CARE HOMES FOR OLDER PEOPLE
Rose Cottage 136 Rothley Road Mountsorrel Leicestershire LE12 7JX Lead Inspector
Keith Williamson Unannounced Inspection 26th October 2005 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 Rose Cottage DS0000001696.V260397.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 DS0000001696.V260397.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Rose Cottage Address 136 Rothley Road Mountsorrel Leicestershire LE12 7JX 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) 0116 2302860 0116 2375358 nicola-schofield@amserve.com Mrs Nicola Dawn Schofield Mrs Nicola Dawn Schofield Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Rose Cottage DS0000001696.V260397.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. No additional conditions of registration. Date of last inspection 24th May 2005 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 large 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 DS0000001696.V260397.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over one day, commenced at 10.00 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 three staff were also interviewed are included in this report. Comments from the residents’ or their relatives’ questionnaires, were included in the last report of this service. The owner (and manager) deputy manager and senior care staff all assisted with the Inspection, spending time with the Inspector discussing the management of the home. What the service does well:
The registered person continues to provide a homely and comfortable home for the residents. 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 provider is 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. Clear guidance is given to staff members regarding keeping residents’ care records up to date. The fixtures and fittings are maintained to a very high standard creating a homely environment. A number of resident choices are evident pastimes, hobbies and meals are varied and well presented; most comments about meals were very positive, one resident finding the portions being too big. All residents and relatives spoken with indicated that they are satisfied with the overall care given in the home. Rose Cottage DS0000001696.V260397.R01.S.doc Version 5.0 Page 6 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 DS0000001696.V260397.R01.S.doc Version 5.0 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 Rose Cottage DS0000001696.V260397.R01.S.doc Version 5.0 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 the following standard(s): None. None of these standards were viewed on this occasion. EVIDENCE: Rose Cottage DS0000001696.V260397.R01.S.doc Version 5.0 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 the following standard(s): 7 & 9. 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. Residents spoken with said that staff continue to be respectful and “very caring” and that they (residents) “were treated as individuals”.
Rose Cottage DS0000001696.V260397.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 15. Residents are offered a balanced diet in line with dietary requirements and plans of care. EVIDENCE: Menus are made up in advance and residents though not offered a recognised choice of main meals residents are happy to be offered a number of alternative meal choices, one stating there were “always 2 or 3 “alternative choices) on offer”. There was evidence of fresh meat, vegetables and fruit on offer throughout the menu system. Residents stated the meals were “man sized portions” and too big for me to eat. Rose Cottage DS0000001696.V260397.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 16 & 18. Residents are protected by the policies and procedures regarding complaints and adult abuse, produced by the home. EVIDENCE: The home has the necessary complaints procedure and policies in place. Staff spoken with have a good awareness of the policy content and how the procedure was operated. Residents spoken with were also aware how to make complaints, one stating, “I would speak to the Manager, she speaks to us all every day”. Detailed examination of the adult protection policy indicated that sufficient information is contained in the document for staff members’ guidance on how to prevent elder abuse in the home. Staff members spoken to displayed good verbal knowledge concerning the protection of vulnerable adults in their care, indicating that they occasionally read the adult protection policy to keep their knowledge of adult protection updated. Rose Cottage DS0000001696.V260397.R01.S.doc Version 5.0 Page 12 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 the following standard(s): None. None of these standards were viewed on this occasion. EVIDENCE: Rose Cottage DS0000001696.V260397.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None. None of these standards were viewed on this occasion. EVIDENCE: Rose Cottage DS0000001696.V260397.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 & 38. The management approach promotes effective care practice in the home for resident’s care and protection. EVIDENCE: The manager stated that no monies are held in “safe keeping” for residents at this time. Discussions held with two staff members and three residents indicated that the management approach creates an open and inclusive atmosphere in the home. Fire records examined and dates seen on fire extinguishers indicated that suitable checks of fire safety equipments are being made on a regular basis. Two staff members spoken to gave good demonstration on proper hand washing techniques and gave good verbal responses on how residents’ care needs must be met.
Rose Cottage DS0000001696.V260397.R01.S.doc Version 5.0 Page 15 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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 3 Rose Cottage DS0000001696.V260397.R01.S.doc Version 5.0 Page 16 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. 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. Refer to Standard OP1 Good Practice Recommendations It is recommended 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. It is recommended care plans could have more detail added with regard to the specific abilities each resident has retained, and details regarding what specific personal assistance is required. It is recommended that 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. It is recommended that all “non-blistered” medications stock levels are monitored periodically, to ensure proper administration. The blending valves recently fitted in the home are, periodically serviced and the temperature of hot water
DS0000001696.V260397.R01.S.doc Version 5.0 Page 17 2. OP7 3. OP9 4. 5. OP9 OP38 Rose Cottage monitored (and recorded) and made available for future inspections. Rose Cottage DS0000001696.V260397.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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