Inspection on 23/09/05 for Roseacre

This inspection was carried out on 23rd September 2005.

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

Roseacre 15/12/06

Roseacre 03/05/05

Roseacre 06/09/04

Roseacre 11/05/04

Similar services:

2 Perhaver Park

The Vicarage

Fairfields Country Rest Home

St George`s

5 Seafield Road

Credence House

Poldhu

Queensmount

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

CARE HOMES FOR OLDER PEOPLE Roseacre St Winnolls Polbathic Torpoint PL11 3DX Lead Inspector Mike Dennis Unannounced 23 September 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Roseacre D52-D04 S9219 Roseacre V243067 230905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Roseacre Address St Winnolls Polbathick Torpoint PL11 3DX 01503 230256 01503 230256 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Anthony Ivor Knight Mrs Pauline Knight CRH 22 Category(ies) of Learning disability over 65 yrs of age (4), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 yrs of age (9), Old age not falling within any other category (13) Roseacre D52-D04 S9219 Roseacre V243067 230905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Service users to include up to (MD[E]) Service users to include up to disability (LD[E]) Service users to include up to Total number of service users 9 adults aged over 65 with a mental illness 4 named adults aged over 65 with a learning 13 adults of old age (OP) not to exceed a ,aximum of 22 Date of last inspection 3rd May 2005 Brief Description of the Service: Roseacre is a family run home located in a rural situation, providing care for up to twenty-two service users. Of these service users there are four with a Learning Disability (LD), the home may also admit up to nine service users with mental health problems (MD) . The majority of service users are people who have family in the locality and wish to retain their links with the local community. The main house is an older dwelling with an added extension. There is a pleasant conservatory used as a dining and sitting area to the rear of the property, with patio doors to the garden. From the rear of the property there are panoramic views looking across Plymouth, coastal towns and far out to sea.The home has its own mini-bus, used to take service users on trips. Without transport, service users would be limited if they wished to visit the local village as the home is near the top of a steep hill along a narrow lane with no footpath.The home also provides day care for a maximum of four people per day, which limits disruption to the present service users; and provides an introduction to those who may wish to be accommodated at a later date Roseacre D52-D04 S9219 Roseacre V243067 230905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 23rd. September 2005 over a five hour period. The inspector met with the Deputy Manager, the homes Administrator, 2 of the staff on duty and with 7 service users. During the course of the day the inspector observed the service users being attended to by staff in a courteous and professional manner. Service users informed the inspector that their expectations of being in a care home were being fully met. Various records, policies and procedures were inspected and found to be satisfactory. The inspector visited all parts of the building and noted a satisfactory standard of hygiene. Service users expressed satisfaction with all aspects of the home What the service does well: What has improved since the last inspection? Roseacre D52-D04 S9219 Roseacre V243067 230905 Stage 4.doc Version 1.40 Page 6 The ratio of staff in possession of an NVQ has increased, 66 of staff now holding this qualification with the remainder undertaking courses. The home continues to operate in a positive way. 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. Roseacre D52-D04 S9219 Roseacre V243067 230905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Roseacre D52-D04 S9219 Roseacre V243067 230905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, and 5 Prospective service users have full information concerning the home prior to admission. A contract or Statement of Terms and Conditions is issued on admission. Service users are fully assessed prior to admission to the home. Prospective service users and relatives are afforded the opportunity to visit the home to assess it’s suitability as to meeting their needs. EVIDENCE: Four service user files were inspected and case tracked. All contained information pertaining to pre-admission assessment. The files also contained signed copies of contracts/statements of terms and conditions Policy documents indicate that prospective service users can visit the home before making the decision to move in. The Statement of Purpose and Service User Guide is comprehensive and complies with regulation. It is regularly reviewed and kept up to date. Roseacre D52-D04 S9219 Roseacre V243067 230905 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, and 10 The health care needs of service users are identified, planned for and met. Medication policies and procedures are adhered to. Service users are treated with dignity and respect. The standard of care planning set is high and is being maintained EVIDENCE: The comments and findings from the last inspection remain entirely pertinent. They were:- “The home maintains a comprehensive system of care planning. Service users are assessed at regular intervals. The care plan includes a photograph of the service user, physical and mental health assessments, GP and external health / social care professional visits, record of all meals and a daily record which includes social activities and visits from friends and relatives. All service users are registered with a GP at the local practice. The deputy manager reported a good rapport with the District Nurses. CPNs support some service users; and will visit otherwise as required following a GP referral. Chiropody and dentistry is available on a domiciliary basis. The home has a medication policy. The home uses a ‘blister pack’ system for the medications, which were appropriately stored in a locked medication room. MAR sheets were signed and dated appropriately. The Controlled Drugs register is appropriately maintained. Roseacre D52-D04 S9219 Roseacre V243067 230905 Stage 4.doc Version 1.40 Page 10 There are no service users self medicating at the present time. Service users informed the inspector that they were treated with due respect and dignity”. Roseacre D52-D04 S9219 Roseacre V243067 230905 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 and 14 Visitors are encouraged and the registered person conducts the home so as to maximise service users’ capacity to exercise personal autonomy and choice. EVIDENCE: Service users informed the inspector that they were able to choose who visits them and when. The visitors book was well documented. Policies and procedures indicate that service users may have access to their own records. Some service users were aware of this fact but no one claimed to have taken up the opportunity. All rooms displayed personal possessions. Service users can handle their own finances if they are so able. Roseacre D52-D04 S9219 Roseacre V243067 230905 Stage 4.doc Version 1.40 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The complaints procedure is well publicised and would be used when required. The registered persons ensure that service users are protected from all forms of abuse with staff having knowledge through training of Adult Protection issues which helps to protect service users EVIDENCE: The home has a complaints policy that meets all the requirements of Regulation 22. A complaints log is available to ensure that a record of all complaints is recorded and kept. Details of the complaints policy are available in the statement of purpose and a full copy included within the service users guide The home has a policy in relation to adult protection, which includes information on whistle blowing. This policy references the Department of Health No Secrets guidelines and physical / verbal aggression by service users. Staff are made aware of this policy during induction and training sessions at staff meetings. Roseacre D52-D04 S9219 Roseacre V243067 230905 Stage 4.doc Version 1.40 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The location and layout of the home is suitable for it’s stated purpose and provides a safe environment. The home was clean, hygienic and free from offensive odours providing a homely place to live Bedrooms are comfortable and contain the personal possessions of the occupant EVIDENCE: There is level access to the home, with car parking next to the main entrance. Grounds are kept tidy and appeared generally well maintained. There is easy access to the main garden area through the patio doors of the conservatory, where there are tables and chairs arranged for the use of the service users. A two-staged stair lift is provided to gain access to the first floor for those with mobility problems, however a degree of mobility is required between lifts. The first floor has varying levels that could cause difficulty for service users with mobility problems, however grab rails are provided and the steps are clearly marked. The home is homely and domestic in nature Roseacre D52-D04 S9219 Roseacre V243067 230905 Stage 4.doc Version 1.40 Page 14 The home appeared clean, hygienic and generally free from offensive odours. Disposable gloves and aprons are available as required. Hand washing facilities were satisfactory, with liquid soap and paper towels provided. The home has an Infection Control policy. Night staff undertake the laundry duties. The laundry appeared clean and well organised, with commercial machines and suitable flooring Roseacre D52-D04 S9219 Roseacre V243067 230905 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Recruitment policies and procedures are implemented. All staff are supported and Inducted through improved training opportunities. A positive number of staff are on duty to meet the service user’s needs EVIDENCE: The home has a duty rota that accurately reflected the number and skill mix of staff on duty during the inspection. Additional staff are on duty at busier times of the day. Currently at night there are 2 waking night staff on duty. Senior staff may be contacted if needed. Evidence that at least 66 of the staff team have now achieved NVQ level 2 was presented at the inspection.. The home’s employment policies and procedures are implemented. 2 written references were evidenced within a random selection of staff files. CRB checks and POVA checks are completed. Staff training, induction and development programmes are undertaken. Individual staff files have been set up to record content of training and frequencies Roseacre D52-D04 S9219 Roseacre V243067 230905 Stage 4.doc Version 1.40 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35 The management team have a commitment to provide good standards of care. Positive and pro-active quality monitoring systems are employed. Accounting procedures are robust. EVIDENCE: The management team consists of the registered provider, registered manager, deputy manager and administrator. These four work cohesively as a team to promote the welfare of the service users. An excellent quality monitoring system is employed to obtain feedback from a wide range of sources to include service users, visitors/relatives, staff and visiting professionals. A ‘quality control board oversees procedures and analyses results. Service users are regularly consulted regarding their lifestyle at the home. There is a business and financial plan for the establishment which is regularly reviewed. Records of all financial transactions are kept. Insurance cover is in place. Roseacre D52-D04 S9219 Roseacre V243067 230905 Stage 4.doc Version 1.40 Page 17 Some monies are held in respect of service users. An audit trail exists by way of clear and concise records. Roseacre D52-D04 S9219 Roseacre V243067 230905 Stage 4.doc Version 1.40 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 3 4 3 3 x x x Roseacre D52-D04 S9219 Roseacre V243067 230905 Stage 4.doc Version 1.40 Page 19 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation none Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard none Good Practice Recommendations Roseacre D52-D04 S9219 Roseacre V243067 230905 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection John Keay House Tregonissey Road St Austell PL25 4AD 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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