Inspection on 06/12/07 for Rookwood

This inspection was carried out on 6th December 2007.

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

Rookwood 06/06/06

Rookwood 18/01/06

Rookwood 24/08/05

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 Melanie Freeman Key Unannounced Inspection 6th December 2007 10:00 X10015.doc Version 1.40 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 Rookwood DS0000014684.V354386.R01.S.doc Version 5.2 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 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 DS0000014684.V354386.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rookwood Address 26 Silverdale Road Burgess Hill West Sussex RH15 0EF 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) 01444 232215 South Coast Nursing Homes Limited Post Vacant Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Rookwood DS0000014684.V354386.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2006 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. Local shops and community facilities are close by. Private accommodation is arranged on two floors, the upper floor being 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 and two lounges and an attractive garden is accessible. The range of fees charged (at the time of this report) are £420 - £540 per week, with additional charges for hairdressing, toiletries, chiropody, daily newspapers and escorts for any appointments. Intermediate care is not provided at Rookwood Care Home. Rookwood DS0000014684.V354386.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Rookwood Care Home will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with visiting health/social care professionals. The allocated inspector spent approximately five hours in the home and was able to discuss matters with the appointed manager and her two assistant managers. During the assessment visits the inspector was able to spend most of her time meeting with the staff, residents and observing practice in the home. A brief tour of the premises was undertaken and a range of documentation was reviewed including the homes statement of purpose and service users guide, pre-admission assessment procedures, the systems in place for handling complaints and protecting residents from harm, staff recruitment files, quality assurance systems and some health and safety records. The care documentation pertaining to three residents were reviewed in depth. At the time of compiling the report, in support of the visit, the Commission received survey forms about the service from three staff, three residents and one relative. The required Annual Quality Assurance Assessment (AQAA) was completed by the home the contents of which have been used to plan the inspection and inform the report. What the service does well: The home provides a comfortable and homely environment with a positive atmosphere. The communal space allows for residents to have a choice of where to spend their time. Staff morale is good and staff were noted to be happy going about their work. They were caring, friendly and respectful to residents. Staff were observed to interact very well, and positively, with the residents. It was evident they were aware of the importance of providing care in a way that maximises residents’ independence, dignity and privacy. Resident’s benefit from a well managed service, which works with health care professionals to maintain a good standard of care. Rookwood DS0000014684.V354386.R01.S.doc Version 5.2 Page 6 Staff training is given a high priority and staff are provided with training that they need to meet the varied care needs of residents and the requirements of the legislation. The quality and standard of the food in the home is good and residents complimented the food. 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 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Rookwood DS0000014684.V354386.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Rookwood DS0000014684.V354386.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 3 and 6 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents and their families have the information they need to make an informed choice about where they live and are suitably assessed before a placement is offered. EVIDENCE: The homes statement of purpose and service users guide is a combined document and this was found to be available in the front entrance area along with a copy of the last inspection report. This document was found to be informative and up to date although the manager confirmed that she would Rookwood DS0000014684.V354386.R01.S.doc Version 5.2 Page 9 amend the document to ensure that it reflected that she is not currently the registered manager. An assessment of the admission process followed included the review of the documentation used and this recorded that all prospective residents are assessed either by the manager or one of the assistant managers before admission. Staff spoken to confirmed that many residents admitted to the home have been to the home on respite care or they spend a day visiting before choosing the home. Although the manager confirmed that prospective residents are told verbally if the home is able to meet their needs this is not currently confirmed in writing. This was discussed with the manager and the administrator and both agreed that in future a suitable letter would be sent following the assessment as required. Intermediate care is not provided at Rookwood Care Home. Rookwood DS0000014684.V354386.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home was found to be meeting resident’s health and general needs with assessed additional community support when needed. The homes practice ensures resident’s medicines are administered safely and residents are treated with respect and have their privacy and dignity maintained. EVIDENCE: The care documentation pertaining to three residents was reviewed as part of the inspection process and each of these residents were met with during the inspection visit to the home. Individualised plans of care are recorded and records indicated that these are reviewed regularly and completed in consultation with the resident or their representative. On the whole the plans of care provide clear guidelines for care Rookwood DS0000014684.V354386.R01.S.doc Version 5.2 Page 11 staff to follow and to record other health care professionals input advice and guidance. Further specific and specialist care should be further developed within the care documentation. Individual risk assessments are completed that include nutrition, moving and handling and pressure sore development. There was evidence that these risk assessments are responded to appropriately to promote good standards of care. All residents spoken to were very satisfied with care provided at the home and this view was supported by the surveys received. One relative commented ‘Staff have responded well to the changing needs of my mother as dementia has progressed’ and a resident spoken to had a good understanding of all her care needs which were reflected in the plans of care. Visiting health care professionals were also positive about the care provided. A key worker system is operated in the home and this with an improved hand over system ensures staff are aware of residents needs and maintains a continuity of care. Practice observed confirmed that medicines were being administered in a safe way and the records examined were found to be accurate. Staff involved in the administration of medicines has all received training and a record of their signatures is readily available for audit purposes. Individual risk assessment were also evidenced so that when ever possible residents administer their own medicines. Throughout the inspection visit staff were seen to be attentive and kind to residents and to speak to them in a respectful way. Rookwood DS0000014684.V354386.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Links with friends, relatives and the community are encouraged and choices made are respected. Resident’s opportunities for stimulation through leisure and recreational activities have been developed and meals provided promote variety and choice. EVIDENCE: Residents spoken to were well able to express their views on the home and were able to say what they did in the home and how they liked to spend their time. Residents were seen to enjoy the company of other residents and the communal space allowed for groups of residents to miss as they wished sharing papers and talking about daily life. The home has responded to resident’s comments on the provision of activities and social events and has worked on improving these with extra dedicated Rookwood DS0000014684.V354386.R01.S.doc Version 5.2 Page 13 staff and time, residents said that they enjoyed the quizzes and the outings arranged. Further resources including improved transport for more outings and the development of individual social assessments is also being progressed by the acting manager. Residents are able to spend their day as they wish spending time where they wanted to and interacting with staff and other residents if they wanted to. Residents said that they were able to make choices throughout the day including when they got up and when they went to bed. Visiting is not restricted and residents said how important visitors were to them. Visiting professionals said that they were always greeted warmly on arrival at the home. Everyone spoken to about the food was complimentary. Residents mentioned the new menu system and said that the variety and choice of food was good ‘the variety is very good’. They confirmed that snacks were available in the evenings and it was noted that a fresh bowl of fruit was available in the lounge. Rookwood DS0000014684.V354386.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Procedures and practice in the home ensures that complaints and any allegation or suspicion of abuse made would be managed appropriately. EVIDENCE: The home has a suitable complaints policy and procedure, and a condensed version of this is readily available to residents and their representatives within the statement of purpose/service users guide. The home has not received any complaints since the last inspection and the acting manager says that staff respond quickly to any issue raised quickly to avoid complaints developing. There have been no complaints made about the home to the CSCI. Residents said they would make a complaint if they needed to and would feel able and comfortable to do so. Records confirmed that staff have received training on Safeguarding Adults and that the home has relevant policies and procedures in place. Senior staff in the home have completed Safeguarding Adults training provided by Social Services. Rookwood DS0000014684.V354386.R01.S.doc Version 5.2 Page 15 Rookwood DS0000014684.V354386.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, suitable and clean environment for those living in the home and visiting. EVIDENCE: Rookwood DS0000014684.V354386.R01.S.doc Version 5.2 Page 17 The location and layout of the home is suitable for its stated purpose. It is well maintained both externally and internally and meets resident’s needs in a comfortable and homely way. The home was found to be a good standard of repair and ongoing redecoration and refurbishment was evident. The homes management have identified that the bathing facilities in the home need to be improved and are progressing this. The home was found to have a high standard of cleanliness throughout. The homes own laundry completes all residents’ personal laundry whilst bed linen and towels are sent out for laundering. All bedrooms are individual and attractive the acting manager confirmed that all the fire issues raised by the fire brigade have now been addressed. In addition the poor ventilation issue relating to one bedroom has been resolved. When checking the hot water records it was identified that some areas accessible to residents in hand basins was hot according to the homes own records approximately 53 degrees C. The manager accepted that she should have responded to this risk. She agreed to complete new risk assessments for all the areas where residents had access to hot water and put in place measures to ensure residents do not scald themselves. She also confirmed that this hot water would be controlled to a safe temperature with the use of fail-safe valves within a month. Rookwood DS0000014684.V354386.R01.S.doc Version 5.2 Page 18 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is sufficient staff that are suitably trained on duty to ensure that residents receive the level of care they need. Residents are not fully protected by the home’s recruitment procedure. EVIDENCE: At the time of this assessment visit 24 residents were living at Rookwood Care Home, the residents have a mixed dependency most being mobile and some with increasing mobility problems. Staffing arrangements provide three care staff per day with the acting manager in addition, at night there are two waking care staff. Staffing levels on this day were seen to be appropriate with resident needs being attended to. All feedback received indicated that the staffing arrangements were suitable and that all staff were well thought of comments included ‘staff could not be more helpful’ ‘my mother has dementia and it is good to see that she is treated with respect and consideration’. Rookwood DS0000014684.V354386.R01.S.doc Version 5.2 Page 19 Staffing levels on this day were seen to be appropriate. No one indicated that there was not enough staff. Staff were positive about working in Rookwood and the care that the service provided. The recruitment files pertaining to the three staff were reviewed as part of the inspection process and whilst most documentation and records were full and included Criminal Records Checks and POVA checks on all staff however it was noted that two of the staff only had one reference. This was identified to the manager and administrator. It was confirmed that these would be followed up as a priority. Staff said that staff training is well promoted and that opportunity for staff development was provided. Records confirmed that staff training is well promoted. Staff supervision and appraisals are in place along with staff and residents meetings, which are fully recorded. Rookwood DS0000014684.V354386.R01.S.doc Version 5.2 Page 20 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management arrangements provide clear leadership and an appropriate management structure. Systems for monitoring the quality of care take account of resident’s views and are used to improve the service. Resident’s financial interests are safeguarded. The health, safety and welfare of residents and staff are generally promoted and protected. EVIDENCE: Rookwood DS0000014684.V354386.R01.S.doc Version 5.2 Page 21 During the inspection it was clear that the manager has a good rapport with all staff and residents and maintains a friendly and relaxed working environment. She took up post as acting manager in November 2006 and confirmed that the decision has been made for her to remain as the manager and that she would be applying for registration this month. She has been the manager of this home previously and has the relevant skills and experience to manage the home. The home has developed a quality monitoring system that is based on seeking residents and their representative’s views. These are reported on and there was evidence that the homes management has responded to the findings of this report to improve the facilities and service. One of the company’s directors visit the home regularly and completes the required monthly report, although this was found to be minimal in content. Service users are encouraged to manage their own affairs with the help of relatives or advocates if necessary, the home does not have any involvement with resident’s personal monies. Records relating to Health and Safety in the home were reviewed and on the whole were found to be full, and included an electrical installation safety certificate. Rookwood DS0000014684.V354386.R01.S.doc Version 5.2 Page 22 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Rookwood DS0000014684.V354386.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 OP25 Regulation 12 (1) 13 (5) Requirement That risk assessments in respect of hot water accessible to residents are kept up to date in consultation with the Environmental Health Department and responded to, to ensure resident safety. That a thorough recruitment procedure is operated that includes securing two authentic/appropriate references for each employee. Timescale for action 16/12/07 2. OP29 19(1) 16/12/07 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 OP33 Good Practice Recommendations That the results generated from the quality monitoring are made available to all interested parties. Rookwood DS0000014684.V354386.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000014684.V354386.R01.S.doc Version 5.2 Page 25 - 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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