Inspection on 20/12/05 for Rose Cottage Nursing Home

This inspection was carried out on 20th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Rose Cottage Nursing Home 24/08/06

Rose Cottage Nursing Home 21/09/05

Rose Cottage Nursing Home 16/03/05

Rose Cottage Nursing Home 23/06/04

Rose Cottage Nursing Home 09/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Rose Cottage Nursing Home Station Road Halfway Sheffield South Yorkshire S20 3GS Lead Inspector Mrs Claire McAuley Unannounced Inspection 20th December 2005 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 Nursing Home DS0000021802.V273203.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 Nursing Home DS0000021802.V273203.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Rose Cottage Nursing Home Address Station Road Halfway Sheffield South Yorkshire S20 3GS 0114 251 0595 0114 251 0595 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) RC Developments Limited Mrs Elizabeth Helena Hodson Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Rose Cottage Nursing Home DS0000021802.V273203.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 13 OP Old Age, not falling within any other category, PC (Personal Care) beds. 16 OP Old Age, not falling within any category, N (Nursing Care) beds Date of last inspection 21st September 2005 Brief Description of the Service: Rose Cottage is a care home providing personal and nursing care for twentynine older people, with sixteen nursing beds and thirteen personal care beds. The home is privately owned. Rose Cottage is situated at Halfway in a residential area with good access to public services and amenities (eg supertram, bus services, shops, libraries etc). The accommodation is over three floors accessed by a lift. The home is well decorated, with a majority of single rooms and one double. The home has an appropriate number of lounges and dining rooms. The gardens are landscaped and there is a car park. Rose Cottage Nursing Home DS0000021802.V273203.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 from 9.00 am to 2.00 pm. Previous requirements were checked and key standards not assessed at the previous inspection were checked. A proportion of the environment was inspected. The inspector spoke to seven residents who expressed their views on the service they received. Three members of staff were also asked their opinions. A number of records were checked and discussion with the manager took place. What the service does well: What has improved since the last inspection? What they could do better: In order to fully meet the needs of residents, the care plans still required further work to record the actions taken by staff to meet resident’s needs. Risk assessments on falls and moving and handling were not completed for all residents. Not all residents had a full needs assessment in place before admission to the home. A record of the discussion at resident’s reviews needed to be added to care plans. Staff supervision did not take place at the required level. Staff meetings and service users/relatives meetings did not take place regularly. Dependency levels of some residents had changed and required Rose Cottage Nursing Home DS0000021802.V273203.R01.S.doc Version 5.0 Page 6 reassessment to ensure that a suitable number of staff were in place. There was no quality assurance system to ascertain service users and relatives views on the service provided. Activities had not been recorded for some months. The Regulation 26 notifications did not contain all the required information. Due to their changing needs, fire risk assessments for residents required updating. The storage of records remains a problem because of the lack of space in the office, and although some floorboards have been replaced, squeaky floorboards on the first floor corridor require replacement. A number of requirements have been brought forward from March 2005. 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 Nursing Home DS0000021802.V273203.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 Nursing Home DS0000021802.V273203.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): 3 The majority of residents admitted during the past year had a full needs assessment in place which identified their needs. Those who did not have one, had their needs reviewed. The manager assessed private residents prior to their admission. EVIDENCE: To identify the needs of residents, the majority of care plans for resident’s admitted to the home during the last year contained a full needs assessment. Prior to this, full needs assessments were not always undertaken. The service users without full needs assessments had had their needs reviewed. The manager confirmed that she would undertake a full needs assessment prior to admission of any private resident. One resident had recently been admitted to the home without a full needs assessment, and the manager could not therefore adequately assess whether their needs could be fully met. Rose Cottage Nursing Home DS0000021802.V273203.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 and 8 There was still insufficient information on care plans of actions taken by staff to meet residents needs. The system of review was unclear and required recording. For the safety of residents, risk assessments on falls and moving and handling required completion. Contracts were in place. There was insufficient evidence on care plans that residents health needs were met, although visits from health professionals were recorded. EVIDENCE: The care plans contained a range of information on residents health and personal care needs. There was insufficient information recorded on actions taken by staff to meet resident’s needs. The manager said that residents and their relatives were involved with reviews, however, it was unclear if these were formal reviews or reviews only of the care plan. There was no recorded information on the content of reviews, those attending and the outcome. The majority of care plans were regularly updated. Not all care plans contained risk assessments on falls, and monitoring of falls. Some files did not contain a moving and handling assessment. Service users spoken to were not aware of Rose Cottage Nursing Home DS0000021802.V273203.R01.S.doc Version 5.0 Page 10 who their key worker was and this information was not recorded on care plans. For their security, each resident had a signed contract in place. It was not clear if resident’s health needs were met, as health needs identified in care plans were not described as met in the recordings. However, there were records of GP, dentist and chiropodist’s visits, as well as other health professional visits in place, and residents said that their health needs were met. The home had links with professionals such as continence and pressure care nurses. Nutritional screening took place, with fluids and food monitored, and residents were regularly weighed. Rose Cottage Nursing Home DS0000021802.V273203.R01.S.doc Version 5.0 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 and 14 An appropriate range of activities was provided, although recording of activities was inadequate. Residents were able to choose their daily routines and activities. They were assessed to handle their own finances and medication. Relatives acted as advocates. Residents brought personal possessions to the home. EVIDENCE: Residents said they made choices about their daily routines and social activities within the home, which enabled them to make their own lifestyle choices. There was a range of activities taking place at the home for Christmas, including a carol service, party, and Salvation Army concert. The home had recently extended its range of activities by including materials and information for reminiscence work, including washday, and clothing. All of the service users spoken to said they had enough to do and were happy with the activities offered. Staff members interviewed said they had time to sit with residents and share in activities such as bingo or sing-a-long. No activities had been recorded for a number of months. Residents were assessed on admission to the home to ascertain if they were able to handle their own financial affairs and medication. Relatives acted as Rose Cottage Nursing Home DS0000021802.V273203.R01.S.doc Version 5.0 Page 12 advocates for residents. Resident’s rooms contained personal possessions such as photos and some items of furniture. Residents spoken to were aware that they could access their personal records. Rose Cottage Nursing Home DS0000021802.V273203.R01.S.doc Version 5.0 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 and 18 For the protection of service users a complaints procedure was in place. There was also a policy and procedure on adult protection and staff had received appropriate training. EVIDENCE: The home had a complaints procedure which met the standards. No complaints had been received during the previous twelve months. Residents interviewed said they had no complaints and were happy with the service. They would be able to approach the staff or manager if they had any worries or complaints. The home had a policy and procedure on adult protection. Staff members had received training in adult protection and were confident they would report any potential abuse to the manager. There had been no incidents of abuse at the home. Management were aware that any incidents of abuse should be reported to Social Services Adult Protection. Rose Cottage Nursing Home DS0000021802.V273203.R01.S.doc Version 5.0 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 and 25 The home’s environment was of a good standard. To prevent disturbing residents, squeaky floorboards required replacing. An area of carpet required cleaning. The lights were regularly checked. EVIDENCE: The home’s environment was of a good standard and was fresh smelling, clean and well decorated. Furnishings and fixtures were of a good standard. Resident’s bedrooms were well decorated and personalised. There was a programme of refurbishment and redecoration in place. One area of carpet was stained, and some floorboards on the first floor were very squeaky. Work had been undertaken to repair the majority of squeaky floorboards in the home. Shaving gel and several safety razors were found in a bathroom. The building complied with the requirements of the fire service and environmental health department. The faulty strip lights fitted above sinks in service users en-suites had been repaired, and all lights were regularly checked to ensure that they were in good working order. Rose Cottage Nursing Home DS0000021802.V273203.R01.S.doc Version 5.0 Page 15 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, 29 and 30 The home maintained the required levels of staff. Dependency levels in the residential unit must be re-assessed to ensure that sufficient staff are on duty to meet residents needs. The manager is now fully supernumerary. Staff recruitment procedures protected the welfare of residents, and a range of mandatory training was offered to staff. Health and Safety training was not completed for all staff. Induction training had been introduced. EVIDENCE: The staffing rotas showed that the home maintained the agreed staffing levels. Staff sickness and absence was covered by staff working extra shifts. Staff and the manager confirmed that there had been no problems with sickness or shortage of staff recently, and the manager was now completely supernumerary. The inspector noted that there were two staff on duty to cover the first and second floor residential unit of sixteen residents, and that some residents could not walk, or required two carers for moving and handling. Other residents had dementia. Staff said that the staff team worked well together and helped each other out, although they did feel stretched at times in the residential unit. There were sufficient domestic staff employed at the home. The recruitment information obtained for staff was sufficient to adequately protect the welfare of residents who lived at the home. The manager confirmed that staff did not start at the home until a Criminal Records Bureau check had Rose Cottage Nursing Home DS0000021802.V273203.R01.S.doc Version 5.0 Page 16 been completed. One file seen did not record a gap in employment, although the manager was aware of how this time had been spent. All staff had received a copy of the GSCC code of conduct and practice. The manager and staff members confirmed that a range of training including health and safety, first aid, moving and handling, fire, infection control and food hygiene was in place. This was offered on a rolling programme. Some health and safety training was outstanding. An external induction programme which met TOPS standards had been introduced, and staff were sent on this when they began work at the home. Records of staff training were in place. Rose Cottage Nursing Home DS0000021802.V273203.R01.S.doc Version 5.0 Page 17 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, 35, 36, 37 and 38 The manager was competent to run the home. Her NVQ 4 qualification had been delayed. Staff had confidence in her abilities. There was no system of quality assurance in place to monitor the quality of the care provided. The systems in place for dealing with service users money were appropriate to protect their interests. Supervision of staff did not take place at the required level, and staff meetings did not take place regularly. Storage of records in order to maintain confidentiality remained a problem. Health and safety measures and appropriate risk assessments maintained a safe environment for residents. However fire risk assessments for service users were out of date, and therefore presented a safety risk for them. EVIDENCE: The registered manager had over nine years experience in senior management and in the care of the elderly in a care setting. She had an appropriate nursing Rose Cottage Nursing Home DS0000021802.V273203.R01.S.doc Version 5.0 Page 18 qualification and was sufficiently qualified and experienced to run the home. The manager stated that there had been a problem in completing her NVQ 4 management qualification as the organisation offering the training was no longer viable. Staff members expressed their confidence in her abilities and said that she was supportive and helpful towards them. A quality assurance and monitoring system was not in place, and development of surveys to ascertain service users and relative’s views of the service still needed to be completed. The manager audited some aspects of the home, including the kitchen, food provided, the health and safety of the home, and redecoration and refurbishment, She also confirmed that residents were continuously asked their opinions on how they were, and aspects of the service, such as food choice. The manager said that residents and relatives meetings did not take place at the home, as residents did not want them. Attempts had been made in the past without success to start regular residents meetings. The manager confirmed that residents were assessed to look after their own finances prior to admission, but there were no residents at present who could do this. All residents had relatives to look after their finances. The home only dealt with small amounts of money, for such things as hairdressing and chiropody. Written records of all transactions were kept, and appropriate receipts were kept. The home had secure facilities for the safe keeping of money and valuables. Supervision of staff did not take place at the required level. Informal supervision took place on a regular basis, and staff said that the manager was always available for help and advice. Staff were still not clear of the difference between formal supervision and appraisal. They confirmed that staff meetings were not held on a regular basis and that there was no set pattern for when one would be organised. The records confirmed this. These issues are brought forward from the previous two inspections. The written monthly reports from the registered provider visits still did not meet and cover the areas stipulated in Regulation 26. Aspects of health and safety were checked. The staff interviewed and the records checked confirmed that they had received fire instruction training in the last six months. Appropriate checks and fire drills had been carried out and recorded. Fire risk assessments for residents were out of date, and some were no longer appropriate because of residents higher dependency needs. Accidents were appropriately recorded. Risk assessments were in place for the safe storage of hazardous substances and for safe practice within the home. There was an ongoing problem with storage, and a lack of space in the office. Although records were kept in locked filing cabinets, the manager said that the open door policy meant that they did not lock the office door, and therefore files were not as secure as she would wish. Rose Cottage Nursing Home DS0000021802.V273203.R01.S.doc Version 5.0 Page 19 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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 3 X STAFFING Standard No Score 27 2 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 2 2 Rose Cottage Nursing Home DS0000021802.V273203.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? YES 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 OP3 Regulation 14 Requirement Timescale for action 01/03/06 2 OP7 15 3 OP7 15, 17 and 18 No service users must be admitted to the home without a full needs assessment completed prior to their admission. All care plans must contain risk 01/02/06 assessments on falls. Monitoring of falls must take place. All care plans must contain a moving and handling risk assessment. Daily records must include 01/02/06 details of the action taken by staff to facilitate each service users needs as identified within their care plan. Minutes from formal care plan reviews must be retained on individual files. Service users must be aware of the staff allocated to them as key worker and details of this must be recorded in the care plan. All sections of the care plan must be kept up to date. This requirement had been carried forward from March 2005. Rose Cottage Nursing Home DS0000021802.V273203.R01.S.doc Version 5.0 Page 21 4 OP8 15 12 5 6 OP12 OP19 16 12 and 13 7 8 9 OP19 OP19 OP27 23 23 18 10 OP29 19 11 12 OP30 OP33 19 24 13 OP33 24 14 OP36 18 Daily recording must record specific actions taken to maintain residents health needs, in accordance with their care plan. All activities undertaken by residents must be recorded. Resident’s toiletries and razors must not be used communally. The gel and razors must be returned to their individual owners. The area of stained carpet must be cleaned. The squeaky floorboards must be repaired or replaced. Dependency levels of residents living in the residential unit must be reassessed and sufficient staff employed to meet their needs. Staff files must include evidence to confirm that any gaps in the CV have been checked. Full details relating to this must be retained on individual files. This requirement had been carried forward from March 2005. All mandatory training, including health and safety training must be completed. A system of quality assurance must be developed to monitor the opinions of residents and relatives on the quality of the care provided. Attempts must be made to reestablish service users and relatives meetings within the home. All staff must receive supervision at least six times per year. Records of these sessions must be maintained. This requirement had been carried forward from March 2005. 01/02/06 01/03/06 20/12/05 01/02/06 01/03/06 01/03/06 01/02/06 01/03/06 01/03/06 01/03/06 01/03/06 Rose Cottage Nursing Home DS0000021802.V273203.R01.S.doc Version 5.0 Page 22 15 OP36 18 and 12 16 OP37 26 and 17 17 OP38 17 18 OP38 17 19 OP38 13 Staff meetings must be held regularly and all staff must be provided with the opportunity to attend. Minutes of these meetings must be available. This requirement had been carried forward from March 2005 The Regulation 26 reports must include all of the required information. This requirement had been carried forward from March 2005. The office door must be locked when the office is left unattended. All records must be safely stored as required. This requirement had been carried forward from March 2005. Systems must be developed to ensure there is an effective system for the storage of, and access to, the required records in the main office. This requirement had been carried forward from March 2005. Fire risk assessments for all service users must be updated. 28/10/05 01/02/06 01/02/06 01/02/06 01/01/06 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 OP31 Good Practice Recommendations The registered manager must achieve a NVQ level 4 in management and care or equivalent by December 31st 2005. Rose Cottage Nursing Home DS0000021802.V273203.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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. 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