Inspection on 18/04/05 for Rocklee

This inspection was carried out on 18th April 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

Rocklee 08/07/09

Rocklee 18/11/08

Rocklee 10/07/08

Rocklee 06/11/07

Rocklee 09/05/06

Rocklee 09/10/05

Rocklee 08/10/04

Rocklee 12/05/04

Rocklee 13/02/04

Rocklee 19/09/03

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

CARE HOMES FOR OLDER PEOPLE Rocklee 341 & 343 Stone Road Stafford Staffordshire ST16 1LB Lead Inspector Dawn Dillion Announced 18 April 2005 8.15am 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 Older People. 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. Rocklee E51 E09 S4995 Rocklee V202543 180405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Rocklee Address 341 & 343 Stone Road Stafford Staffordshire ST16 1LB 01785 602347 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) Mrs Jaqueline Downes Mrs Jaqueline Downes Care home 11 DE MD DE(E) MD(E) Category(ies) of 7 registration, with number 4 of places 7 4 Rocklee E51 E09 S4995 Rocklee V202543 180405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 7 Dementia (DE) - Minimum age 60 years on admission 4 Mental Disorder (MD) - Minimum age 40 years on admission Date of last inspection 08 October 2004 Brief Description of the Service: Rocklee is a residential home that is registered to provide a service for older people, the registration category also identifies that the home is also able to accommodate individuals with dementia and mental health problems. The home is located on the Stone Road (A34 leading to Stafford town), having easy access to local transport and local amenities. The large mature premise accommodates eleven service users with complex mental health needs. There are nine bedrooms seven of which are of single occupancy and two shared rooms, a number of bedrooms are fitted with a telephone point. Bathrooms and toilets are located throughout the home and are in close proximity to bedrooms and communal areas. Service users have access to two lounges that are equipped with essential furnishings to provided a relaxing area. There are two kitchens; service users are encouraged to participate in the preparation and cooking of meals. There was a small laundry within the home equipped with a washer/dryer. Rocklee E51 E09 S4995 Rocklee V202543 180405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection of Rocklee was undertaken within a day and consisted of the examination of systems, records and practices to ascertain the quality of care provided within the home. During the process of the inspection both service users and staff members were informally interviewed to establish their views and opinion in relation to the service and provisions provided within the home. Service users confirmed their satisfaction with regards to the service and provisions provided and the support offered by staff. What the service does well: What has improved since the last inspection? There was a marked improvement with reference to the format of care plans and information held, identifying the care needs of the service users. The pre admission procedure was more robust and consistent to establish the homes capacity to meeting the prospective service users care and social needs. The majority of requirements identified within the previous inspection report relating to the environment have now been addressed. Rocklee E51 E09 S4995 Rocklee V202543 180405 Stage 4.doc Version 1.20 Page 6 Formal supervision sessions for staff working within the home have now commenced. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Rocklee E51 E09 S4995 Rocklee V202543 180405 Stage 4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Rocklee E51 E09 S4995 Rocklee V202543 180405 Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3, 4, 5 The homes admission procedure was consistent and robust with regards to establishing prospective service users needs and to ascertain whether the home has the capacity to meet the individual’s care and social needs. EVIDENCE: The examination of the homes diary evidenced that a service user who had recently been admitted, had visited the home prior to admission. Three records pertaining to service users that were examined evidenced that the individual was in receipt of a contract of residency, relating to the service and provisions provided within the home. Records relating to a new service user evidenced that the individual was subject to a pre admission assessment prior to admission to the home. Three care plans that were examined evidenced that service users were able to obtain specialist services relating to their healthcare needs. Rocklee E51 E09 S4995 Rocklee V202543 180405 Stage 4.doc Version 1.20 Page 9 Training records relating to staff evidenced that there was a positive commitment to on-going training pertaining to the individual’s respective roles and responsibilities. Rocklee E51 E09 S4995 Rocklee V202543 180405 Stage 4.doc Version 1.20 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 and 11 There was a marked improvement with reference the format and information contained within the individual care plan, to ensure that service users care needs are met appropriately and that they have access to relevant healthcare services. EVIDENCE: Information derived from the pre admission assessment provided the foundation for the development of the care plan. Three care plans were randomly selected for examination all of which identified the care needs of the individual and provided information relating to the support and assistance required, to enable the service users to live a full and active lifestyle. Records evidenced that service users were encouraged to participate in the development of their care plans and subsequent reviews. Care plans and the homes diary evidenced that service users had access to relevant healthcare services for routine health screening. Records were Rocklee E51 E09 S4995 Rocklee V202543 180405 Stage 4.doc Version 1.20 Page 11 clearly maintained of all healthcare appointments of which also identified review dates. Systems and records relating to the administration, disposal, storage and recording of medicines were all found to be satisfactory, the home had had a inspection by the dispensing pharmacist on 8 March 2005, whereby a few recommendations were identified. During the course of the inspection staff members’ manner and approach was observed to be positive and professional promoting the rights and individuality of service users. The registered Manager informed the Inspector that she was currently in the process of purchasing an appropriate locking device, in compliance to recommendation from the Fire Prevention Officer for all bedroom doors, to afford service users additional privacy. Information relating to the death of a service user was in place, providing details relating to the appropriate actions to be taken in the event of the death of a service user. Rocklee E51 E09 S4995 Rocklee V202543 180405 Stage 4.doc Version 1.20 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Social activities were varied to reflect the needs of the individual service user, with a positive emphasis focused on ensuring that service users had access to outside leisure services and that the individual have a positive presence within their local community. EVIDENCE: Records were maintained of all activities within and outside the home. Discussions with service users confirmed that they had access to leisure services within the community. Service users informed the Inspector of trips to Blackpool and of their specific social interests. On the day of the inspection one service user informed the Inspector that she would be attending day care services that day. The examination of records and discussions with service users confirmed that they were able to maintain contact with their family and friends. On the day of the inspection, it was identified that one service user had gone to her parents for a few days. Service users confirmed that meals provided were good, one service user informed the Inspector that she told her family otherwise, so that they would Rocklee E51 E09 S4995 Rocklee V202543 180405 Stage 4.doc Version 1.20 Page 13 send her food parcels, of which contained items that were not conducive with regards to her special diet. Rocklee E51 E09 S4995 Rocklee V202543 180405 Stage 4.doc Version 1.20 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 and 18 Complaints and areas of concerns were recorded and provided information relating to the actions undertaken to resolve the complaint. EVIDENCE: There was a simple and clear complaints procedure in place of which was located within each bedroom. Service users had access to a self-advocacy service; contact details were located on the notice board within the main corridor. Records pertaining to service users that were examined evidenced that a number of service users had access to a solicitor for legal advise and support. Discussions with service users confirmed that they were able to exercise their political interests and were able to vote at the elections if they so wished. Records relating to service users finances were examined and were found to be satisfactory. Rocklee E51 E09 S4995 Rocklee V202543 180405 Stage 4.doc Version 1.20 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 23, 24, 25 and 26 The environment appeared suitable for its stated purpose; a number of areas had been decorated since the last inspection visit. Service users had access to all parts of the home, of which appeared to be safe and conducive in meeting their needs. EVIDENCE: Rocklee consists of two semi-detached properties; the exterior design had been maintained in keeping with the local community. The interior had been designed to allow access through both properties. Two lounges were provided on the ground floor, equipped with essential furnishings and fitments to provide a comfortable area for relaxation and recreational purposes. There were two domestic style kitchens in place, service users confirmed that they had unlimited access to the kitchens. Rocklee E51 E09 S4995 Rocklee V202543 180405 Stage 4.doc Version 1.20 Page 16 Bathrooms and toilets were located throughout the home and were in close proximity to bedrooms and communal areas. The home provided 7 single occupancy and 2 shared bedrooms of which were located on the ground and first floor level. Glazing within one bedroom was cracked and the ceiling in another bedroom was stained and was in need of repainting. A small garden area was provided at the rear of the property and was accessible to all service users. The previous report identified a requirement; regarding exposed wiring within a linen cupboard, this still remains outstanding. The cleanliness and hygiene within the home were of a good standard. Rocklee E51 E09 S4995 Rocklee V202543 180405 Stage 4.doc Version 1.20 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 The homes recruitment and selection process was not robust or consistent in ensuring the protection of service users within the home. EVIDENCE: The examination of files and records pertaining to staff working in the home evidenced that there was a lack of consistency with regards to the home obtaining two written references prior to the offer of appointment. With reference to disclosures of criminal activities identified on Criminal Records Bureau checks, there was no evidence of contingency plans or risk assessments to safeguard the service users or reasons to establish the purpose for the recruitment of these individuals. Relevant documents that should be maintained in accordance to Schedule 2, of the Care Homes Regulations were not in place. Training records relating to staff working within the home evidenced that there was a positive commitment to on going training, pertaining to their specific roles and responsibilities. Staff rotas identified that between 6.00pm – 8.00pm one staff was provided to meet the needs of eleven service users with complex mental health problems. A minimum of two staff were provided throughout the remaining day Rocklee E51 E09 S4995 Rocklee V202543 180405 Stage 4.doc Version 1.20 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, 36, 37 and 38 There was a positive leadership within the home, with a clear line of accountability with reference to the individual’s respective roles and responsibility. There was a marked improvement with regards to systems and practices to ensure the health, safety and welfare of both the service users and the staff group. EVIDENCE: Discussions with service users confirmed that they were consulted and actively involved in the running of the home. Minutes of service users meetings evidenced that service users were encouraged to participate in the running of the home and areas affecting their lifestyle. Rocklee E51 E09 S4995 Rocklee V202543 180405 Stage 4.doc Version 1.20 Page 19 Quality assurance questionnaires were distributed to service users, information collated from these questionnaires were feedback to the service user group during the process of service user meetings. Records relating to service users evidenced that a number of service users had access to a solicitor to safe guard their finances. Financial records relating to service users appeared satisfactory. General discussions with service users confirmed their satisfaction with regards to the service and provisions provided within the home. Records and files relating to staff evidenced that the home had improved with providing formal supervision sessions however, there was still a short falling of providing at least six supervision sessions per year. Records and policies that were examined during the process of the inspection appeared to be accurate and up to date and were accessible to service users and the staff group. Records and systems relating to the health, safety and wellbeing of service users identified that fire fighting appliances were serviced/ checked on a regular basis. There was a lack of recording with regards to fire drills; a professional company had checked water supplies within the home. Rocklee E51 E09 S4995 Rocklee V202543 180405 Stage 4.doc Version 1.20 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 N/A 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 2 3 2 Rocklee E51 E09 S4995 Rocklee V202543 180405 Stage 4.doc Version 1.20 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. 2. 3. Standard op10 op38 op19 Regulation 12(4)(a) 23(2)(b) & 13(4)(a) 23(2)(b) Requirement To ensure that a locking device is provided to all bedroom doors as standard. Cracked glazing identified within the bedroom should be replaced as a matter of urgency. The stained ceiling identified within a bedroom is required to be painted to a suitable standard. To review the homes recruitment and selection procedure to ensure that suitable candidates are appointed. To review the current rota to ensure that there is a minimum of two staff on duty during the day. Exposed electrical wiring identified within the linen cupboard should be made safe and removed by a competent person. To ensure that all staff have at least two fire drills per year, with night staff having at least four per year, information of which should be recorded for inspection purposes. Timescale for action 02/01/05 30/05/05 30/05/05 4. op29 Schedule 2 & 19 18(1)(a) 30/05/05 5. 0p27 30/05/05 6. op38 13(4)(a) &23(4)(a) 30/05/05 7. op38 23(4)(e) 09/09/05 Rocklee E51 E09 S4995 Rocklee V202543 180405 Stage 4.doc Version 1.20 Page 22 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 Good Practice Recommendations Rocklee E51 E09 S4995 Rocklee V202543 180405 Stage 4.doc Version 1.20 Page 23 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. Extracts may not be used or reproduced without the express permission of CSCI Rocklee E51 E09 S4995 Rocklee V202543 180405 Stage 4.doc Version 1.20 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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