Inspection on 28/09/07 for Rose Cottage

This inspection was carried out on 28th September 2007.

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

Rose Cottage 24/09/08

Rose Cottage 09/11/06

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Rose Cottage 14 Kipping Lane Thornton Bradford West Yorkshire BD13 3EL Lead Inspector Steve Marsh Key Unannounced Inspection 28th September 2007 09:30 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 DS0000066838.V346715.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. Rose Cottage DS0000066838.V346715.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rose Cottage Address 14 Kipping Lane Thornton Bradford West Yorkshire BD13 3EL 01274 833641 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) Rajal Karavdra Rajesh Karavdra Mrs Patricia McCann Care Home 16 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (12), of places Physical disability over 65 years of age (2) Rose Cottage DS0000066838.V346715.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9 November 2006 Brief Description of the Service: Rose Cottage Care Home is ideally located in the centre of Thornton village, which is about four miles from Bradford. The home is on a bus routes and there are a variety of shops and other amenities close by. Rose Cottage is a protected building providing facilities on two floors. Access to the first floor bedrooms is by a stair lift. There are three communal rooms comprising of separate dining room, lounge and conservatory. There is a large well kept garden to the rear of the property, which is accessible by a ramp and provides a very pleasant area for people to sit and enjoy the good weather. The majority of people living at the home are elderly although a small number have physical or mental health needs. The weekly fees for services provided in the home range from £410:00 to £420:00. Details of exact charges can be obtained from the manager Rose Cottage DS0000066838.V346715.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out between the hours of 9:30am and 4:00pm. The purpose of this visit was to assess how the home is meeting the needs of people who live there. The methods I used included looking at records, watching staff at work, talking to people living at the home, the manager and staff. Survey questionnaires were also sent to people living at the home and their relatives so that they can share their views and opinions of the service with us. Four questionnaires were returned by people living at the home and three by relatives. Survey questionnaires were also left at the home for staff to complete and eight were returned. The manager had completed an Annual Quality Assurance Assessment (AQAA) form and the information provided has been used as evidence in the body of the report. What the service does well: What has improved since the last inspection? All new staff now receive induction training using the Skills for Care Common Induction Standards to make sure they have the skills and experience to carry out their roles effectively. Rose Cottage DS0000066838.V346715.R01.S.doc Version 5.2 Page 6 Staff meetings are now held on a more regular basis to make sure that there are clear lines of communication within the home and staff feel valued. More emphasis is being placed on providing people with an appropriate range of social and leisure activities and a newsletter is now published, which highlights forthcoming events. Extensive improvements to the building have been carried out including installing a new emergency call system and completing fire safety work, so that people can be sure that they are living in a safe environment. 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. Rose Cottage DS0000066838.V346715.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 Rose Cottage DS0000066838.V346715.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): 1,3,4 and 5 – Standard 6 is not applicable to this service. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are provided with sufficient information to enable them to make an informed decision about the home. The admission procedure is thorough and people will not be admitted unless staff are able to meet their needs. EVIDENCE: The manager confirmed that no changes have been made to the home’s statement of purpose or service users guide, which are made available to all people considering using the service. The home is in the process of publishing a new colour brochure, which will provide people with more information about the care and facilities offered. Rose Cottage DS0000066838.V346715.R01.S.doc Version 5.2 Page 9 The records show that pre-admission assessment visits are carried out to see people before they are admitted and the needs identified during this visit form the basis for the initial care plan. People are encouraged to visit before admission to view the accommodation and meet the staff and other people living there. The manager confirmed that people offered a place at the home are always supported throughout the admission process and care is taken to make sure they settle in to their new environment. One person recently admitted for a short stay said that although she had been unable to look around the home before admission she had chosen it because it was a small home with a good reputation in the local community. She confirmed that she had not been disappointed with her choice and would have no hesitation in moving into the home on a long-term basis should the need arise. Comments from other people included “It’s such a lovely place to live – everyone is so kind and caring” and “staff will do anything at all to help you and they always treat you with such kindness.” Feedback from people clearly indicates that they feel the skill mix within the staff team is good and staff have a good understanding of their needs. Rose Cottage DS0000066838.V346715.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 quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s social and healthcare needs are being met although the care plans need reviewing to make sure they contain all relevant information. EVIDENCE: Care plans have been completed for people living at the home and cover all aspects of their social and healthcare needs. The manager confirmed that care plans are reviewed on a regular basis and reflect the current level of care or support required by the individual. However, it was difficult to find some information in the care plans I looked at and information that should have been in the care plans had instead been recorded in the daily living plan or other supporting documentation. Questionnaires returned by three staff also indicated that the care plans did not always provide them with enough information or guidance on how individual’s needs were to be met. Rose Cottage DS0000066838.V346715.R01.S.doc Version 5.2 Page 11 Everyone is registered with a general practitioner and are supported in having access to the full range of NHS services. The input of other healthcare professionals is clearly recorded in the documentation available, which shows that staff are seeking advice if they have concerns about an individual’s health. People living at the home said that they were very pleased with the care and attention they received and comments included “staff are always quick to contact a Doctor if I feel unwell” and “the staff are kind and caring and make sure I am well looked after.” Feedback from relatives confirmed that they were always contacted about significant changes in people’s general health. Comments included “the manager and staff are very good at keeping me informed if my mum is poorly and I trust them to take the appropriate course of action” and “I have no doubt that people living at the home are well cared for and treated with kindness and respect.” On reviewing the medication system I noted that a stock control system was not in place for some medication administered on a PRN (as and when required) basis. I also found that the stock control for medication prescribed for one person was wrong and painkillers for another person had not been recorded on the Medication Administration Record (MAR) sheet. Staff must therefore be more vigilant when recording and administering medication so that people can be confident it is being given as prescribed. Rose Cottage DS0000066838.V346715.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): People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are encouraged and supported to participate in a range of activities and make decisions about their lives, which helps to improve their quality of life. EVIDENCE: People said that they are encouraged to make as many decisions and choices as possible about their daily lives and how they want to spend their time. Feedback from people showed that there are no set times for getting up or going to bed and they generally feel that daily routines are based around their needs. People also felt that the level of activities and outings arranged for them was adequate to their needs and enjoyed both the trips out, in-house entertainment and other activities organised for them. The home publishes a newsletter, which highlights forthcoming events and special occasions like birthday parties or anniversaries. Rose Cottage DS0000066838.V346715.R01.S.doc Version 5.2 Page 13 Rose Cottage is very much part of the local community and information provided in the Annual Quality Assurance Assessment forms indicates that the home is involved with local schools and churches. Throughout the visit staff were observed to interact well with the people in their care and people were relaxed and clearly felt comfortable in their presence. People said that they were able to see visitors in their own room if they wished to do so and family and friends were always made to feel welcome and offered light refreshment. During the visit I had my lunchtime meal with everyone in the dining room and the food was very good both in quality and presentation. Tables were nicely set, the meal was unhurried and the atmosphere was relaxed with lots of friendly banter between staff and individual people. People living at the home said that the food is always good and their preferences are taken into account when menus are planned. Comments included “there is always a good choice at mealtimes” and “the meals are very good.” People have input into menu planning through the meetings with the manager and staff held at regular intervals during the year. Rose Cottage DS0000066838.V346715.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): People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Thorough complaint and adult protection policies and procedures make sure that individuals are listened to and protected from any form of abuse. EVIDENCE: There is a clear complaints procedure in place and people spoken with said that they would have no problems approaching the manager if they had any concerns about the standard of care being provided. Questionnaires returned by relatives also clearly indicated that they were aware of the complaints procedure and who to contact if they had any concerns. The Annual Quality Assurance (AQAA) form completed by the manager shows that the home has received four complaints within the last twelve months all of which have been investigated within the appropriate timescales. No complaints have been received since the last inspection in November 2006. Adult protection policies and procedures are in place and staff have received appropriate training in the recognition and reporting of abuse. Rose Cottage DS0000066838.V346715.R01.S.doc Version 5.2 Page 15 Feedback from staff indicates that they are aware of the home’s policy on “whistle blowing” and were aware of what to do if they felt any practices put in place at the home were not in the best interest of the people using the service. Policies and procedures are available regarding staff involvement in the financial affairs of people living at the home, which does not allow them to become involved in the making of, or benefiting from their wills. Rose Cottage DS0000066838.V346715.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): 19,20,22,24 and 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home continues to provide people with a pleasant and comfortable environment in which to live. EVIDENCE: The home is situated in a main road position in the centre of Thornton village. There is a large garden to the rear of the property, which is accessible by a ramp. There is an ongoing programme of refurbishment and renewal and since purchasing the home in 2006 the new providers have made a substantial financial investment in improving the standard of accommodation. Rose Cottage DS0000066838.V346715.R01.S.doc Version 5.2 Page 17 All communal areas used by people including the lounge, dining room and conservatory are situated on the ground floor of the home, conveniently close to toilet facilities. Bedrooms are situated on both floors of the home and consist of both single and double rooms. A stair lift is available to the first floor although at present people would still need to be able to climb three steps to reach the bedroom accommodation. There are however plans to extend the stair lift so that it reaches the first floor, which will resolve this matter. People said that they were pleased with both their private accommodation and communal areas. Comments included “the home is warm and comfortable” and “the owners and manager are lovely and are making sure the home is nicely furnished and decorated.” On the day of the visit the standard of hygiene and cleanliness throughout the home was good and no unpleasant odours were noted. Rose Cottage DS0000066838.V346715.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): People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People that use the service are protected by the agency’s recruitment and selection procedures. EVIDENCE: The home has a thorough staff recruitment and selection procedure, which includes obtaining at least two satisfactory written references and a Criminal Record Bureau check before new staff start work. The home has a very stable staff team, which makes sure that people receive continuity of care. The staff rota showed that sufficient staff are employed to meet people’s needs. However, questionnaires returned by two staff indicated that the home has recently experienced staffing problems due to sickness. This matter was discussed with the manager who confirmed that she was dealing with the issues raised and that the level of care received by people had never been affected All staff are provided with written job descriptions, which outline their roles and responsibilities and a copy of the new staff handbook. The manager confirmed that there is commitment to provide staff training and that all new staff now receive induction training using the Skills For Care Common Induction Standards. Following which there is an expectation that Rose Cottage DS0000066838.V346715.R01.S.doc Version 5.2 Page 19 they will achieve a National Vocational Qualification (NVQ) at level two or above depending on the post they hold. The Annual Quality Assurance Assessment (AQAA) form completed by the manager shows that currently 77 of care staff have achieved a NVQ at either level two or three. Questionnaires returned by three staff however clearly indicated over the last year there has been less opportunity to attend training courses and update their knowledge. As the staff training matrix was not available on the day of the visit the manager agreed to forward me a copy to evidence the level of training provided. Rose Cottage DS0000066838.V346715.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): People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home is well managed and people are supported in making decisions and exercising choice. EVIDENCE: The registered manager of the home Mrs Patricia McCann has many years experience in the caring profession and has a recognised management qualification. It is apparent through discussion with the manager that she is well supported by the Registered Providers and there are clear lines of accountability. Feedback from staff shows that the manager has an open and approachable management style and ensures clear channels of communication within the home by holding regular staff meetings. Rose Cottage DS0000066838.V346715.R01.S.doc Version 5.2 Page 21 Staff also have formal one-to-one supervision with the manager to discuss care practices and their personal development needs, although at present this does not take place as often as required. The manager does however work alongside the staff on a daily basis and is therefore able to provide the support they need to carry out their roles effectively. Quality assurance monitoring systems are in place and the manager is proactive in seeking the views and opinions of people living at the home and their relatives by sending out survey questionnaires on a six monthly basis. As part of the quality assurance monitoring process the registered provider also visits Rose Cottage at least monthly and provides us with a written report on the conduct of the home. The home holds money in safekeeping for a number of people and transaction sheets are in place showing income, expenditure and a balance. Only senior staff complete the transaction sheets and regular audits are carried out to make sure the records are accurate and in good order. Receipts are obtained for any items purchased by staff on behalf of people. Policies and procedures are in place to ensure the health and safety of the people living at the home, visitors and staff and they are audited on a regular basis to make sure that they meet present legislation. It was recommended to the manager that a risk assessment be carried out on the opening width of windows on the first floor of the building and restrictors fitted if appropriate. Information provided in the Annual Quality Assurance Assessment (AQAA) form also indicates that all equipment in use at the home is serviced in line with the manufacturers guideline, so that people can be sure that it is in good working order. Rose Cottage DS0000066838.V346715.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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 3 3 X 3 Rose Cottage DS0000066838.V346715.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 OP7 Regulation 15 Timescale for action Care plans must contain accurate 30/11/07 and up to date information about people so that staff can provide the level of care they need. An accurate stock control system must be in place for medication administered on a PRN (as and when required) basis and all medication must be recorded on the Medication Administration record (MAR) sheet, so that people can be confident that medication is being given as prescribed. 31/10/07 Requirement 2. OP9 13(2) 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 OP38 Good Practice Recommendations It is recommended that a risk assessment be carried out on the opening width of windows on the first floor of the building and restrictors fitted if appropriate. DS0000066838.V346715.R01.S.doc Version 5.2 Page 24 Rose Cottage Rose Cottage DS0000066838.V346715.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Rose Cottage DS0000066838.V346715.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!