs.net 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) Northumberland, Tyne & Wear NHS Trust ** Post Vacant *** Care Home 5 Category(ies) of Learning disability (5), Mental disorder, registration, with number excluding learning disability or dementia (2), of places Physical disability (1) Roslin DS0000007405.V336155.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2006 Brief Description of the Service: Roslin can provide personal care for five people primarily with a learning disability, but who may also have a significant physical or mental health need. The home cannot provide nursing care. Roslin is a detached house in a quiet area of Low Fell in Gateshead, close to local amenities including a shopping area, Doctors surgeries and local public transport. The local college is within walking distance of the home. The home provides 4 bedrooms on the first floor and 1 bedroom on the ground floor suitable for a service user unable to use the stairs. The home comprises of a large entrance hall, a sitting room, a conservatory and a combined kitchen/breakfast room. There are gardens to all sides of the house, which service users can reach easily. The home has its own transport. Roslin DS0000007405.V336155.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over one full day in April 2007 and was a scheduled unannounced inspection. A separate visit to the Northumberland, Tyne & Wear NHS Trust human resources (staffing) offices at Northgate Hospital, to inspect staff records was also carried out. This inspection included a separate look at a pre inspection questionnaire and comment cards received from service users and some of their relatives. The care experienced by a sample of service users was ‘case tracked’ (this is where the inspector focuses on the service provided for individual service users). Due to the communication needs of some service users, they can find it difficult to comment directly on the service they get. Because of this, time was spent observing life in the home. The inspector also spent time chatting with service users and staff, and a service user showed him around their home. A sample of staffing and service users’ records was inspected. The judgements made are based on the evidence available to the inspector during the inspection and from the information received before and during the site visit. What the service does well: There is a relaxed and friendly atmosphere in the home, and service users and staff get on well. Staff in the home have a range of work and life experience, are knowledgeable about service users’ needs. They work well to help and encourage access to community services and facilities, albeit within their limited resources. There is a shared vehicle available to help service users to get out and about. Relatives and visitors are made welcome in the home, kept up to date about service users’ progress, and those who commented are satisfied with the overall care provided. Service users needs are clearly detailed in written care plans, and their records are kept up to date. Comments received from service users included: • • “I like the staff here.” “Aye, I like going out in the car.” Roslin DS0000007405.V336155.R01.S.doc Version 5.2 Page 6 Staff recruitment checks include references and Criminal Records checks. These help to ensure safe recruitment practices are in place. Staff also receive regular, structured supervisions (meetings with their manager), which allow them to discuss issues relevant to service users and themselves. It also means that the staff team is well managed, and that their work meets service users’ requirements first and is focused on their needs. The care provider has a clear policy on equal opportunities. This relates to both care practice and staffing issues. For example, staff recruitment is in part governed by equal opportunities principles, and the staff team vary in age, cultural and gender background. Service users cultural and spiritual needs are identified, acknowledged and supported. Service users are encouraged to be involved in day to day choices and in discussing plans and making decisions at meetings, which also helps them to be involved in the running of the home. The home is well managed and there are clear lines of accountability within and outside of the home. What has improved since the last inspection? What they could do better: Service users made several comments that related to support levels. These were: • • • “I would like to be able to get out more.” Would like to have more support so can do more activities outside Roslin.” “I would like to be able to go and do more activities on weekends.” Roslin DS0000007405.V336155.R01.S.doc Version 5.2 Page 7 There were several requirements made as a result of this inspection. The home’s prospective manager needs to ensure that data sheets are readily available for the stocks of cleaning products and other chemicals held in the home. Data sheets are forms that provide information on individual chemical products, such as household cleaners, that may be hazardous to health. For example, they provide information on what action needs to be taken if the product is spilled, swallowed or comes into contact with the skin. It would be beneficial to clearly order and index these data sheets for ease of access should they be needed urgently. Staff need more regular training to make sure are kept up to date with current good practice. Staffing levels also need to be reviewed to ensure service users have good levels of support, particularly at the weekend. The homes kitchen also needs to be refurbished, as decoratively it is in poor condition, and work tops and work units are worn and the laminate surfaces breaking down. 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. Roslin DS0000007405.V336155.R01.S.doc Version 5.2 Page 8 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 Roslin DS0000007405.V336155.R01.S.doc Version 5.2 Page 9 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): 2, 3 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are assessed before their admission to the home and are also periodically re-assessed to an adequate standard. Detailed assessments can help ensure that the service can be planned in a way that meets service users needs and wishes. The home is able to meet the range of service users’ diverse needs to a good standard. Each service user has an individual, written contract that has been written in an excellent manner to aid clarity of understanding for service users. This can help ensure that service users have clear information about the terms and conditions of their residency and about their rights and obligations. Roslin DS0000007405.V336155.R01.S.doc Version 5.2 Page 10 EVIDENCE: Two service users have moved to the home since the last inspection. Both service users moved to the home with little notice, and for one service user the manager had little time to get clear information about his needs. This was because the referral was made just before this persons previous home was due to close. Of the case files examined it was evident that service users needs are subject to periodic review and re-assessment. Following such an assessment plans of care and risk assessments are developed by ‘key workers’. These mirror the needs observed by the inspector. The needs of each service user are detailed within their personal case files, and they also detail the action taken to meet these needs and progress made. Staff received training and guidance relevant to the majority of service users specific, diverse and specialist needs, such as those relating to epilepsy, and medication. Further advice is available from specialists within Social Services and from the Community Learning Disability Team. Those people who commented are generally satisfied with the overall care provide at Roslin. Roslin DS0000007405.V336155.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 and 8. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ care plans are in place, and reflect their observed needs (including their cultural needs and personal preference) to a good level. Effective care planning can offer guidance to care staff regarding care practice and ensure consistency where necessary. Service users are, as far as is practicable, consulted on and participate in the life of the home to an adequate level. Effective consultation, involvement and control can help in the development of an inclusive and person led service for those living here. Service users are supported to take risks within a planned framework, irrespective of their age, gender or level of ability. This can help ensure their independence is promoted, balanced against a judgement about any risks involved. This can also help promote an awareness of safety to a good level and ensure equality of access to community facilities and activities. Roslin DS0000007405.V336155.R01.S.doc Version 5.2 Page 12 EVIDENCE: Each service user has a personalised care plan file. These follow a standardised format. These care plans include picture prompts to aid discussion and understanding. One section summarises areas of need, likes, dislikes and so on. Another section outlines more detailed plans of care to help describe and guide staffs care practices. These plans are developed by key workers (staff who work specifically with an individual service user) in consultation with them, and cover a broad range of need areas. These are linked to regular monitoring of some areas such as personal care, behavioural needs, diet, weight and activities, and are then periodically reviewed and subsequently updated. Staff are also able to comment on and describe service users’ strengths, abilities and needs. For those service users case tracked, these plans of care accurately mirrored the needs observed by the inspector. The care plans for each service user are numerous, and for one service user there were 21 care plans, some of which overlap in what is covered. The effectiveness of having this many care plans was questioned with the manager who is recommended to review and then prioritise these. Each service users needs are reviewed annually, where their progress and wishes can be discussed. The prospective manager indicated that service users are invited to attend their care review meetings, however the review records show that service users do not always attend or have independent and family representation. This means that they are not always involved or represented in important decisions about their care. Service users were observed to make decisions affecting day to day choices including plans for the day, mealtime choices and so on. Service users and staff will discuss routines in the home, and service users have been able to make choices about décor schemes, trips out and personal purchases. There are regular house meetings where service users can voice their opinions on plans for the week ahead, menus and activities. Areas of risk are also documented within each service users’ care file, including assessments relating to activities out of the home, behaviours that may challenge the service, and the use of equipment. This can contribute to staff having guidance to enable service users to access community facilities without being placed at undue risk of harm. A model is used, whereby each risk area is identified, who or what may be harmed is noted, current and additional control measures are documented, and this is then reviewed. Roslin DS0000007405.V336155.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, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Current staffing levels mean that service users are assisted, to an adequate degree, to lead an active and fulfilling lifestyle by having an occasional community presence, and by accessing a range of community facilities. This will assist in them leading a full and enjoyable life. Service users are supported to maintain their personal relationships and friendships, to a good level, which helps them to keep in touch, and be involved in their family life. Service users rights are respected and routines in the home are flexible to a good level. This can help to promote a flexible service that encourages and promotes service users’ choices and preferences. Service users are offered and receive a varied, wholesome, nutritious and wellpresented menu. This can contribute to their general health and wellbeing. Roslin DS0000007405.V336155.R01.S.doc Version 5.2 Page 14 EVIDENCE: Several service users commented that they would like more help at the weekend to go out of the home. Some service users need the help of two staff when out, and as there are only two to three staff on duty (one of whom may be the manager), this may be hard to provide at times. Service users and staff explained to the inspector some of the activities they take part in and that are planned for the future. Most service users attend formal day services in the week, have been to college courses, go shopping and have occasional trips out. Other activities participated in include gardening, crafts, discos and trips to the shops and to the pub. Service users can spend time in their own rooms or in the various communal areas as they wish. A variety of relationships exist within and beyond the home. These are outlined within care plans, and should there be any concerns or needs in this area, plans of care have been developed to guide staffs’ practice. Relatives and friends are able to visit the home flexibly and a vehicle is available to service users to help them get out and about and to visit friends and relations. Staff have received training in respect of equal opportunities, and human rights awareness forms part of staffs’ NVQ work. The rights and obligations of service users are, in part, expressed and outlined within their residency agreement. Service users responsibilities towards one another, and in their conduct towards staff members are also outlined in their care plans. Service users are encouraged to respect the rights and privacy of others. Service users have a range of dietary needs, which are outlined within their care plans. They are also involved in menu planning, shopping and meal preparation. These skills are promoted and supported. Staffs’ practice reflects the guidance and risk assessments provided. There is a record kept of the meals planned and provided. Meals are normally taken within the dining room, although service users can eat elsewhere if they wish. Staff share meals with service users and can provide support and prompting in a discreet way that promotes service users independence and personal dignity. Roslin DS0000007405.V336155.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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal support appropriate to their needs and preferences, to a good standard, which can help to ensure their privacy and dignity is respected. Service users health care needs are identified and arrangements are made to help ensure they are promoted and met to a good degree. Medication arrangements are appropriate for the needs of service users, and are managed in a good and safe manner. EVIDENCE: The service users living at Roslin have their personal care needs outlined within their case files. Their needs are supported and met, where appropriate, in private, and they are encouraged to be independent where possible. Care staff are able to demonstrate, through discussion and observed practice, a good understanding of service users’ needs. Roslin DS0000007405.V336155.R01.S.doc Version 5.2 Page 16 Regular access to primary and secondary health care services, such as GP, occupational therapy and the dentist, is supported. Contact with health care professionals is documented within the service users care records, and regular healthcare updates are entered into service users care plans. All service users have an ‘okay health check’ which is an assessment of their health needs. Staff also monitor service users health and wellbeing closely and work with a range of professionals to promote service user’s needs. Locked storage has been installed for service users’ medications, with internal and external medicines stored separately from one another. Printed administration records are kept, and a sample signature list is maintained to identify what staff were responsible for each medication administration. Due to their levels of need, service users are not able to administer their own medicines, and designated staff therefore assist in this area. Staff at the home have undergone training in relation to medication administration. A stock check was undertaken for a sample of medications held in the home. This was concluded successfully, with stocks held corresponding to those recorded. One service user needs help with a specific, specialised treatment, and staff have received training and guidance from a medical professional in this area. However, the guidance in this person’s care plan is limited, and needs more detail to identify areas such as who can administer this medication, where, how, what training is needed, concerns to look for and where to seek additional guidance and advice. Roslin DS0000007405.V336155.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 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints are adequately acknowledged, and dealt with in a poor manner. This can help contribute to a service user centred service. Steps are taken to help ensure that service users are protected from abuse, neglect and self-harm to an adequate manner. EVIDENCE: A complaints procedure is available within the home, and informs service users that they can contact the Commission if they wish regarding complaints. A record of complaints and suggestions is maintained. Two have been documented over that past year. Although the subject of the complaint itself is documented, there is no evidence that either complaint has been acknowledged as having been received, investigated by anyone, or any outcome communicated to the complainant. One complaint has also been referred to the Commission. This was referred back to Gateshead Council as originally the complaint was made to them (although not investigated at that time) and related to an individual service user placed by this council. Service users are aware of who to speak to within the home should they be unhappy about the service they receive. Roslin DS0000007405.V336155.R01.S.doc Version 5.2 Page 18 Staff have, in the past, received training on the local Adult Protection arrangements, which will help to explain the role of adult protection, and to offer guidance to staff. However, many of the original staff team have now left and there is no record of when or if such training has been undertaken by current staff members. Written material is available in the home regarding these procedures should staff need guidance in this area, and individualised guidance is developed where necessary. Should a service user have an injury apparent a body chart is completed. Those examined have been completed, but provide only limited detail, and corresponding personal records provide little explanation of any injuries apparent, whether these were the result of observed accidents or not, and so on. Roslin DS0000007405.V336155.R01.S.doc Version 5.2 Page 19 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, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from an adequately maintained, homely and generally safe accommodation. The home is kept clean to a good standard. This can help promote a positive image for service users, and ensure they remain comfortable and safe. Service users have an adequate level of specialist equipment. Suitable equipment can promote service users’ independence and safety. Service users bedrooms are furnished to a good standard. This can contribute to their comfort during their stay at the home. Roslin DS0000007405.V336155.R01.S.doc Version 5.2 Page 20 EVIDENCE: Roslin is an adapted, detached house, with accommodation provided over two floors. There are no shared bedrooms and there is a bedroom on the ground floor, that would be suitable for people who have a physical frailty or disability that meant they could not easily walk up stairs. All other private accommodation is provided on the first floor. There are two W.C.’s and a shared bathroom on the first floor and a communal shower and W.C. on the ground floor. Communal areas consist of a lounge area, conservatory and a kitchen diner. Domestic style furnishings and fittings are provided, and decoration schemes have been developed in consultation with service users. Bedrooms have been decorated and furnished in a domestic manner and a regular, planned cycle of cleaning is implemented. Access into the home is level, but needs to be looked at by a suitable professional, such as an Occupational Therapist, to ensure that the needs of a service user who is unsteady when walking are fully and safely met. This is because there is no hand-rail to the main entrance, and the side entrance currently used has a drain hole and hot boiler vent that could both prove hazardous to this and other service users. Also, a conservatory is fitted at the rear of the home. There is no board fitted to the roof to prevent debris from falling onto it and potentially breaking the glass. This must be attended to. Domestic type laundry facilities are provided, which all service users are encouraged to use. The kitchen remains to be refurbished. Roslin DS0000007405.V336155.R01.S.doc Version 5.2 Page 21 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): 31, 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by a staff team, deployed in adequate numbers. Suitable levels of staffing can help ensure service users’ needs are safety met. An excellent number of staff have obtained qualifications in care. Service users are supported by competent staff who have received an adequate range of training, relevant to their roles, the purpose of the home and the majority of service users’ needs. Effective training can ensure that service users are supported in a safe manner by staff who have an understanding of these needs. Service users are protected by the home’s recruitment policy and practices, which can help ensure unsuitable candidates do not gain employment in the home. These are implemented to a good standard. Roslin DS0000007405.V336155.R01.S.doc Version 5.2 Page 22 EVIDENCE: Some service users at Roslin are able to meet many of their needs independently, with staff support needed when accessing community facilities, with catering, medication and some aspects of personal care. Other service users are more dependant on staff to ensure their safety, particularly when in the community. There is always at least two members of staff on duty during the day. Due to current staff levels there is limited scope to provide additional staff to assist with various activities and appointments, either during the day or in the evening. As the needs of service user’s have increased, and more able people moved on, the adequacy of staffing levels and deployment needs to be reviewed, particularly in respect of supporting service users activities safely. Staffing levels are detailed within a staffing rota, which is available for inspection. Staff are supported by an ‘on-call’ arrangement, whereby they can contact a designated experienced staff member for advice and additional support if necessary. There has been one new staff recruited to the home, and staff are only employed in the home after sufficient background checks have been carried out, which help determine their suitability to carry out their role. These checks include the receipt of a Criminal Records Bureau ‘disclosure’, two written references, and confirmation of physical fitness. There has been a high level of staff turnover, due to staff being moved internally across ‘the Trusts’ other local services. Most of these staff had pre-employment checks undertaken whilst working in other ‘Trust’ homes. Service users are not involved in decisions about staff transferring to and from the home, as a formal interview process is not undertaken. Staff receive a limited range of training, which is of relevance to the needs of service users, health and safety, and to care in general. This falls well short of the five days per year recommended in the National Minimum Standards, and for the six staff whose records were inspected, training varied from between none to two and a half days over the preceding year. No staff have received mental health awareness training (that is relevant to both the registration of the home and the needs of a service user). The newly recruited staff member is working through the Learning Disability Awards Framework. This is to develop her learning and awareness of the needs of people who have a learning disability, as well as to provide a basic foundation of knowledge relevant to the care sector. Specialist support to help a service user with specific medication needs has been provided, with ongoing support available as necessary. The manager keeps clear records of the training staff have received, which can assist in the planning of future training for the staff team. All but one of the staff team are qualified to NVQ level 2 or higher. Roslin DS0000007405.V336155.R01.S.doc Version 5.2 Page 23 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 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well managed home. Quality assurance systems seek the views of service users and their representatives to a good degree, which can help ensure the service remains focused on their needs and aspirations. The home is, to an adequate standard, free from hazards to service users and staff. This can contribute to the health, welfare and security of service users and staff. Roslin DS0000007405.V336155.R01.S.doc Version 5.2 Page 24 EVIDENCE: The registered manager has yet to undertake an assessment by the Commission for Social Care Inspection, and be adjudged fit to manage a care home. He has a nursing qualification and previous experience of working with this client group in a community setting. He has undertaken periodic training to keep his skills and knowledge up to date, but this has been limited during his employment at Roslin. The home operates a robust self-monitoring system using the Regulation 26 visits carried out by their external managers. These look at a range of aspects of the home, and make sure the service users are cared for properly. Due to the nature and size of the home the staff talk to the residents and visitors at all times and there is an open atmosphere that encourages them to let their views be known. The service users hold regular meetings so that they can tell the staff how they feel and talk about concerns and about the way the house is run as a group. The views of families are also sought. Staff hold separate meetings to share issues and talk about how they can improve the care they give to the residents. These meetings are recorded clearly and used to help develop plans for the future of the home and development for the residents. At the time of the inspection there were no observed hazards to safety (other than the matters noted in the premises section of this report). There is a health and safety policy available to guide staff, and various risk assessments have been developed, both to enable service users to be independent, but also to ensure care and working practices are undertaken in a safe manner. Health and safety checks are also undertaken regularly, including an audit of the building, fire safety checks and instruction, and regular water temperature tests. The COSHH data sheets for cleaning and chemical products could not be located during the site visit, although the prospective manager later indicated that these were available in the home. These must be made readily and easily accessible to staff and reflect the stocks of hazardous products held in the home. Roslin DS0000007405.V336155.R01.S.doc Version 5.2 Page 25 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 2 3 3 4 X 5 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 2 30 3 STAFFING Standard No Score 31 2 32 4 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Roslin DS0000007405.V336155.R01.S.doc Version 5.2 Page 26 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 YA20 Regulation 13(2) Requirement Timescale for action 25/07/07 2. YA22 22(2, 3 & 8) 3. YA23 13(6) 3. YA24 23(2)(d) The registered person must provide sufficient detail in care plans to guide the specialist medication practice of staff. The registered person must 25/07/07 ensure that complaints are fully investigated and the outcome communicated to the complainant. A written copy of this must be maintained. The registered person must 25/08/07 ensure that all staff receive training on abuse awareness and adult protection procedures that operate locally. The kitchen must be refurbished 25/09/07 and redecorated (Previous timescale of 01 Nov 2005 and 01 May 2006 for redecoration). The registered person must ensure that there are adequate adaptations to ensure safe access to and from the home for service users with a physical disability. The registered person must review staffing levels and staffing deployment in the home to ensure that service users DS0000007405.V336155.R01.S.doc 4. YA29 23(2)(n) 25/07/07 5. YA33 16(2)(m & n), 18(1)(a). 25/07/07 Roslin Version 5.2 Page 27 6. YA35 7. YA42 social interests and programme of activities are supported. 18(1)(c)(i) The registered person must ensure that staff receive training relevant to the needs of service users and the purpose of the home, including training in respect of mental health awareness. 13(4)(c) The registered person must arrange for COSHH data sheets to be available in the home for all hazardous chemical products stored and used in the home. 25/09/07 25/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA6 YA6 YA35 Good Practice Recommendations The registered person should ensure that service users have their views independently represented at their care review meetings. The registered person should review service users care plans to allow them to be prioritised and to reduce unnecessary duplication and administration. The registered person should ensure staff receive a minimum of five days paid training per year (pro rata for part time staff). Roslin DS0000007405.V336155.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. Extracts may not be used or reproduced without the express permission of CSCI Roslin DS0000007405.V336155.R01.S.doc Version 5.2 Page 29 - 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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