Inspection on 09/11/06 for Rose Cottage

This inspection was carried out on 9th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 28/09/07

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 Susan Knox Key Announcement Inspection 9th November 2006 09:00 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 DS0000066838.V312728.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.V312728.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.V312728.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New registration Brief Description of the Service: Rose Cottage care home is ideally placed in the middle of the small village of Thornton. Local bus routes are conveniently close by along with shops, public houses, post office and hairdresser. This protected building provides 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. The large rear well kept garden is accessible by ramped pathways and provides a very pleasant patio area for service users to sit and enjoy the good weather. The majority of service users are elderly although a small number may have physical and mental health needs. Information about the services provided could be obtained from the home in information packs that contain the Statement of Purpose, Service user Guide and complaints procedure. The weekly fees for services provided in the home range from £380 to £400. Details of exact charges can be obtained from the manager Rose Cottage DS0000066838.V312728.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) carries out inspections of care homes at a frequency determined by the assessed quality rating. The inspection process has become a cycle of activity rather than a series of oneoff events. Information is gathered from a variety of sources, one being a visit to the home. All regulated services will have at least one key inspection before 1st July 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people living at the home. The entire key National Minimum Standards (which are identified in each section of the report) are assessed and this provides the evidence for the outcomes experienced by residents. At times it may be necessary to carry out additional visits, which might focus on specific areas like health care or nutrition and are known as random inspections. This visit was announced because this was a newly registered service and was carried out by two inspectors over one day. It started at 9 am and finished at 3.30pm. Feedback was given to one of the providers who was present throughout the inspection Mrs Rajal Karavdra and also to the registered manager Mrs Pat McCann. In June 2006 Mr and Mrs Karavdra were successful in being registered as the new providers of Rose Cottage. Shortly afterwards Mrs McCann was successful in being registered as the manager. The purpose of the visit was to make sure the home was being managed for the benefit and well being of the residents and to see what progress had been made. Information to support the findings in this report was obtained by looking at the information supplied in the pre inspection questionnaire (PIQ). Examples of information gained from this document include details of policies and procedures in place, maintenance and safety, menus, staff details and training. In addition the new providers had carried out a user survey in September 2006 the results of this have been included in the report. Records in the home were looked at such as care plans, staff files, and complaints records. Residents, their relatives and visitors were spoken to as well as members of staff and the management team. CSCI survey cards were sent prior to the inspection to three visiting professionals to the home none were returned in time for this report. A number were also sent to be given to residents and their relatives. At the time of writing this report four relatives and one resident had replied in the majority with positive responses. The evidence gathered at this inspection means that the quality rating for this home is good. Rose Cottage DS0000066838.V312728.R01.S.doc Version 5.2 Page 6 What the service does well: 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 DS0000066838.V312728.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.V312728.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 5. Standard 6 is N/A. Quality in this outcome area is good. This judgement has been made following a site visit, talking to relatives and by checking records. The manager does ensure residents are fully assessed prior to admission and that staff can meet their needs. EVIDENCE: The providers have worked hard to adapt and alter the Statement of Purpose and Service User guide to reflect the changes in owners and management. Although some minor changes were required this information was available in the home for residents and visitors. Written information is available about the home so that an informed choice can be made before moving into the home. The manager confirmed that she carries out pre admission assessments wherever possible in the prospective resident’s own home or hospital. A preadmission assessment is undertaken to ensure the home will meet the needs of individuals. A relative confirmed that an assessment had been undertaken before moving to the home. In discussions with staff and checking training records it was clear that staff are fully trained in being able to meet the needs of the residents. Rose Cottage DS0000066838.V312728.R01.S.doc Version 5.2 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, 8, 9, & 10. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The manager is currently working to transfer all care plans to new documentation. Health care needs are met. Residents are treated with respect. EVIDENCE: The inspectors looked at care documentation and talked to residents and staff in order to track the care of three residents. One had been admitted into the home within the week of inspection. The manager is currently working to transfer care plans to new documentation. It was agreed this would be done within four months. Some care files would be easier to use if some of the old documents were archived. Health and personal care needs were set out in a care plan and these are supplemented by daily care plans. Recognised assessment tools are in use and risk assessments were in place. The care plans are discussed with service users (if possible) and with relatives in regular reviews that include relatives. Signatures were evident on some care Rose Cottage DS0000066838.V312728.R01.S.doc Version 5.2 Page 10 plans that also confirmed this. The provider intends to introduce reviews biannually. Health needs are met. Health care is promoted by the home including the use of equipment such as Profile nursing beds (although this is not a nursing home). One person spoke about the improvement in the health and well being of a relative in the short time since admission. The user survey showed that 95 of residents were very satisfied or satisfied with the personal care and support they receive. Dissatisfaction was expressed about the chiropody service and the providers and manager have secured the service of a regular chiropodist. Discussions with a visiting professional on the day of the inspection showed that there has been little change since the business changed hands and the home continues to operate to the same ethos of putting resident’s needs first. The home does operate with a monitored dosage system (MDS) for medication. Stocks are delivered to the home from the local pharmacist. The owners have recently provided a medication trolley. Staff have recently updated their training relating to the MDS in place and this does include some training about contra-indications but the provider was advised to put in place accredited medication training. The administration of medication was observed during the inspection and was satisfactorily carried out. Medication records in the majority were appropriately kept although staff had omitted to sign on occasions. A random check of medication was satisfactory. The provider was able to confirm in writing the day after the inspection that staff had been instructed to remember to sign medication administration records (MAR) charts immediately. No controlled drugs were prescribed at the time of the inspection. Stock control checks are in place for PRN (as and when required) medication. During the visit the inspectors were able to observe routines and staff interaction with residents. It was noted that staff treated residents with respect. This was confirmed during discussions with residents and a visiting professional. The resident’s spoke well about the care provided and raised no negative issues. Rose Cottage DS0000066838.V312728.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14 & 15. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The home does provide choice in daily living and includes residents in decision-making. The majority of the residents enjoy the meals but a definite choice should be provided at all meals. EVIDENCE: Many of the residents said they enjoyed the activities arranged by the home. A full programme is displayed in the home ensuring that residents can make their own decision about attending. A long established scrabble club is held every Monday. The provider regularly talks to each resident and has recently identified one resident who would like to join in but needs the assistance of others. This is to be arranged. Outings are regularly arranged including a recent canal trip and a forthcoming visit to St. George’s hall. Photographs were displayed in the home showing residents involved in the different events. It was apparent that an ongoing programme of activities is available for the benefit of residents. Two residents attend different day centres this helps them to remain in touch with old friends and make new ones. In house entertainers visit and the providers have many plans to encourage further stimulation such as organising video afternoons. Local churches are involved in the home and visit regularly. Rose Cottage DS0000066838.V312728.R01.S.doc Version 5.2 Page 12 The recent user survey found that 96 of residents were either very satisfied or satisfied with their daily living arrangements. The 4 who were dissatisfied said they would like more social activities. The provider has addressed this in part and has plans for further activities. In discussions with residents it was said that the staff were kind and caring and ‘we are like one big family’. It was said that staff welcomed visitors and this was observed on the day. Relatives on the day and in returned comment cards spoke well about being kept informed. The majority of relatives said they could visit residents in private; one issue relating to visits in private has been addressed by the provider and was due to the resident’s perception about staff time. Residents are encouraged to be independent and for one unable to enjoy walking out alone, staff ensure that she accompanies them to local shops. The dining room provides a pleasant setting and tables were laid appropriately. One inspector sat with the residents for the midday meal. This was an excellent meal and well presented. The meal was a social event there was a relaxed atmosphere and no one was rushed. A clear alternative was not on offer for the mid day meal, however the home is presently addressing this matter. Residents said the food was always good and there was plenty of choice. One relative also said the food was good, as he had sampled it on occasions. The user survey carried out by the providers found that 97 of residents were either very satisfied or satisfied with the catering service. The remaining 3 were dissatisfied with seating arrangements and availability of additional snacks and drinks. The provider is working with catering staff to address these issues. Rose Cottage DS0000066838.V312728.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgment has been made using the available evidence and during a visit to the home. An appropriate complaints procedure is in place. Staff have received training about abuse. EVIDENCE: The home’s complaint procedure was displayed in the home readily available for visitors to see. The procedure is also in the Statement of Purpose and the Service User guide. Residents when asked said they would speak to staff about any concerns. The pre inspection questionnaire (PIQ) returned from the home identified that the home had received one complaint. No complaints have been made to the CSCI about the home. A separate record of complaints is kept and was available for inspection and included the complaint, the investigation and any action taken to resolve the issues. The provider said that she always contacts the complainant to check for satisfaction with the outcome. She was advised to do this in writing. Staff training files show that abuse training has been attended. In discussions with staff they said they would refer any concerns about possible abuse to management. The manager has attended local adult protection training in the authority she last worked in. To ensure that the providers and manager have the knowledge to fully protect the residents they should attend Bradford local authority adult protection training. Rose Cottage DS0000066838.V312728.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. Quality in this outcome area is good. This judgment has been made using the available evidence and during a visit to the home when some bedrooms and communal areas were seen. EVIDENCE: This home provides personal care and residents are ambulant. There is easy access into the building and some bedrooms are located on the ground floor. Access to the first floor for those less able is by a stair lift. There is a patio located near to the conservatory and a ramped path to the garden. The new providers having taken over the business in June 2006 have already redecorated some bedrooms has they have been vacated. They are aware other areas of the home require redecoration and new carpets and are committed to achieving this improvement in the environment. This is part of their development plan for the home. They have recently replaced some unstable dining room chairs. Rose Cottage DS0000066838.V312728.R01.S.doc Version 5.2 Page 15 Cleanliness and odour control were to a good standard. Infection control procedures were good. Rose Cottage DS0000066838.V312728.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): 27, 28, 28, 30. The quality of the outcome in this area is good. This judgement was made using available evidence including a site visit when documentation was inspected and discussions held with the staff on duty. Management have ensured the protection of residents by obtaining CRB checks of staff working at the home. Relevant training that matches the needs of the residents is ongoing and more is planned. EVIDENCE: The home provided a copy of the rota for the week of the inspection and it was well staffed. The person in charge was the registered manager. The manager was advised to record her hours on the weekly rota. Staff were aware of their responsibilities. National Vocational Qualification (NVQ) training is on going. The requirement is to have 50 of care staff with level 2 or above NVQ qualifications. Currently the home achieves this standard. This means the home has 50 of care staff with this qualification. Staff confirmed NVQ training during discussions and this was also evidenced in training records and the pre inspection questionnaire (PIQ). Since the new providers took over the home there has been little change in the staff group. One domestic has been employed and one new recruit is pending awaiting confirmation of a CRB check. This is as required. The recruitment files for the newest member of staff was satisfactory. An application form had been completed and two references obtained. There was evidence of verification of Rose Cottage DS0000066838.V312728.R01.S.doc Version 5.2 Page 17 identity checks and Criminal Records Bureau (CRB) checks including POVA first. For the new member of staff there was no written induction into working in the home. Although the manager confirmed that an induction had taken place this was not recorded as required. The standard is for an initial induction to take place over six weeks and then foundation training according to Skills for Care (former TOPPS) over six months. Evidence was available in training records, the PIQ and in discussions with management and staff that proactive training is ongoing. Five staff have a current first aid certificate. Staff confirmed recent training NVQ level two and three. The PIQ confirmed recent training as Dementia, MDS training and food and nutrition. Other planned courses are recognising mental health problems. Rose Cottage DS0000066838.V312728.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 31, 33, 34, 35, 36, 38. Quality in this outcome area is excellent. This judgment has been made using the available evidence and during a visit to the home. The new providers and manager have worked hard in keeping residents, staff and relatives well informed and ensuring resident’s views are heard. EVIDENCE: The manager is a registered nurse and has extensive experience in managing care homes. She has achieved a Certificate in Management Studies and NVQ level 4. Staff and residents spoke well about her management qualities and efficiency. She continues to update her knowledge and is due to attend an up date on Palliative care. The providers have recently completed a user survey checking the resident’s satisfaction or dissatisfaction with living at Rose Cottage. The results showed a great deal of satisfaction. The providers are reacting positively to address the few areas of concern. Rose Cottage DS0000066838.V312728.R01.S.doc Version 5.2 Page 19 The providers have formulated a development plan for the coming year. This was available for inspection and showed there is a commitment to improving the environment and number of activities for residents. Staff and residents meetings have been introduced and are held regularly. The home has developed a number of ways to ensure that residents and relatives are kept fully informed. Appropriate quality assurance systems have been implemented and residents are benefiting from this process. The responsible person for the home submits regulation 26 reports about the conduct of the home every month. These are well formulated and show the depth of inspection undertaken in ensuring that resident’s needs are foremost. The provider was able to show evidence of the fees paid by or on behalf of residents. The manager confirmed that the home does not retain any valuables on behalf of residents other than monies left by relatives to pay for sundries. No personal allowances are dealt with by the home. One resident has an advocate to act on her behalf. The manager has undertaken regular supervision of care staff as required. These records were available for inspection. Maintenance records were available for inspection. A random check showed these were up to date. Kitchen staff were recording the temperatures of cold storage and hot foods. Cleaning schedules were available for the kitchen. A recent environmental health officer’s report for the kitchen showed a satisfactory result. Rose Cottage DS0000066838.V312728.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME 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 3 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 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 3 3 3 X 3 Rose Cottage DS0000066838.V312728.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? N/A 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 OP30 Regulation Requirement Timescale for action 01/12/06 12, 13, 18 The manager to ensure that all new staff have a written induction according to Skills for care (former TOPPS) 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 4 Refer to Standard OP7 OP16 OP18 OP27 Good Practice Recommendations Complete the work to transfer care plans to new documentation within four months. The provider to follow up investigations of complaints in writing to ensure the satisfaction of the complainant. The providers and manager should attend Bradford local authority adult protection training. The manager to ensure that her hours are recorded on the staff rota. Rose Cottage DS0000066838.V312728.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Rose Cottage DS0000066838.V312728.R01.S.doc Version 5.2 Page 23 - 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. 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