Inspection on 14/12/05 for Three Roses

This inspection was carried out on 14th December 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Three Roses 28/06/07

Three Roses 31/05/05

Three Roses 20/10/04

Three Roses 06/04/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Three Roses Bromsgrove Road Holy Cross, Clent Stourbridge West Midlands DY9 9QP Lead Inspector R McGorman Unannounced Inspection 14th December 2005 10:00 Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 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 Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 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. Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Three Roses Address Bromsgrove Road Holy Cross, Clent Stourbridge West Midlands DY9 9QP 01562 730730 01562 730310 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) Three Roses Homes Limited Ms Isobel Bowen-Shaw Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 31st May 2005 Brief Description of the Service: Three Roses is registered to provide residential care for up to fourteen younger adults who have learning difficulties. The home is under the control of Three Roses Homes Ltd., a registered charity, which is run on the basis of a non-profit making company. The Board of Trustees have appointed three Directors, one of these being Mr Michael Noott, who acts as Company Secretary and also maintains regular oversight of the home. Mrs Isobel Bowen-Shaw, the registered care manager, has responsibility for the day-to-day running of the home. The fundamental philosophy underpinning the operation of the home was said to be an adaptation of the Rudolph Steiner approach to care and many of the existing resident group previously attended schools that had been run on Steiner principles. The premises have been developed and upgraded over the years to provide suitable and very pleasant accommodation. The building is single storey, and set in extensive grounds which border open countryside. The stated aim of Three Roses is to provide an environment which enhances the dignity, self respect and individuality of residents, where they are assisted to develop independence in self-care, domestic competence and daily living skills by Learning through Doing. Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this inspection was to fulfil the statutory requirement and to monitor the care provision at the home in relation to the stated aims and objectives. The inspection took approximately 3 hours, and time was spent with service users, in various areas within the home, whilst undertaking their activities. Discussions were also held with several members of staff, and a very favourable impression was gained about what it is like to work at Three Roses. The documentation was checked with the assistance of the Registered Care Manager, and consideration given to the organisational arrangements at the home. The care records of residents were seen, together with some staff files, and records kept in respect of the maintenance of equipment and safe working practices were also checked. What the service does well: Three Roses is a happy home, where a strong sense of community exists. Service users are considered to each have a valid contribution to make and are encouraged to express their personal beliefs, wishes and views. This ethos contributes to the development of the mutual respect and consideration evident amongst the group, and involves both residents and staff, and is also extended to inspectors. Comprehensive information is provided for residents, and good lines of communication ensure that everyone has the relevant information to enable appropriate decisions to be made about their daily lives. Staff members are flexible, and this approach enables them to respond to the changing needs of service users. Training opportunities are provided and each person knows they are valued. Recording procedures are maintained to a high standard, and confirm the good organisational ability of the management of the home. Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: 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 Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 Page 7 contacting your local CSCI office. Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 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 Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Appropriate documentation is in place to enable prospective service users to make an informed decision about their future care needs. EVIDENCE: These standards were not inspected in detail on this occasion, although were previously met. A Statement of purpose has been produced, which together with the Service Users Guide provides detailed information for residents and their families, on which to base decisions about their future care needs. The documentation can be produced in an appropriate format if needed, and the Service Users Guide contains numerous photographs. A statement of terms and conditions of residence is provided for each service user. The details of these documents are discussed with each individual, and their family, and a signature obtained. A contract is also provided for each service user by the placing authority. Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 Page 10 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 the following standard(s): 6 & 10 The service users plan of care is based on the initial assessment, which clearly identifies their assessed needs, and how these will be met. The well-documented views of service users are central to the delivery of the person centred care that is provided at the home. The policy on confidentiality reassures service users that information about them is handled appropriately. Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 Page 11 EVIDENCE: An Individual plan of care is maintained for each service user, and these are regularly updated. The preferences of each person are also discussed, and residents are involved in planning every aspect of their day, with the support and encouragement of staff. A weekly diary sheet is posted in each bedroom, to remind them of their proposed activity for each day. The policy on confidentiality is explained to service users, and staff are aware of the issues surrounding confidentiality. All records are kept securely and service users are informed of their right to access their records. Information recorded in respect of each service user is discussed with them routinely. Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 13 & 16 Three Roses is a hive of activity with service users obviously enjoying, and gaining fulfilment from their busy lives. The community ethos contributes to the mutual respect and consideration evident amongst the group and involves both residents and staff. The manner in which support is provided by staff ensures that the rights of service users are respected and their independence is promoted. Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 Page 13 EVIDENCE: These standards were not all inspected in detail on this occasion, but were met previously. A programme of leisure, recreational and educational activities is compiled in discussion with individual service users, their families or an advocate. Service users are encouraged to maintain and develop their skills and to achieve their potential in several areas. Most residents attend a local college every week during term-time, but no-one is currently in paid employment, although one person helps at a residential home. A strong sense of community exists within Three Roses, and also extends outside the home. Service users are considered to each have a valid contribution to make and are encouraged to express their personal beliefs, wishes and views. Service users are involved in the local community in various ways, and enjoy shopping, going to the cinema, visiting the library, going to the pub and eating out. A wide variety of experiences are provided, and their enthusiasm about the many things they do is delightful. Citizenship meetings are held with service users, led by the Care Manager, when rights and responsibilities are discussed, and house rules are produced. Arrangements have been made for service users to be involved in the voting process, although the need to ensure that individuals are aware of the implications was identified. Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 19 & 21 Procedures are in place to ensure that the personal and health care needs of service users are appropriately met. Advice and guidance is available from the primary healthcare teams, and associated specialists, to ensure that the health needs of service users are fully understood, and that appropriate responses are made. Procedures are in place for managing the ageing process and possible illness and death of service users, to ensure that their dignity is maintained and their wishes respected. Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 Page 15 EVIDENCE: The personal and healthcare needs of service users are well documented, and there is evidence to show how staff understand and respond to them in an appropriate way. Staff receive advice and support from the Primary Health Care Team when needed. Service users attend the local medical centre for an annual health check, regular six monthly dental checks are undertaken and the Dental Hygienist is seen every 6-8 weeks. Frequent cleaning of teeth is considered to be important, and therefore encouraged for all service users. A Health Action Plan, which forms part of the national development framework for people with a learning disability, has been developed for each service user living at the home, and staff have been trained in their implementation. Death has not been experienced within the resident group at the home, although discussions with service users and their families, to determine their wishes in the event of illness or death, have been undertaken, and a record maintained on individual care plans. Training has been provided for staff on Loss and Bereavement, Care of the Dying and Basic Counselling. A policy for dealing with the ageing, illness and death of a service user has been produced at Three Roses, and is also reviewed regularly. Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 Page 16 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 the following standard(s): EVIDENCE: These standards were not inspected on this occasion, although met previously. Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 Page 17 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 the following standard(s): 24,29 & 30 The premises are suitable for their purpose and are safe, comfortable and clean. The standard of the accommodation is excellent, and provides service users with an attractive and homely place to live. EVIDENCE: Three Roses has been improved over several years to provide a very pleasant environment for fourteen service users, which complies fully with the National Minimum Standards, and exceeds these in many respects. There is a planned programme for the maintenance of the building. An all weather conservatory has recently been erected, and an additional assisted bath provided. The existing equipment is appropriate for the needs of service users, and consideration will be given to the future provision of aids or adaptations to meet any identified needs. Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 Page 18 A high standard of cleanliness is evident throughout the home and there is no malodour. A policy for the control of infection has been produced, and is reviewed regularly. There are no outstanding requirements following a visit from the Environmental Health Officer earlier in the year. The recommendations of the Fire Safety officer following a recent visit are being implemented currently. The home does not have, or need a sluice, but the washing machine has a sluicing cycle. Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 & 35 The home is staffed by an experienced team, who are able to demonstrate a commitment to their work. The training provided for staff ensures that they are competent, and able to meet the assessed needs of service users living at the home. The recruitment policy and practices ensure that service users are supported and protected appropriately. Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 Page 20 EVIDENCE: The rotas indicate that staffing levels are being maintained at a satisfactory level, and this enables many planned activities to be undertaken with service users. A thorough recruitment and selection procedure is followed at the home, and induction and foundation training is being implemented in line with the Learning Disability Award Framework (LDAF). The files seen by the Inspector confirmed that appropriate procedures for the recruitment and selection of staff are followed at the home. Training for staff is the responsibility of the Care Manager, and is given a high degree of importance at Three Roses, which is reflected in the abilities and commitment of all staff employed at the home. A training programme is in place, which has enabled approximately 75 of the staff team to gain the National Vocational Qualification Level 2 in Care. All staff have been trained to administer medication. Recent training has been organised on fire awareness, food hygiene, basic first aid, and dementia awareness. Instruction has also been provided on the implementation of Health Action Plans. Proposed training includes Person Centred Planning in January 2006. Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 40,41 & 43 The management arrangements at Three Roses are satisfactory, and staff and service users benefit from the positive leadership they receive. The policies and procedures, and records maintained at the home, comply with legislative requirements and therefore help to safeguard the rights of service users. The high standards maintained in the management of the business help to ensure that it is effective and financially viable, with obvious benefits to service users and staff. Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 Page 22 EVIDENCE: The Care Manager, Mrs Isobel Bowen-Shaw, has many years experience working with this client group. Initially training as a teacher, she obtained the Certificate of Education, specialising in mental handicap. She has completed the Registered Managers Award, and the updated Assessors Award. There is evidence of a clear sense of direction and strong leadership skills in the management approach within the home. The policies and procedures at Three Roses have been produced in line with current legislation, and are regularly reviewed. Staff and service users are familiar with these, and are assisted in their understanding and implementation, when necessary. Appropriate records are maintained to a satisfactory standard at the home, and those seen on this occasion provide confirmation. Service users are enabled to access their records and were involved in the devleopment of their individual plan of care, which is reviewed each month. A Director of the Trust is involved with the Home on a daily basis. The financial viability of the business was confirmed verbally, and an annual forecast is also produced. Insurance cover to the appropriate level is maintained, and the certificate is available for inspection. Service users are not involved in these management issues but are made aware of any relevant information. Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 Page 23 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 3 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X 3 X X X 3 3 X 3 Three Roses DS0000018490.V274891.R01.S.doc Version 5.1 Page 24 NO 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard YA24 YA42 Good Practice Recommendations The recommendations of the Fire Safety Officer in respect of the Emergency Contingency Plan for the home should be implemented Notification should be made to the Commission regarding any event that may adversely affect the wellbeing of a service user. 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