Inspection on 24/08/05 for Rookwood

This inspection was carried out on 24th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Rookwood 06/12/07

Rookwood 06/06/06

Rookwood 18/01/06

Rookwood 16/12/04

Rookwood 25/05/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Rookwood 26 Silverdale Road Burgess Hill West Sussex RH15 0EF Lead Inspector Mrs D Peel Announced Wednesday, 24 August 2005, 10.30am, V237498 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. Rookwood H60-H11 S148684 Rookwood V237498 240805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Rookwood Address 26 Silverdale Road, Burgess Hill, West Sussex, RH15 0EF 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) 01444 232215 South Coast Nursing Homes Limited Mrs Charmain Holmes Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (OP) - 25 Both of places Rookwood H60-H11 S148684 Rookwood V237498 240805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th December 2004 Brief Description of the Service: Rookwood is a care home able to provide personal care and support to 25 residents who are over 65 years of age. The property is detached and situated in a residential area close to the centre of Burgess Hill, with its local shops, community facilities and public transport links.The majority of private accommodation is arranged on two floors, which are accessed by passenger lift. Four bedrooms are on an upper mezzanine floor, which can only be accessed by a short flight of steps.Communal space consists of a dining room, a lounge and a conservatory. The home is currently undertaking a building project which will provide six additional ensuite, single bedrooms, additional bathing and toilet facilities and a lounge. The office and kitchen will be extended. Rookwood H60-H11 S148684 Rookwood V237498 240805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over five hours on the 24th August 2005. The inspector arrived at 10.30 am and was welcomed by the manager, staff and residents at Rookwood. A full tour of the home took place and the majority of the 20 residents living at the home were met. Three residents were spoken with in depth to find out if they felt that their needs were being met and other residents were spoken with informally during the visit. The inspector met with three visitors to discuss the care, which their relative living at the home receives, and discuss the standard of the accommodation provided. The care records of three residents were inspected during the visit along with other records, which showed how care needs are to be met. The records of three staff were also inspected and the majority staff were spoken with informally. Seven service user comment cards and five relative/visitors comment cards were returned prior to the visit to Rookwood along with two letters and one comment card from professionals who have visited the home recently. All comments made were positive commending the care and attention provided to residents living at the home. What the service does well: What has improved since the last inspection? There have been improvements made to the Statement of Purpose and Service user Guide. Information is now available for prospective residents to ensure that they can make an informed choice about where they want to live. Rookwood H60-H11 S148684 Rookwood V237498 240805 Stage 4.doc Version 1.40 Page 6 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. Rookwood H60-H11 S148684 Rookwood V237498 240805 Stage 4.doc Version 1.40 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 Rookwood H60-H11 S148684 Rookwood V237498 240805 Stage 4.doc Version 1.40 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) 1,2,3,4,5 and 6 A Service User Guide provides information about the home and the service, which it offers, to enable prospective residents to make an informed choice about moving into the home. Residents are assessed prior to moving into the home to make sure that the home can provide a care plan which residents or their families know will meet their needs. Prospective residents, their relatives and friends have an opportunity to visit the home to look at the facilities available and assess its suitability before moving in. EVIDENCE: The home now has a Service User Guide, which is reflective of the facilities and services, which can be provided at the home. Prospective residents and their families are able to use this information to make an informed choice before moving into the home. Care records showed that relatives usually visit the home on behalf of prospective residents to see if the home will meet their relative’s needs. Visitors spoken with during the inspection confirmed that they had visited the home prior to their relative moving to the home. One resident had spent two weeks respite care at the home on a previous occasion before coming to live at Rookwood H60-H11 S148684 Rookwood V237498 240805 Stage 4.doc Version 1.40 Page 9 the home permanently. One visitor said that they had chosen the home because someone had told them about it and it is near to where they live. A resident who had recently moved to the home said that her son had been to look at the home for her and then she had moved in a few days later. A sample contact was viewed during the inspection, which stated what the fee paid covered but it did not include the room number to be occupied. Intermediate care is not provided by the home although the home does offer periods of respite care. Rookwood H60-H11 S148684 Rookwood V237498 240805 Stage 4.doc Version 1.40 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,and10 Clear information is provided in the care plans to assist with all aspects of health, personal and social care needs. Records are in place to monitor the health care needs of residents to make sure that any signs of residents being unwell are recognised Medication procedures are in place, but some practices do not ensure that all medication can be accounted for. EVIDENCE: The care plans examined gave staff the information, which they need to meet the needs of the residents in all aspects of heath, personal and social care whilst allowing residents to retain some level of independence. The plans were regularly updated to show the changing needs of the residents. Progress notes are updated to monitor the heath and well being of residents. District Nurses visit residents who are in need of short-term nursing care and they have the responsibility of assessing pressure area needs and providing wound care. Staff mentioned that the companies future standardisation of care plans will include pressure assessments to be done using recognised tools by staff at the home. As Rookwood is not a nursing home the inspector has expressed concern that staff may be asked to carry out assessments, which they are not trained to do. This matter should be addressed to ensure that only staff trained to use the assessment tools carry out any such assessments. Rookwood H60-H11 S148684 Rookwood V237498 240805 Stage 4.doc Version 1.40 Page 11 Risk assessments are in place ensure the safe moving and handling of individual residents. Medication procedures are in place and the majority of care staff have undertaken a safe handling of medicines training programme. Rookwood uses a monitored dosage system. Medication, which is in tablet form, arrives at the home in blister packs, which provides each resident with a monthly supply of prescribed medication. Records are then kept of medication, which is administered to each resident. On this visit to the home the system was sampled to ensure that medication could be accounted for. It was noted that procedures for recording waste medication are not always being followed. One tablet at the end of the cycle for one residents medication sampled was missing and could not be accounted for. A recommendation has been made that a record of any medication taken from the blister packs and not actually taken by residents i.e. waste medication, is kept. Residents spoken with during the visit commented that they thought their privacy was respected. All residents, relatives/friends and professionals returning comment cards reported that residents right to privacy is respected and that residents can be visited in private. Rookwood H60-H11 S148684 Rookwood V237498 240805 Stage 4.doc Version 1.40 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 and 14 The home provides a lifestyle that respects privacy, dignity and choice, matching resident’s expectations and individual preferences. Residents are able to have visitors and are encouraged to be part of the local community. EVIDENCE: Rookwood has a homely atmosphere where residents can be visited in private if they wish. Visitors to the home on the day of the inspection spoke about their experiences of visiting the home. One visitor said, “you can visit anytime and will always be made welcome”. Another visitor commented that you can arrange to stay for a meal and that “you are always offered a drink”. When the inspector arrived at the home the majority of residents were in the lounge awaiting morning coffee/tea. Four residents were getting ready to attend the Age Concern day centre. One resident who was going to the centre said that she liked going because it allowed her to meet other people and take part in different activities to those which the home offers. Rookwood H60-H11 S148684 Rookwood V237498 240805 Stage 4.doc Version 1.40 Page 13 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) 16and18 There is a clear complaints procedure, which enables those using the service to have the confidence that their complaint will be responded to within a maximum of 28 days. The home has policies and procedures for responding to adult protection matters but not all staff have received training to ensure that they were fully aware of their responsibility to recognise and report abuse. EVIDENCE: The complaints procedure is available in the Service User Guide and on display in the main hall. It is clear and specifies how complaints should be made, with an assurance that any complaint will be responded to within 28 days. There has been one complaint made to the Commission for Social Care Inspection (CSCI) since the last visit to the home. The manager was asked to respond to the complaint using the homes own complaint procedure. The investigation carried out showed that the registered manager takes all complaints seriously and acts appropriately to rectify matters of complaint. Rookwood has its own policies and procedures to safeguard residents from abuse in addition to the West Sussex Multi-Agency Policy for protecting vulnerable adults from abuse. Adult protection training was provided by the company in 2004 and is scheduled to take place again in October 2005. A recommendation has been made that the registered persons ensure that all staff attend adult protection training. Rookwood H60-H11 S148684 Rookwood V237498 240805 Stage 4.doc Version 1.40 Page 14 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) 19,20,21,22,23,24,25,26 The home is clean and residents have a comfortable, homely environment to live in and enjoy. Bedrooms are comfortable and meet the needs of the residents. Residents are encouraged to contribute to making their bedrooms their own by having their own personal possessions around them. Vulnerable residents are at risk from excessive hot water temperatures, which could scald them. EVIDENCE: A building project is currently being undertaken at the home. This will improve communal space and provide six additional single en suite bedrooms. Presently all double bedrooms are being used for single occupancy. The kitchen and the office will be extended and there will be new bathing and toileting facilities. All residents spoken with during the visit were satisfied with their bedrooms and during the tour of the home it was observed that the majority of residents had taken the opportunity to personalise their rooms by displaying paintings, photographs and ornaments. Rookwood H60-H11 S148684 Rookwood V237498 240805 Stage 4.doc Version 1.40 Page 15 Some radiators in the home do not have covers to protect residents from scalding when the central heating is on. A recommendation has been made that these radiators are covered before the central heating is switched back on. There has been no recent visit from the Fire Officer but the inspector expressed concern to the manager about the number of doors which do not have intumescent strips fitted. A recommendation has been made that the fire officer is contacted and advice sought to ensure that the Fire Officer is satisfied with the present arrangement. Hot water outlets in wash hand basins sampled during the visit to the home were not regulated and water leaving the taps of those outlets sampled were too hot, this places vulnerable people at risk. Records of hot water temperatures are kept by the staff, recording that the majority of wash hand basins in resident’s bedrooms and en suite bathrooms are excessive. The providers have been informed but no action has yet been taken. A requirement has been made that this matter is attended to protect vulnerable people from the risk of scalding. Rookwood H60-H11 S148684 Rookwood V237498 240805 Stage 4.doc Version 1.40 Page 16 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) 27,29 and 30 Staffing numbers are set at a level, which allows residents assessed needs to be met. Procedures for the recruitment of staff are not robust and do not fully safeguard and protect residents at the home. Staff receive training to support them in carrying out their jobs and meeting the needs of residents. EVIDENCE: Staffing rotas observed prior to the visit show that sufficient staff are employed with the appropriate skill mix to meet the needs of residents over the 24-hour period. The staff files of three members of staff were fully inspected during the visit and other records were viewed to make sure that Criminal Record Bureau (CRB) and Protection of Vulnerable Adult (POVA) clearance is sought for all staff. Records showed that one of the three staff did not have the results of checks on file. The CRB for this person had been sought by the person’s previous employer. There were no references for this person available to the inspector. A new CRB and POVA application had been made and the manager took immediate action during the inspection to acquire two references. The manger was reminded that there is a statutory requirement on care providers to check if workers, which they want to appoint, are included on the POVA list and that this can only be done by a new CRB application. This process should be concluded prior to staff starting work at the home to protect residents. There is a staff-training programme organised by the company. Records showed that staff attended training regularly. Not all staff have attended adult Rookwood H60-H11 S148684 Rookwood V237498 240805 Stage 4.doc Version 1.40 Page 17 protection training. A recommendation has been made that the company ensures that all staff attend adult protection training. Rookwood H60-H11 S148684 Rookwood V237498 240805 Stage 4.doc Version 1.40 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) 31,32,33,34,35,36,37,38 The home is well managed providing leadership and guidance for staff. Some practices do not promote and safeguard the health and safety of residents living at the home. EVIDENCE: Residents and staff feel that the home is well managed. Visitors spoke highly of the manager and the staff team. The registered manager has more than two years experience as a manager and has worked at the home for many years. She has now completed an NVQ Level 4 in Care Management. The Responsible individual has not provided the CSCI with Regulation 26 reports required to show regular monitoring of the homes practices. Although the manager of the home carries out her own quality assurance surveys with residents and visitors this is not a formal quality assurance system linked to an annual development plan by the company. Rookwood H60-H11 S148684 Rookwood V237498 240805 Stage 4.doc Version 1.40 Page 19 There needs to be some improvement in recruitment practice at the home. Not all staff records sampled had sufficient evidence to show that residents are protected by the homes recruitment practices. Vulnerable residents are at risk from excessive hot water temperatures in some hot water outlets. Rookwood H60-H11 S148684 Rookwood V237498 240805 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 Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 1 3 3 2 3 3 1 3 STAFFING Standard No Score 27 3 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 2 2 3 3 3 1 1 Rookwood H60-H11 S148684 Rookwood V237498 240805 Stage 4.doc Version 1.40 Page 21 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 19,25,38 Regulation 13.4(a)(c) Requirement Timescale for action 21/9/05 2. 3. 29,37 32,33 19 26 4. 33 24.1 The providers must take action to prevent residents from being scalded by excessive hot water temperatures(the providers must write to the CSCI and state what action has been taken by the time scale for action date) Recruitement practices must 21/9/05 comply with the requirements of Regulation 19. Regulation 26 reports must be 1/10/05 supplied to the CSCI in accordance with Regulation 26.5 (previous timescale of 1/2/05 not met) A formal quality assurance 1/12/05 system must be established 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 2 9,37 Good Practice Recommendations The contract should detail the number of the room to be occupied. Medication proceedures should record any disposal or wastage of prescribed medication. H60-H11 S148684 Rookwood V237498 240805 Stage 4.doc Version 1.40 Page 22 Rookwood 3. 4. 5. 6. 18,33 25,38 19,38 30,8 All staff should take part in Adult Protection training All radiators should be guarded by the time the central heating is switched on for the winter. The Fire officer should be consulted with regard to the doors which do not have intumescent stips. Any staff asked to carry out pressure area risk asessments should be trained to use the tool provided. Rookwood H60-H11 S148684 Rookwood V237498 240805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Ridgeworth House Liverpool Gardens Worthing, West Sussex BN11 1RY 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 Rookwood H60-H11 S148684 Rookwood V237498 240805 Stage 4.doc Version 1.40 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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