CARE HOMES FOR OLDER PEOPLE
Rose Cottage 136 Rothley Road Mountsorrel Leicestershire LE12 7GB Lead Inspector
Keith Williamson Unannounced 24 May 2005 at 9.00am 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. Rose Cottage C51 S1696 Rose Cottage V228093 280705.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Rose Cottage Address 136 Rothley Road Mountsorrel Leicestershire LE12 7JX 0116 2106915 0116 2375358 None Mrs Nicola Dawn Schofield 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 Nicola Dawn Schofield Care Home 13 Category(ies) of OP - Older Persons - 13 registration, with number of places Rose Cottage C51 S1696 Rose Cottage V228093 280705.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: There are no conditions of registration. Date of last inspection 25-01-05 Brief Description of the Service: Rose Cottage is a home for thirteen older people located in the village of Mountsorrel, which is close to the local shops and health centre. The home is converted from three Victorian terraced cottages and has a large lounge/dining area and quiet lounge. Bedrooms are located on the ground and first floor with access via the stairs and stair lift. Some bedrooms provide en-suite facilities, details of which are enclosed in the homes Statement of Purpose. The rear of the property has a garden area, with seating and a raised fishpond. Rose Cottage has recently added to the garden through the provision of a raised decking area, which is accessible to wheelchair users, and those with mobility difficulties. Rose Cottage C51 S1696 Rose Cottage V228093 280705.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over one day, commenced at 9.15 am and was completed in four hours by one inspector. An opportunity was taken to view the care plans and other records in detail. Three residents’ were spoken with on this visit; comments made from them and the resident and relative questionnaires are included in this report. Three staff were also interviewed. Thirteen residents’ or their relatives’ questionnaires were returned to the inspector prior to the inspection process, all comments were very positive, bar one which indicated a lack of staff at certain times, though on investigation of the staffing rota appears unfounded. Other comments include “ I find the home beautiful, all the staff are always very friendly and care well for the people”, and “ excellent care, loving, happy, hands on all the time and professional”. The registered person, manager and deputy manager all assisted with the Inspection, spending time with the Inspector discussing the management of the home. This is the inspectors’ first visit to this home and overall the inspector recognised the home, continues to function very well and provides a homely but secure environment for residents’. What the service does well:
The registered person provides a homely and comfortable atmosphere for the residents. Clear guidance is given to staff members regarding keeping residents’ care records up to date. Residents spoken with indicated that they feel safe residing in the home and that they are well taken care of. A tour of the premises took place, which indicated that the premises are maintained to a very high standard creating a homely environment for residents. The registered providers are committed to raising and maintaining good standards of care for this service based on the outcome of the inspection. Residents and staff spoke positively about the approach to managing the home indicating that it creates an open and inclusive atmosphere. The fixtures and fittings are maintained to a very high standard creating a homely environment. A number of resident choices are evident pastimes,
Rose Cottage C51 S1696 Rose Cottage V228093 280705.doc Version 1.30 Page 6 hobbies and meals are varied and well presented; all comments about meals were very positive. All residents and relatives spoken with indicated that they are satisfied with the overall care given in the home. 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. Rose Cottage C51 S1696 Rose Cottage V228093 280705.doc Version 1.30 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 Rose Cottage C51 S1696 Rose Cottage V228093 280705.doc Version 1.30 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, 3 & 6. The admission process is followed consistently for all planned admissions. EVIDENCE: The Statement of Purpose is inclusive of all the information required to ensure prospective residents make an informed choice of living in the home. Resident and their relatives are provided periodically with questionnaires, the results of which shall be added to complete the document. Pre admission assessments are used by the home for all admissions. All service user files seen on the day included a contract, which had the appropriate information enclosed to protect residents residency in the home. The home does not currently offer a service under Standard 6. Rose Cottage C51 S1696 Rose Cottage V228093 280705.doc Version 1.30 Page 9 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 & 11. Residents are well looked after in respect of their health and personal care needs. Medication is administered appropriately with the practice being consistent with the last inspection. EVIDENCE: Individual resident care plans are in place, are detailed on a personal basis and are under regular review. Residents and their relatives are included in the care planning process, though some elect not to. Residents have the possibility of retaining their registered General Practitioner. A number of files showed a good level of intervention by health care professionals. The medication system is well managed with a sample check of the system indicating all information on dispensing and returning medication to the pharmacy is accurate. Observation during the inspection showed that staff have a good awareness of how to protect residents privacy and dignity. They were seen to knock on doors and wait for a response before entering private areas, and spoke to
Rose Cottage C51 S1696 Rose Cottage V228093 280705.doc Version 1.30 Page 10 residents in a respectful, friendly and supportive way. Residents spoken with said that staff are respectful and very caring, a visiting health professional indicated she was always well received and supported throughout her visits. The home organises information in the plan of care, with regard to the final wishes of residents, this is good practice as the information is at hand at this emotive time. Rose Cottage C51 S1696 Rose Cottage V228093 280705.doc Version 1.30 Page 11 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 & 15. Residents are assisted to exercise choice and control over their lives. Residents are offered a balanced diet in line with dietary requirements and plans of care. EVIDENCE: A variety of activities are offered to residents, these are recorded on a daily basis by staff, these are culturally appropriate, and meet residents’ religious preferences and personal abilities. Of the residents interviewed all indicated visiting was not restricted at any time. Personal choice is offered throughout the home, and evidence is in place to suggest the homes’ practices are flexible, promoting resident’s individuality and independence. The menu system offers a well-balanced dietary choice, and is provided to residents at a time to suit them. Rose Cottage C51 S1696 Rose Cottage V228093 280705.doc Version 1.30 Page 12 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) None. No standards were viewed on this occasion. EVIDENCE: Rose Cottage C51 S1696 Rose Cottage V228093 280705.doc Version 1.30 Page 13 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, 24, 25 & 26. The premises are maintained to a very high standard with strong emphasis on residents’ comfort. EVIDENCE: An inspection of the flooring, fixtures and fittings in the home indicated that the registered provider make strenuous efforts in maintaining the home to a very high standard. One resident spoke positively about the upkeep of the home commenting, “I like my room, I was able to bring all my ornaments and photos in” and “I like to go into the garden in the warmer weather, it’s so peaceful” The bathroom, toilet and en-suite facilities were inspected and found to be sufficient in numbers based on the number of residents residing in the home. An inspection of the premises found it to be very clean and hygienic in appearance. There is sufficient communal space including adequate numbers of toilet and bathing facilities.
Rose Cottage C51 S1696 Rose Cottage V228093 280705.doc Version 1.30 Page 14 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 & 30. The number of staff employed to work in the home is sufficient in meeting residents’ assessed care needs; and the recruitment process is sufficient to ensure resident safety in the home. EVIDENCE: The staffing rota was examined and a physical count indicated that there was adequate numbers of care staff on duty. The staffing rota was viewed and discussion held with the registered manager indicated that there is appropriate skill mix of staff employed to work in the home, specific staff are employed to see to residents social care needs, a visiting health professional commenting “they employ staff just to sit and talk with the residents”. Residents’ spoken to indicated that there are staff members available when needed. A comment passed by a resident indicated, “(the staff) were like one big family”. A range of training is available to staff. Rose Cottage C51 S1696 Rose Cottage V228093 280705.doc Version 1.30 Page 15 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, 33, 37 & 38. The management approach promotes effective care practice in the home for residents’ care and protection. EVIDENCE: The manager attained her professional qualification last year and is continuing to plan and execute her professional development. The inspector viewed questionnaires that have recently been given to residents and their relatives for quality monitoring purposes, the results of which shall now be advertised within the home and added to the Statement of Purpose. A number of residents’ care records were inspected. All care records seen are kept up to date and in order in accordance with the Data Protection Act 1998 and the Care Homes Regulations 2001. Rose Cottage C51 S1696 Rose Cottage V228093 280705.doc Version 1.30 Page 16 The recommendation from the last inspection of introducing hot water regulating valves has been followed up, overall staff have a good knowledge of health and safety issues. Rose Cottage C51 S1696 Rose Cottage V228093 280705.doc Version 1.30 Page 17 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 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 x 3 x x 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 x 3 x x x 3 3 Rose Cottage C51 S1696 Rose Cottage V228093 280705.doc Version 1.30 Page 18 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 1 7 9 Good Practice Recommendations The results of the resident and relative questionnaires be added to the Statement of Purpose and made available for residents and their relatives in the home. Care plans could have more detail added with regard to the specific abilities each resident has retained, and details regarding what specific assistance is required. Medication should be receipted and signed for on being received at the home, and medication which is not blister packed have the start date added to the original packaging. The blending valves recently fitted in the home are, periodically serviced and the temperature of hot water monitored (and recorded) and made available for future inspections. 4. 38 Rose Cottage C51 S1696 Rose Cottage V228093 280705.doc Version 1.30 Page 19 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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