Inspection on 28/09/05 for Freehold Cottage

This inspection was carried out on 28th September 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Freehold Cottage 05/02/09

Freehold Cottage 28/02/07

Freehold Cottage 07/03/06

Freehold Cottage 07/12/04

Freehold Cottage 27/04/04

Freehold Cottage 16/01/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Freehold Cottage 452 Market Street Shawforth Rochdale Lancashire OL12 8JB Lead Inspector Mrs Marie Dickinson Unannounced Inspection 28th September 2005 1:00 Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 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 Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 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. Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Freehold Cottage Address 452 Market Street Shawforth Rochdale Lancashire OL12 8JB 01706 853384 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) kiaran@gmail.com Mr Kiaran Desmond Burke Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2004 Brief Description of the Service: Freehold Cottage is registered to provide accommodation and personal care for six adults with a mental illness. The home is a large detached cottage style building with a garden area to the rear of the house. It is situated on the Market Street a short distance by car /public transport to all local amenities such as shops, post office, library, pubs etc and is situated on a main bus route to neighbouring towns such as Manchester, Rochdale, Bury and Bacup. The home is owned and managed by Mr Kiaran Burke with the support of senior staff. Residents accommodation is in six single bedrooms on the first floor. Ground floor living arrangements include a lounge, dining area, laundry and kitchen for residents use. Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and completed over a two-day period on the 28th September and 13th October 2005. The inspection included looking at written information and records about residents and staff. People who live at the home and three staff on duty were asked for their views about the home and how it was managed. Consideration was also given in methods used to get residents views by Mr Burke and staff employed. How care was provided was discussed with everyone. To help carry out this inspection comment cards were sent to the residents and their relatives and visitors. These were returned and used to get information about resident’s life at the home. Mr Burke also filled in a form showing how the home was managed and kept safe for the residents and staff. What the service does well: What has improved since the last inspection? Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 Page 6 There were no improvements recommended or required during 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 contacting your local CSCI office. Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 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 the following standard(s): 2,3,4,5 Procedures were in place for residents to be admitted in a proper manner. Proper use of assessment information planned for resident being admitted. Sufficient information was recorded to write a plan of care. People living at the home had a written contract. EVIDENCE: There had been no new admissions since the last inspection. Residents currently living in the home had copies of assessments completed by health and social care professionals and a care plan for mental health needs. Together these documents provided a clear and detailed picture of what people needed. There was evidence in these completed assessments, people are visited prior to their admission. Assessments had taken into account the resident’s needs in relation to the type of home environment, staffing levels and current residents living at the home. Staff were trained to care for people with mental health problems and records showed they worked with other professional people in caring for residents, such as community psychiatric nurses, psychologists and psychiatrists. At the time of inspection preparations were in progress for a possible new admission. The person interested in living in the home had visited and spent time looking around and talking to the staff. These types of contact such as Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 Page 9 short visits were encouraged and if the placement is agreed a settling in period of stay is offered. Contracts were given to residents. Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 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): 6,7,8,9,10 Residents benefited from good assessments showing all their needs were considered. Being involved in writing their own care plans meant they could have personal goals that staff knew about and helped them achieve safely. Information such as policies and procedures and regular contact with Mr Burke, helped residents to be involved in important issues of life in the home. A confidentiality policy also informed them of the principle of keeping their records private. EVIDENCE: The standard of residents’ care records was good, and included an up to date assessment of needs. There were clear directions for staff as to the type and amount of support residents’ required meeting their needs. Specialist help required for residents was identified and the support provided. Restrictions on residents doing what they liked that may cause them problems was recorded and agreed with them. Residents understood how these agreements helped them. Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 Page 11 Residents benefited from the support of staff, and care records showed how changing needs of residents were monitored. Care plans were reviewed regularly showing progress and changes needed in meeting needs or achieving goals. Residents had signed these and during inspection openly discussed with staff and Mr Burke current issues in their care programme. The residents looked after their own money with the help of staff. This was recorded in their files. Residents said that they had meetings if they wanted. They had their own handbook with information such as policies and procedures. Comments received at the Commission from residents showed mixed opinions on wanting to be involved in discussion about important issues that may affect them. However during the inspection it was evident residents were involved on a daily basis with ‘living at the home’. Information that showed how people might be at risk assessments was clearly written. Action required to reduce the risk was also recorded and agreed with each resident. During the inspection it was clear staff considered confidentiality of resident information and records to be important. This was included in induction training and the staff handbook. Records were kept secure in the office. However better recording of incidents must be followed and this information treated as an individual record for each resident. Residents had information on confidentiality given to them. Decision-making was encouraged and residents were given time to consider the individual choices they made. They looked after their own money with the help of staff. This was recorded in their files. Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 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): 11,12,13,14,15,16,17 Residents living in the home were given opportunities to live a lifestyle that suited them. This included social activities and learning new skills for personal development. Residents were helped to keep in touch with their families and friends. Residents were provided with a nutritious and varied diet. EVIDENCE: Care planning was used to help people living in the home have opportunities to learn and use practical skills. For example one resident was hoping to live independently in the community. Resident’s views about their opportunities to take part in activities were positive. The did what they wanted to do and what they were comfortable in, such as going to clubs, day centres or just going out for shopping. Residents were able to make full use of community facilities if they wished. To get out and about residents used public transport or staff took them out in their cars. Staff work time was flexible for this. All residents are placed on the electoral register. Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 Page 13 One resident in the home enjoyed listening to music. Activities were people’s own choice. Residents must be given the option of a seven-day annual holiday as part of the basic contract price, which they help choose and plan. Records showed family links and friendships were kept up for residents. Visitors to the home were made welcome and could be made in private. Comments from relatives/visitors confirmed this. The home was managed in a manner to avoid any institutional routines. Letters were delivered unopened and during the course of the inspection, staff working in the home treated residents with respect. One comment received at the Commission stated ‘the standards are high in relation to staff/residents interaction.’ Residents had their preferred name stated on their plan. They had locks on their doors and managed their own keys. They said they spent time in their bedroom when they wanted, and had agreed flexible times for going to bed and getting up. House rules were detailed in the resident’s handbook. Meals and meal times was a relaxed event. During inspection residents discussed their preferences for food and enjoyed a chip shop dinner together. They decided their own menus and staff helped to prepare and cook food. Residents learning independent skills made meals. Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 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): 18,19,20, By recording individual preferred routines likes and dislikes, this allowed residents to enjoy personal care in a dignified way. Residents said staff considered their privacy. The healthcare of residents was monitored and medication records were correct. EVIDENCE: Residents said their routine was special to them. Individual records were kept outlining what each person liked doing and the encouragement give from staff. Resident’s support with personal care if needed was given in private. This was recorded in care plans and daily records. Comments received at the Commission from residents showed they were treated well by the staff. Residents said they were happy with how staff helped them. Part of their care included links with other professionals for example mental health care. The healthcare needs of residents were identified and written in their plan of care. Appointments were recorded and staff accompanied residents where needed. Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 Page 15 Medication was recorded correctly. None of the residents managed their own medication. Staff had attended training with the supplying pharmacist. Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 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): 22,23 Residents felt their interests were protected. They were confident Mr Burke and staff dealt with complaints properly. Good practice in employment safe guarded resident’s. EVIDENCE: Residents in the home were aware they had the right to make a complaint should the need occur and were confident Mr. Burke or the staff would listen to them. Comments received at the Commission from residents confirmed this. The complaints procedure assured residents their ‘complaints would be taken seriously’. Comments sent to the Commission show residents ‘feel safe’ in the home, and knew who to talk to if they were unhappy. Abuse procedures had been discussed with staff and were part of their training. As part of staff recruitment they are told staff are not allowed to gain financially from residents. Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 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): 24,25,27,28,30 Residents lived in a homely environment, which they said they liked. Their rooms were private. The lounge, dining room, kitchen and laundry were shared. Maintenance and general upgrading of the premises was needed. EVIDENCE: Freehold cottage is a detached property situated just off the main Road running through the town of Whitworth. It is located near to a bus route that services towns such as Rossendale Valley, Rochdale and Bacup. Improvement was required in the residents’ accommodation. This included decoration and general repair work. This was discussed with Mr Burke who arranged for contractors to visit during the inspection to look at what was needed for improvement. This included the kitchen, which required decorating and some woodwork replacing. Living areas were reasonably maintained and the living room was comfortable. However sufficient dining room chairs was required for the number of residents living there. The home was generally clean and residents felt ‘at home’ and were ‘happy’ with their accommodation. They had their own bedrooms. To improve the Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 Page 18 standard of resident’s accommodation, some of the bedrooms needed decorating, carpets and furniture replacing and fittings upgrading. Attention to floor coverings, tiles and decoration was also required in the bathrooms. Laundry facilities were satisfactory. Records showed the premises met with the requirements of the local fire service and environmental health department. Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 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): 31,32,33,34,35,36 Good staff recruitment procedures were followed. Resident benefited from staff they liked who enjoyed their work. Staff were given opportunities for relevant training and were supervised properly. EVIDENCE: The home was fully staffed during the inspection. The current level of staffing hours provided was linked to the needs of the residents currently living at the home. Staff were clear about their roles and responsibilities. The residents were very happy with the staff in the home. They said they had time for them, and were involved in ‘home life’. They were introduced to new staff before they started work. Staff records showed correct recruitment procedures had been carried out. References had been applied for and Criminal Record Bureaux (CRB) and Protection of Vulnerable Adults (POVA) check was in place. Interviewing staff was over a period of time. This was to make sure residents had an opportunity to meet with them and give an opinion if they thought the applicant would be right to work at the home. Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 Page 20 On appointment staff are issued with a staff handbook that includes their conditions of employment, for example grievance and disciplinary procedure. The percentage of staff trained to National Vocational Qualification in Care level two was 100 . There was evidence staff had induction training. Both staff discussed their role as support workers and what was involved in caring for people with mental health problems. It was clear they had a good positive relationship with the residents. In their discussions with residents during inspection, both staff showed they were knowledgeable about individual needs and were sensitive and respectful to them at all times. Staff had been given a code of conduct and practice. This was in line with the code of conduct issued by the General Social Care Council (GSCC). All staff had a yearly appraisal. In addition to this staff had regular formal supervision. Records were kept. Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 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): 37,38,39,41,42 Residents and staff were happy with the way the home was managed. Guidance and support was given to staff. Residents and staff had regular contact with the owner and had their say in running the home. The health, safety and welfare of residents, was considered on a day-to-day basis. EVIDENCE: Mr Burke has many years experience looking after people with a mental health problem. He runs the home with the help of carers. He works in the home and has regular contact with the people who live and work there. Staff and residents share in the running of the home. They discuss issues on a regular basis and everyone knows their particular responsibilities. Staff said they had meetings and had regular supervision. To complete quality monitoring the owner should have a yearly check on the running of the home, and put into place an action plan that deals with the Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 Page 22 findings. The results of any surveys must be published for everyone to see. A copy must be sent to the Commission. Records needed to manage the home and those belonging to residents and staff were kept safe. The health and safety of residents was safeguarded. Policies for safe working practices and staff instructions in fire safety were available. Routine servicing and testing of essential household services and safety equipment was carried out. Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 2 3 X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Freehold Cottage Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 3 3 2 X 2 3 x DS0000009524.V256043.R02.S.doc Version 5.0 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. 1 Standard YA10 Regulation 17.1 Requirement Recording personal information about residents must be done on as a separate record and kept private from other resident’s records. The home requires some improvement of residents accommodation by general repair and decoration Adequate dining chairs must be provided. Some resident’s bedrooms require decorating, new floor coverings and furniture. Bathrooms require upgrading. Timescale for action 28/09/05 2 YA24 23(2) 31/12/05 3 4 5 YA24 YA26 YA27 23(2) 16(2) 23(2) 13/10/05 31/12/05 31/12/05 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 YA14 YA39 Good Practice Recommendations It is recommended residents have the option of a planned holiday included in the cost of living at the home. It is recommended results of quality of premises and service review are published and given to residents and DS0000009524.V256043.R02.S.doc Version 5.0 Page 25 Freehold Cottage 3 YA41 people interested in the home. A copy should be sent to the Commission. It is recommended that incident record sheets be kept in resident’s files. Freehold Cottage DS0000009524.V256043.R02.S.doc Version 5.0 Page 26 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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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