Inspection on 26/07/05 for The Rookery Cottage

This inspection was carried out on 26th July 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

The Rookery Cottage 20/02/08

The Rookery Cottage 07/11/05

The Rookery Cottage 20/12/04

The Rookery Cottage 17/08/04

The Rookery Cottage 21/03/04

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

CARE HOME ADULTS 18-65 THE ROOKERY COTTAGE 249 Shinfield Road Reading Berkshire RG2 8HE Lead Inspector Lucy Martin Unannounced 26 July 2005, 09:30 am 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. THE ROOKERY COTTAGE H52-H01-S11353-Rookery Cottage-V232260260705-Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Rookery Cottage Address 249 Shinfield Road, Reading, Berkshire, RG2 8HE 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) 0118 9872278 Milbury Care Services Limited Mrs Helen Mary Petty Care Home (CRH) 6 Category(ies) of Learning Disability (LD) registration, with number of places THE ROOKERY COTTAGE H52-H01-S11353-Rookery Cottage-V232260260705-Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 20 December 2004 Brief Description of the Service: Rookery Cottage is a large detached listed building with an extension added at a later date. It is a few miles from Reading town centre and is situated on a busy main road. The house is set back from the road and has a large garden. The home is close to public transport and offers easy access to all local amenities. A range of shops are within walking distance of the home. Rookery Cottage is a residential home for up to six adult service users with a learning disability, some of whom have additional mental health needs. THE ROOKERY COTTAGE H52-H01-S11353-Rookery Cottage-V232260260705-Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection which started at 9.30am and finished at 12.40pm. The inspector saw four of the five service users currently living at the home and two were spoken with. The inspector spoke to the Manager and two of the staff on duty. Records, including service user’s files were seen. What the service does well: What has improved since the last inspection? What they could do better: There is a need to ensure that the unmet requirement to carry out a training needs assessment for the staff team as a whole is carried out. Training courses undertaken by staff should be clearly recorded with the name of the course recorded as well as the date. Risk assessments for service users need to be reviewed to ensure that all areas are covered. The unmet requirement to replace the lounge and communal carpet downstairs must be met within the timescale given or enforcement action may be THE ROOKERY COTTAGE H52-H01-S11353-Rookery Cottage-V232260260705-Stage 4.doc Version 1.40 Page 6 considered. The home was given a week to secure the frayed carpet by the fire exit in the lounge which presents a tripping hazard to service users and staff. 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 ROOKERY COTTAGE H52-H01-S11353-Rookery Cottage-V232260260705-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 THE ROOKERY COTTAGE H52-H01-S11353-Rookery Cottage-V232260260705-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) 1 Individual service users’ guides are in place. EVIDENCE: It has been a requirement since 2002 that work is undertaken to ensure that the service user’s guide is in a format that can be understood by service users. This has now been met and individual folders were seen for each service user which contained a number of photographs giving information about the home and their daily lives. THE ROOKERY COTTAGE H52-H01-S11353-Rookery Cottage-V232260260705-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 Service users have care plans and risk assessments in place. All of the care plans and most of the risk assessments are reviewed on a regular basis. There is a need to ensure that all relevant risk assessments are included in service users files. EVIDENCE: The work to update and improve the content of service user’s files has continued. All service users now have three files – a management file, a file containing daily support plans and a current file. The care plans were seen and the programme to update and ensure that they are regularly reviewed has continued. Three service user’s files were seen and all the plans had been reviewed in the last six months. Some of the care plans are handwritten and advice was given that they are typed to make them easier to read and to look more professional. It was an unmet requirement at the last inspection that all risk assessments must be reviewed on a regular basis. This has been met and risk assessments are written and filed with the care plan they relate to. Although the care plans are being reviewed at least six monthly and generally risk assessments, there were still a few risk assessments found that had not been reviewed in the last THE ROOKERY COTTAGE H52-H01-S11353-Rookery Cottage-V232260260705-Stage 4.doc Version 1.40 Page 10 six months. It was noted in one of the files seen, that the service user did not have a bathing care plan and there are risks due to epilepsy. In another, there was no risk assessment relating to going missing and this is a service user who likes to wander alone in the garden. It is a requirement that the risk assessments relating to service users are reviewed to ensure that all relevant areas are covered. The keyworker reviews the care plans and the individual support required monthly and the written details provide good evidence of changes made to the service user’s plans. There is also a monthly summary sheet written which is an excellent way of highlighting change. THE ROOKERY COTTAGE H52-H01-S11353-Rookery Cottage-V232260260705-Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15 Most service users take part in a variety of activities while living at the home and are part of the local community. There is good support given to service users to maintain contact with their families. EVIDENCE: All the service users have external day activity providers and some have sessions up to four days a week. Activities include horse riding and cookery. On the morning of this inspection, two service users were collected and taken to day services. One service user who attended one computer session a week has now increased this to two which is a positive move. Service users are part of the local community and go out for walks to the local shops and the park. Activities such as trips to Windsor and Henley on Thames have recently taken place. The home is on a main bus route to the centre of Reading and the home has its own car. It was noted that one service user is not going out very much at present. There was evidence that he is being offered opportunities to go out and is refusing. The Manager was aware of the situation which is being monitored. THE ROOKERY COTTAGE H52-H01-S11353-Rookery Cottage-V232260260705-Stage 4.doc Version 1.40 Page 12 All the service users maintain contact with members of their family and some go home on a regular basis. The home had recently had a barbecue and all the service users families had been invited. THE ROOKERY COTTAGE H52-H01-S11353-Rookery Cottage-V232260260705-Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 Service users health needs are well looked after. EVIDENCE: All the service users health needs are closely monitored. There was evidence in the three service users files seen that routine appointments are made with healthcare professionals and the outcomes are recorded. Some of the service users have mental health needs and there are regular appointments with psychiatrists and reviews of medication. THE ROOKERY COTTAGE H52-H01-S11353-Rookery Cottage-V232260260705-Stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 The home has clear complaints procedures in place. EVIDENCE: The home has a complaints book which contained one new entry since the last inspection. This matter had been dealt with swiftly and appropriately. All the service users have received information regarding how to make a complaint in an easy to understand format. All of the service users are in regular contact with members of their family who could make complaints on their behalf if necessary. THE ROOKERY COTTAGE H52-H01-S11353-Rookery Cottage-V232260260705-Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 28 Overall, the home is in a reasonable state of repair but there is an urgent need to replace the lounge and communal downstairs carpet and to ensure that the carpet in the lounge is not frayed at the fire exit. EVIDENCE: On this inspection the communal areas downstairs were seen including the lounge/dining area, the kitchen and the garden. One of the bedrooms situated on the ground floor was seen. Overall, the home is in a reasonable state of repair and some work has been undertaken since the last inspection. The requirement to clean the patio and make good has been met and the wooden around the front of the property has been replaced. Inside the house, there are new light fittings in the lounge. It has been a requirement since March 2004 to provide the CSCI with a timescale indicating when the lounge and communal downstairs carpet will be replaced. This has still not been met and the carpet continues to look heavily worn and marked. It is acknowledged that there have been some difficulties in getting maintenance tasks undertaken as the home is owned by a different organisation, but the replacement of this carpet is urgent. This matter was followed up in separate correspondence to the Operations Manager and the THE ROOKERY COTTAGE H52-H01-S11353-Rookery Cottage-V232260260705-Stage 4.doc Version 1.40 Page 16 Responsible Individual and a timescale of two months was given to replace the carpet. If this timescale is not met, enforcement action may be considered. It was noted that the lounge carpet was extremely frayed around the fire exit which could pose a tripping hazard to service users and staff leaving the building in the event of a fire. An immediate requirement was issued to ensure that the frayed carpet was secured so as not to pose a risk in the event of a fire. The timescale was 2 August 2005. Since the last inspection, the office has been moved to the main part of the building. The room is bigger than before and is more in the heart of the house. THE ROOKERY COTTAGE H52-H01-S11353-Rookery Cottage-V232260260705-Stage 4.doc Version 1.40 Page 17 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) 33, 34, 35, 36 Service users are supported by a staff team in sufficient numbers and there is a thorough recruitment procedure. The staff team are supervised on a regular basis but there was not sufficient evidence of training needs and courses undertaken. EVIDENCE: There has been a reduction in the staffing vacancies at the home since the last inspection. There is a core group of senior staff who know the service users well and a number of permanent part-time staff. The home also has approximately six bank workers who cover shifts on a regular basis. This has meant that there is less use of agency staff and the inspector was informed that there has been no use of agency staff in the past six weeks. This is positive and ensures better consistency and continuity for service users. There are still few male members of staff at the home but there is a good mix in terms of age. Regular staff meetings continue to take place. The recruitment records of two recently appointed members of staff were seen. There was evidence that two written references as well as CRB (Criminal Record Bureau) checks had been undertaken. It was an unmet requirement at the last inspection that a training needs assessment is carried out for the staff team as a whole. This has not been met. THE ROOKERY COTTAGE H52-H01-S11353-Rookery Cottage-V232260260705-Stage 4.doc Version 1.40 Page 18 It was evident that a range of training had been undertaken by members of staff but not all the staff files seen contained a front sheet recording the training attended and the date. These matters must be addressed. It was an unmet requirement at the last inspection that regular recorded supervision sessions take place at least 6 times a year. This is an area of improvement and the requirement has been met. Records seen indicated that all staff including regular bank works have received supervision on a regular basis. THE ROOKERY COTTAGE H52-H01-S11353-Rookery Cottage-V232260260705-Stage 4.doc Version 1.40 Page 19 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) 42 The health and safety of service users is protected. EVIDENCE: The health and safety checks at the home are undertaken on a regular basis. The fire alarm is routinely serviced and there are weekly checks of the fire alarm system. A fire drill had recently taken place. It was a requirement made at the last inspection that the external emergency lighting is mended and this has been done. The temperature of the hot water is checked weekly and is recorded. Fridge and freezer temperatures are taken daily. A health and safety checklist covering all areas is completed monthly. THE ROOKERY COTTAGE H52-H01-S11353-Rookery Cottage-V232260260705-Stage 4.doc Version 1.40 Page 20 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 3 x x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x 3 x x Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x x Standard No 31 32 33 34 35 36 Score x x 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 THE ROOKERY COTTAGE Score x 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x H52-H01-S11353-Rookery Cottage-V232260260705-Stage 4.doc Version 1.40 Page 21 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 35 Regulation 18 Requirement Timescale for action 26/10/05 2. 24 23(2)(b) 3. 9 13(4) 4. 24 13(4)(a) A training needs assessment is carried out for the staff team as a whole. (Previous timescale of 20/3/05 not met) To replace the lounge and 26/9/05 communal downstairs carpet. (Previous timescale of 20/2/05 to provide the CSCI with a timescale for replacement has not been met) The risk assessments relating to 26/9/05 service users are reviewed to ensure that all relevant areas are covered. Action is taken to ensure that 2/8/05 the frayed carpet leaqding to the fire exit in the lounge is secured. 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 35 Good Practice Recommendations There is a front sheet in each member of staffs file recording the name of the training course attended with the date. H52-H01-S11353-Rookery Cottage-V232260260705-Stage 4.doc Version 1.40 Page 22 THE ROOKERY COTTAGE THE ROOKERY COTTAGE H52-H01-S11353-Rookery Cottage-V232260260705-Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 2nd Floor, 1015 Arlington Business Park Theale Berkshire RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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