Inspection on 25/05/07 for Rosswood Gardens (4-10)

This inspection was carried out on 25th May 2007.

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

The inspector 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

Rosswood Gardens (4-10) 20/07/06

Rosswood Gardens (4-10) 20/07/05

Rosswood Gardens (4-10) 14/10/04

Rosswood Gardens (4-10) 15/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Rosswood Gardens (4-10) 4-10 Rosswood Gardens Wallington Surrey SM6 8QZ Lead Inspector Ms Rin Saimbi Key Unannounced Inspection 25th May 2007 09:30 Rosswood Gardens (4-10) DS0000007189.V341436.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 Rosswood Gardens (4-10) DS0000007189.V341436.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. Rosswood Gardens (4-10) DS0000007189.V341436.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosswood Gardens (4-10) Address 4-10 Rosswood Gardens Wallington Surrey SM6 8QZ 020 8647 8193 020 8647 6671 jackmh@threshold.org.uk www.thresholdsupport.org.uk Threshold Housing and Support 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) Mrs Sara Ann Anderson Care Home 22 Category(ies) of Learning disability (22) registration, with number of places Rosswood Gardens (4-10) DS0000007189.V341436.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th July 2006 Brief Description of the Service: Rosswood Gardens is within a short distance of Wallington town centre, with shops, library, pubs and post office all near by. There are good transport links with British Rail station and a number of bus routes within walking distance. There is only limited parking available at the home. The home is owned and run jointly by Threshold Support and Open Door; this merger took place on the 1st April 2005. Subsequently, this organisation has been taken over by Metropolitan in April 2007. This amalgamation has not affected the daily lives of the service users, but will over time change the policies and procedures that are in place. Rosswood Gardens provides a home for up to 17 people with a learning difficulty. The home is divided into three separate units. There is a smaller home for 5 people who come to the home for a break, this is known as respite care. All rooms within the home are single, with their own sink, bed and wardrobe. Service users have their own key to their room and are free to home and go as they wish. Some of the downstairs rooms have their own bathroom, these are for people who are wheelchairs or need a lot of care. The costs from April 2007 per week are £715.34. Rosswood Gardens (4-10) DS0000007189.V341436.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first inspection for 2007/08. It was an unannounced inspection, which took place over two sessions. The first session was between 9.30 and 1.30pm; it mainly comprised of looking through documentation, talking to staff and a tour of the premises. The second part of the inspection took place between 3 and 5.30pm with a view to maximise the opportunity to observe staff interaction with service users and to meet and talk to service users on their return from daytime activities. The inspector also reviewed all information received by the Commission over the last year. The home appointed a new manager, Helen Jackson, in September 2006. She has successfully completed her manager’s registration with CSCI. She was not available on the day of inspection. The home is in a transitional phase as the respite unit is undergoing major structural changes. These changes are will result in an increase in the number of bedrooms. In addition, these rooms will have better facilities for those service users who have additional physical needs. As the respite unit can be treated as a separate entity, disruption to the other units was minimal. The inspector would like to thank all the service users and staff for their time and support through the inspection process. What the service does well: The home remains effective in enabling service users to make decisions about lives. These decisions range from what to eat, what colour to paint their bedrooms and where to go on holiday? There is a real commitment in terms of support to enable this; there is a part time ‘quality assurance’ co-ordinator whose role is to listen to service users and assist them making choices. There Rosswood Gardens (4-10) DS0000007189.V341436.R01.S.doc Version 5.2 Page 6 are service users meeting which are co-ordinatied by independent individuals, rather than staff. The level of training within the home is extensive. All new staff employed by the home have a period of induction during which they shadow another of staff, read polices and procedures and undertake some basic training. The induction period then leads onto the Learning Disability Award Framework, and then finally onto the National Vocational Qualification (NVQ) Level 2 or 3. There is availability and opportunity for staff to attend further training with regard to refresher courses; courses that meet the future needs of service users and courses of interest. What has improved since the last inspection? What they could do better: Reviews relating to service users were found to be out of date, which could potentially restrict freedom of choice. Rosswood Gardens (4-10) DS0000007189.V341436.R01.S.doc Version 5.2 Page 7 Four service users flies were case-tracked; of these two indicated that there had not been statutory reviews since 2004 and 2005. Whilst acknowledging that reviews are the responsibility of Social Services to arrange, there was no evidence that the home had contacted the appropriate department to request a review. In addition, there was no evidence that service users own goals were being reviewed internally. Risk assessments for service users were up-to-date. Although the general environmental risk assessments were reviewed in March 2005. 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. Rosswood Gardens (4-10) DS0000007189.V341436.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 Rosswood Gardens (4-10) DS0000007189.V341436.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): 2,3,4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prior to any new service users coming to live at Rosswood Road, the home gathers as much information as it can so that everyone can be sure that it is the right place for the individual. Prospective new service users are then given the opportunity to ‘test drive’ the home before making a final decision about whether to live there or not. In this way, service users should feel that they are not just be slotted into a vacancy but instead making an active choice. Service users do not have contracts that are written in a way that is appropriate to their understanding EVIDENCE: The inspector viewed paperwork, which related to a new service user coming into the home. The service user came as an emergency admission; they already knew people at Rosswood. Rosswood Gardens (4-10) DS0000007189.V341436.R01.S.doc Version 5.2 Page 10 However, the process was nonetheless thorough and comprehensive, with the manager visiting the day centre where the service user was placed; and also meeting with the service user parents. An assessment had been completed which included the service users routines, for example, ‘what I like to do in the day’ ‘how I communicate’ and ‘what I like to eat’. These assessments had been translated into a support plan, with risk assessments also in place. In general, the process is that the home gathers as much information as possible from the new service users, their family and friends. There is then an introduction period which involves the new service users coming to visit the home at different times of the day and at the weekend so that they get the opportunity to meet everyone at the home. This period can be as long as is needed. Finally, there is an overnight stay, a weekend stay and then moving in. There is then a review at 4 – 6 weeks, and then again at three months so that the service user and everyone involved has the opportunity to say if they want the placement to continue or not. Three other service users files were sampled at random, all had a contract, which gave details of the terms and conditions, fees charged, and the rights and responsibility of the home and the service user. The service user or their advocate then signs the contract. However, the contracts themselves are not in a format or in language that would be appropriate to service users. Instead, they are complicated and written using jargon. This has been an outstanding requirement since July 2005. The Commission recognises that the changes within the organisation have not made this task straightforward. However, this requirement has been outstanding for two years and needs to be addressed for with. Rosswood Gardens (4-10) DS0000007189.V341436.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): 6,7,8,9 and 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users are enabled to take as much control of their lives as is possible, and to make choices with support, information and guidance. The lack of formal reviews could potentially be restricting service users freedom of choice EVIDENCE: Service users are encouraged to make decisions about all aspects of their lives, this ranges from what to eat, wear and how they would like their bedrooms decorated. There are regular service users meetings, and in addition, the home employs a ‘quality assurance co-ordinator’ on a part-time basis. The main focus of the co-ordinator is to listen to what service users want and to try and put it into place. Rosswood Gardens (4-10) DS0000007189.V341436.R01.S.doc Version 5.2 Page 12 The home is in the process of initiating Person Centred Planning (PCP) for all its service users. The deputy manager reported that approximately a third of all people who use the service had already completed their PCP’s. Amongst its staff team, three people have now completed the PCP course and are now qualified co-ordinators. The inspector case-tracked four service users files, in general, they were up to date. However, there were a number of reviews and assessments that were found to be out of date. The statutory reviews for two of the service users were dated 27.09.04 and 17.09.05. Whilst acknowledging that reviews are the responsibility of Social Services to arrange, there was no evidence that the home had contacted the appropriate department to request a review. It is not acceptable that service users reviews are three and two years out of date. A requirement has therefore been made that the home must seek to ensure that reviews are held within a timely fashion. In addition, there was no evidence that service users own goals were being reviewed internally. Risk assessments for service users were up-to-date. Although the general environmental risk assessments were reviewed in March 2005. A requirement has therefore been made that these are updated for with. The home has a policy on confidentially which also outlines what should be done if there is a breach of confidentiality. Staff have signed and dated the document as an indication that they have read and understood it. A discussion with a member of staff indicated that they understood the principals of confidentiality and how it should be maintained. All service users files are kept in the main office, which is locked when not in use. Rosswood Gardens (4-10) DS0000007189.V341436.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): 12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users within the home live ordinary and meaningful lives. There are always a variety of activities that are on offer, and service users choose want they want to do dependent upon their needs and wishes. EVIDENCE: Service users at Rosswood Gardens do a variety of activities depending upon their wishes and needs. Many attend day centres, although none attend on a five-day basis, instead having at least one day off a week. Other service users attend college and some within the respite service go to work. One service user has ‘retired’ from day centres. Rosswood Gardens (4-10) DS0000007189.V341436.R01.S.doc Version 5.2 Page 14 In the near future, there will be a major change in the activities that are undertaken, as Hallmead, the large local day centre is soon to close. The staff team within the home are already considering options. Service users use the resources of the local community, which includes going to the supermarket, shops, library and cafes. Within the home there a two couples in relationships. All service users are offered a holiday, this year they will either be going to Spain, Cyrus or the Isle of Wight. Service users spoke about the how they made the choice of where to go, first they went to the local travel agents and then brought back various brochures. Some service users said that they did not want to go abroad and so had chosen a holiday in this country. All the service users were very excited about the prospect of going on a holiday and some had their bags packed weeks in advance. Service users are responsible for cleaning their bedrooms with varying degrees of assistance. The inspector viewed a number of bedrooms with the service users permission. All had a pleasing degree of personalisation with photographs of family and friends. One room even had monkey stencils on the walls, as the service user was so keen on them. Service users are encouraged to be involved in the preparation and serving of meals. Service users told the inspector what tasks they did; one laid the table, whilst another said they sometimes prepared the vegetables. Meals being prepared on the day of inspection, appeared nutritious, balanced, and attractively presented. The meals were taken in the dining areas of the various houses, which were congenial in setting. Each of the houses compiles a weekly menu, usually on a Sunday. However, if service users decide that they do not want a particular thing to eat, and then an alternative is always available. The home is able to cater for people on special diets; currently this includes someone who is on a gluten free diet, one service users who is Muslim and therefore eats Hahal meat, and someone who is a diabetic. Various snacks and drinks were available, and service users were observed moving freely around the kitchen areas. Rosswood Gardens (4-10) DS0000007189.V341436.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 within the home have access to healthcare, and are supported in keeping appointment if this is required. Staff were knowledgeable and experienced in knowing about the personal care that individual service users needed, and providing that care which ensured privacy and dignity EVIDENCE: The home aims to maintain privacy and dignity for all its service users. This was confirmed via observations made by the inspector and during discussions with staff. Staff were observed knocking on bedrooms doors, addressing service users in an appropriate manner. Staff were also able to confirm what actions they took when providing personal care. Rosswood Gardens (4-10) DS0000007189.V341436.R01.S.doc Version 5.2 Page 16 Service users choose their own clothes and toiletries, with some guidance from staff on occasions. Service users were able to confirm that they had choice in clothes and toiletries. Appropriate professionals assess service users health needs. Most are registered with a local GP, but there is a choice of who to register with. All service users have an annual check with their G.P. to review their health needs and medication. A Community Psychiatric Nurse and chiropodist visit the home on a regular basis; the home uses the Dentist at Orchard Hill and a community dietician and optician. The consultant psychiatrist visits as and when it is required. The home keeps a record of all appointments and the outcome of these. The inspector case-tracked four files of service users to confirm that health records were up to date and accurate with visits to the dentist every six months and the opticians annually unless stated otherwise by the optician. The administration of medication was checked for two of the homes. Medication is stored in locked metal cabinets, which are secured to the wall. The home uses blister packs for much of the medication, which arrives from the pharmacist on a regular basis. Records regarding the administration of medication were checked and found to be up to date and accurate. One member of staff within the home has responsibility for overseeing issues regarding medication. This is advantageous in terms of consistency. This member of staff is also up to date with all training issues regarding medication. A recommendation is being made that the Medication of Administration Records should include a photograph of the service user on individual records with a list of any known allergies. This should assist in minimising the chances of errors occurring. Rosswood Gardens (4-10) DS0000007189.V341436.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 good. This judgement has been made using available evidence including a visit to this service. The home takes complaints seriously and listens to service users about their views of living within the home. The home generally ensures that service users are protected, safe and free from harm. EVIDENCE: The home has a complaints policy, which is in a user-friendly format, copies of which are displayed throughout the home and in the service users files. The home maintains a complaints log, which is also in a computerized format. The complaints log was viewed and showed that this year there had been five complaints made. Several of these referred to the heating and hot water system, which broke down over the winter months and took a long time to fix. Service users when asked whom they would talk to if they had a problem at the home were all clear that they would approach staff. The ‘quality assurance co-ordinator’ assists service users in making complaints. In addition, the residents meetings are only attended by service users and coordinated by independent people. The independent person then take any issues, which arise from the meetings, to staff. Rosswood Gardens (4-10) DS0000007189.V341436.R01.S.doc Version 5.2 Page 18 There were discussions with two staff that indicated that they had an awareness and understanding of vulnerable adults, and what to do if they had any concerns regarding service users. One of these members of staff was new in post. Rosswood Gardens (4-10) DS0000007189.V341436.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): 24,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is reasonably maintained, and is furnished and decorated with domestic style furniture. Service users can therefore feel that this is their home and that they are comfortable with it. EVIDENCE: The lay out of Rosswood Gardens allows for each home to be a separate unit, with its own front door, kitchen/dining room, and lounge and laundry room. Internally there is access through the home should it be required. There is a large shared garden to the rear of the building. A tour of the building was conducted and a number of bedrooms were viewed The home is generally well furnished with domestic style furniture that is of a reasonable quality. There is a pleasing degree of personalisation in the bedrooms, with service users choosing their colour for the room and decorating Rosswood Gardens (4-10) DS0000007189.V341436.R01.S.doc Version 5.2 Page 20 them how they wish. Bedrooms are well equipped with a single bed, wardrobe, chest of drawers and a wash hand basin. Some of the ground floor bedrooms have en-suite facilities. The individual units benefit from recently fitted kitchens. The respite unit is not presently functional as it is undergoing structural changes to increase the number of bedrooms and include aids and adaptations suitable for service users with increased physical needs. On the day of inspection, the work was nearing completion. As the respite unit can be separated from the rest of the home, disruption to service users has been kept to a minimum. Previous requirements relating to the condition of the carpet and the provision of specialist aides and adaptations have both been met and therefore the requirement is withdrawn. Each unit within the home has a separate laundry room with hand washing facilities. Staff within the home undertake all the general cleaning, the premises were hygienic and free from offensive odour. Rosswood Gardens (4-10) DS0000007189.V341436.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff within the home are in general well trained. There is a range of experiences and an understanding of the needs of people with learning difficulties thereby ensuring that the needs of the service users are appropriately met. EVIDENCE: Staff appear generally to have qualities and attitudes that are important in interaction with service users; they are good communicators, comfortable with the service users and aware of their needs. The home has a staffing establishment of twenty-two including four night staff; currently there are eighteen people in post. The shortfall is managed according to the deputy, by the use of agency staff that they use on a regular basis. The number of staff within the home appear adequate, during the morning there is one member of staff in each of the units plus one floating; in the Rosswood Gardens (4-10) DS0000007189.V341436.R01.S.doc Version 5.2 Page 22 afternoons, the numbers remain the same with two members of staff floating. This was confirmed when two weeks of the staffing rota were viewed at random. Staffing levels will clearly need to be reviewed when the day centres closes, and at such time, that the respite unit is registered for additional service users. With regard to training and qualifications, all new staff employed by the home have a period of induction during which they shadow another of staff, read polices and procedures and undertake some basic training. The induction period then leads onto the Learning Disability Award Framework, and then finally onto the National Vocational Qualification (NVQ) Level 2 or 3. The home currently has eighteen members of staff including four night staff; of these seven have completed NVQ Level 2 or 3 Staff within the home feel that there are adequate levels of training available to them, and that if there were areas that they are interested in then these would be considered. The home retains a copy of all training undertaken by staff, and when refreshers courses need to be undertaken. The Human Resources department also holds this information. Documentation relating to two members of staff was viewed, and indicated that staff are receiving the minimum of five days training per year. The inspector viewed two sets of personnel files; both contained an application form, two references, a copy of terms and conditions and current Criminal Records Bureau (CRB) checks Supervision within this home has historically been sporadic. However, it was very positive to note that there has been a vast improvement in this area. Both staff that were viewed showed that supervision is occurring every four to six weeks. Staff were able to confirm that supervision has become more regular. When supervision does occur, it is appropriately recorded and signed by both parties. Annual appraisals have taken place for all staff members. The home does have regular monthly staff meetings. Rosswood Gardens (4-10) DS0000007189.V341436.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Policies and procedures are in place to ensure that the home fulfils its stated purpose and objectives, and to meet the needs of the people who live there. The calibre of a manager is crucial to the running of any home to ensure the well being of service users. It is positive therefore, that the home has appointed a new manager who has recently become registered with CSCI. EVIDENCE: Rosswood Road have a raft of policies and procedures that are written centrally, a random selection at a previous last inspection indicated that all appropriate areas are covered as identified by Appendix 3 of the National Minimum Standards for Younger Adults. Rosswood Gardens (4-10) DS0000007189.V341436.R01.S.doc Version 5.2 Page 24 Staff then sign and date the policies as an indication that they have read and understood them. The home has appointed a new manager, Helen Jackson, who has been in post since September 2006; she has successfully completed her manager’s registration recently with CSCI. Staff are positive about her ethos and leadership qualities; service users and staff alike have described her as approachable. With regard to health and safety checks, Portable Appliance Testing was completed January 2007; Legionella testing dated 20.12.06; certificates for various equipment showed regular servicing and the Landlords Gas certificate was 31.10.06. With regard to fire safety; fire alarm testes are conducted weekly; fire drills are every three months and the fire equipment was last tested on 22.10.06. It was noted however, that every fire door in the building was wedged open. This practice must cease for with, and therefore a requirement has been made in this regard. Whilst touring the building it was observed that two of the three Control of Substances Hazardous to Health cupboards were left unlocked. This practice could affect the well being of service users. This practice must cease for with, and a requirement has been made in this regard. With reference to quality assurance monitoring systems, Regulation 26 visits are conducted on a monthly basis and a copy available for inspection purposes. Rosswood Gardens (4-10) DS0000007189.V341436.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 3 3 3 4 3 5 2 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 3 25 X 26 X 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 3 3 3 X Rosswood Gardens (4-10) DS0000007189.V341436.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 YA5 Regulation 5(1)(c) Requirement The home must provide each service users with a contract that is in a format that is suitable to each individual Outstanding requirement from 20/07/05 2 3 4 5 YA42 YA42 YA6 YA6 15(2) b 15(2) b 12(1) a 12(1) a Statutory reviews must be held within an appropriate timescale Risk assessments must be reviewed at least annually All fire doors must kept closed at all times CoSHH cupboards must be kept closes at all times 24/08/07 24/07/07 25/05/07 25/05/07 Timescale for action 24/08/07 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. Refer to Standard YA4 Good Practice Recommendations It is recommended that Medication Administration Records contain a photograph of individual service users, and any individual allergies that they may have DS0000007189.V341436.R01.S.doc Version 5.2 Page 27 Rosswood Gardens (4-10) Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Rosswood Gardens (4-10) DS0000007189.V341436.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!