Inspection on 28/10/05 for Rosecroft Care Home

This inspection was carried out on 28th October 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

Rosecroft Care Home 06/12/06

Rosecroft Care Home 09/02/06

Rosecroft Care Home 02/12/04

Rosecroft Care Home 21/06/04

Rosecroft Care Home 12/12/03

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 Rosecroft Care Home Rosecroft 34 Wrawby Street Brigg North Lincolnshire DN20 8BP Lead Inspector Ms Matun Wawryk Unannounced Inspection 09:30 27 & 28 October 2005 th th 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 Rosecroft Care Home DS0000045639.V260730.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. Rosecroft Care Home DS0000045639.V260730.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Rosecroft Care Home Address Rosecroft 34 Wrawby Street Brigg North Lincolnshire DN20 8BP 01652 652213 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) rosecraftcarehome@tiscali.co.uk Abbey Residential Homes Limited Position Vacant Care Home 28 Category(ies) of Dementia (4), Old age, not falling within any registration, with number other category (28) of places Rosecroft Care Home DS0000045639.V260730.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd December 2004 Brief Description of the Service: Rosecroft is a purpose built, single storey home situated in the centre of Brigg within close proximity to local amenities and on a bus route to Grimsby and Scunthorpe. It has large well-maintained grounds with ample car parking for visitors. It was originally owned by the local authority but leased long term to Abbey Residential Homes. The home provides accommodation and care for up to twenty-eight people over the age of sixty-five, four of whom may have needs associated with dementia. The home also has the capacity to provide day care facilities. District Nurses and community psychiatric nurses provide any element of nursing care that may be required. The staff ratio is four staff during the morning, three in the afternoon, and three staff at night. The home also has a good complement of domestic and catering staff. The manager is supernumerary and the Care Coordinator has a proportion of their hours designated to care. All bedrooms within the home are single. One bedroom has an en-suite facility. The home has four bathrooms, three of which are assisted and one shower room. There are six single toilets throughout the home close to communal areas. All are accessible to people in wheelchairs. The home has four lounges one of which is a smoking lounge and a large dining room with individual tables set out. The home also has a quiet room/meeting room which is available to service users and their visitors. Rosecroft Care Home DS0000045639.V260730.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on the 27th & 28th October 2005. The inspector spoke to the care manager and three care workers who were on duty at the time of the inspection. Throughout the day the Inspector spoke individually to six people who lived in home. The inspector looked at a range of paperwork in relation to staff recruitment, induction, supervision and training records, the staff rotas and care plans. The inspector completed a partial tour of the building. What the service does well: What has improved since the last inspection? The previous manager of the home had tried to make sure some of the things that needed to be done since the last inspection had been carried out. Redecoration to some areas of the home had been carried and some carpets had been cleaned. Thereby creating a more homely environment for service users. Rosecroft Care Home DS0000045639.V260730.R01.S.doc Version 5.0 Page 6 The manager had ensured fire drills were carried out. Thereby improving health and safety procedures for both service users and staff. Since the last inspection a new manager had been appointed to home. 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. Rosecroft Care Home DS0000045639.V260730.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 Rosecroft Care Home DS0000045639.V260730.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): 1, 3 & 6 Information provided to prospective service users and their carers is detailed thereby enabling them to make informed decisions about whether the home can meet their needs. Service users have their needs assessed prior to admission to the home to ensure the home is able to provide necessary care and support. The home does not provide intermediate care services; therefore National Minimum 6 does not apply to this home. EVIDENCE: The home had a statement of purpose and service user guide. Both these documents include all information set out in National Minimum Standard 1, Regulation 5 and Schedule 1 of the Care Homes Care Regulations. The inspector saw evidence that the guide was routinely issued to new service users or their carers. Rosecroft Care Home DS0000045639.V260730.R01.S.doc Version 5.0 Page 9 The inspector examined the care records for one recently admitted service user. There was evidence to confirm that the home obtained a copy of the local authority assessment and care plan for this person on which to use as a foundation for their own individual plan of care. Rosecroft Care Home DS0000045639.V260730.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 & 10 Care plans generally contained all the information staff needed to meet assessed needs. However in some cases information needed to be more detailed. Personal support is offered in such a way as to promote and protect the service users right to privacy and dignity EVIDENCE: The Inspector examined three care plans and the quality and quantity of information varied. Two care plans were comprehensive with all areas of assessed needs covered. The care plan for one service user contained only basic information. For example the local authority assessment record and care plan for this person identified concerns about skin integrity. Records kept in the home indicated the service user was in receipt of district nursing support for pressure area care. The home had developed a care plan for skin breakdown but guidance provided was very brief and general and did not provide care staff with clear guidance about how to provide necessary support. The registered person must ensure care plans set out all the service users care needs and that they contain sufficient detail to ensure staff have necessary information to deliver all the care that’s needed. Rosecroft Care Home DS0000045639.V260730.R01.S.doc Version 5.0 Page 11 Staff were observed to respond to service users in a respectful and sensitive manner. All of the service users spoken to stated care staff were kind and confirmed staff respected their privacy and dignity. Service users reported that personal care was provided in private. Rosecroft Care Home DS0000045639.V260730.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 15 Service users are encouraged and supported to maintain family links and friendships. The meals in the home are good offering choice and variety. EVIDENCE: Staff reported that service users visitors are made welcome at any reasonable time. Visitors are required to sign in and out when entering and leaving the home for health and safety reasons. The home does not provide a separate visitors room. Key workers helped service users to maintain family contacts by sending cards at significant occasions such as birthdays and Christmas where this was needed. This means service users are enabled and supported to maintain family contacts. This was confirmed in discussions with service users. The home provides service users with three meals a day and a light supper. Staff advised the inspector that hot drinks were available at set times and or on request. This was confirmed in discussions with service users. All of the service users said the meals were good and that choice of meals was provided. Rosecroft Care Home DS0000045639.V260730.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 The home had a satisfactory complaints procedure. Service users, their relatives and staff can be assured their complaints will be listened to and acted upon. EVIDENCE: The complaints procedure is clearly set out in the service user guide and timescales for resolution and contact details are provided. Feedback from discussions with service users and staff evidenced they would feel confident in making a complaint if this was necessary. This means complainants can be assured their complaints and concerns will be listened too and acted upon. Rosecroft Care Home DS0000045639.V260730.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, 21 & 26 The home was clean and free from mal-odours. Service users bedrooms were found to be safe, homely and furnished with their own possessions to varying degrees. EVIDENCE: The inspector carried out a partial tour of the home. A full tour of the premises will be carried out at the next inspection. The home appeared clean and tidy and had a welcoming and homely feel. The home met the requirements of the local environmental health and fire departments. There is ample car parking facilities and CCTV is not used in the home or grounds. Service user bedrooms seen were personalised according to individual preferences. All of the service users spoken to stated they were very happy with their rooms. All commented that they had everything they needed. Rosecroft Care Home DS0000045639.V260730.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 Staffing levels are sufficient to meet the needs of service users, but short term staffing problems has resulted in rota management problems. This matter must be kept under review to ensure the health and welfare of both staff and service users. The arrangements for recruiting staff must improve. This is needed to ensure staff are properly vetted before they commence working in the home to ensure the protection of the service users. Without this service users are potentially placed at risk. EVIDENCE: Staff interviewed were very clear about their roles and responsibilities and understood the management and reporting structures for the home. Feedback from staff and examination of the rota indicates staffing levels are generally satisfactory. However current sickness levels and staff vacancies had resulted in rota management problems. To address this the home was giving extra hours to permanent staff and using agency staff to cover other gaps in the rota. Examination of the staff rota identified some care staff completed double shifts on a regular basis. Service users spoken to said that staff were kind and caring but appeared very busy. This matter must be kept under review to ensure the health and welfare of both staff and service users. Rosecroft Care Home DS0000045639.V260730.R01.S.doc Version 5.0 Page 16 Five staff files were examined and it was found that recruitment processes were not in line with regulation 19 of the Care Homes Regulations in three of the files examined. Two staff members had been recruited by an oversees agency. Completed job application forms had not been obtained and there was no evidence to show how the fitness and suitability of these staff to work in the home had been assessed. Criminal Records Bureau (CRB) checks had not been sought. Furthermore records showed one worker had commenced working in the home without a POVA first check or full CRB. This practice potentially puts service users at risk and must cease. Rosecroft Care Home DS0000045639.V260730.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 & 36 The management arrangements for the home are satisfactory. However there is currently no registered manager for the home. The new manager must submit an application to register with the Commission for Social Care Inspection. This is needed to meet legal requirements. Staff must be provided with more regular supervision to ensure staff are provided with necessary guidance and support and to ensure proper management oversight of the home. EVIDENCE: A new manager was recently appointed to the home and must now make an application to register with the Commission for Social Care Inspection. This is needed to meet legal requirements. Rosecroft Care Home DS0000045639.V260730.R01.S.doc Version 5.0 Page 18 Staff interviewed were very clear about their roles and responsibilities and understood the management and reporting structures for the home. In interview staff demonstrated that they were aware of their own role, skills and limitations. Staff reported that homes managers were efficient and approachable. Systems were in place for the managers to brief staff and to receive feedback from staff for example supervision, staff meetings and handovers. Records of supervision indicated some staff had not been provided with supervision as a minimum of six times a year. This is needed to ensure staff are provided with appropriate guidance and to ensure proper management oversight of the home. From the records examined the inspector was not able to confirm staff had had an annual appraisal. These are needed to ensure the homes training plans and priorities reflect the needs of staff and must now happen. Rosecroft Care Home DS0000045639.V260730.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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 x 3 X 3 X X X X 3 STAFFING Standard No Score 27 2 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X 2 X X Rosecroft Care Home DS0000045639.V260730.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 OP7 Regulation 15 Requirement The registered person must ensure that care plans address all assessed needs. Timescale of By 313.2005 not met The registered person must ensure that CRB’s and POVA register checks are in place prior to confirmation of employment of staff. Timescale of 2.12.04. Superseded by new requirements The registered person must ensure regular monitoring of staffing levels and rota management arranagement o ensure the health and welfare of srtaff and service users until staff vacanices are filled. The registered person must ensure that full CRB’s and/or POVA first checks are obtained prior to staff commencing employment in the home. Immediate requirement notice issued The registered person must carryout appropriate checks and obtain missing records for two named workers. Until received DS0000045639.V260730.R01.S.doc Timescale for action 31/12/05 2 OP29 19(1)(b) 27/10/05 3 OP29 18(1)(a) 30/11/05 4 OP29 19(1)(b) 27/10/05 5 OP29 19(1)(b) 11/11/05 Rosecroft Care Home Version 5.0 Page 21 6 OP31 9 7 OP36 18(2) 8 OP36 18 these workers must work under strict supervision. The registered person must 31/12/05 ensure the new manager submits an application to register with the CSCI. The registered person must 31/12/05 ensure staff are provided with formal supervision as a minimum of six times a year. The registered person must 31/03/06 ensure staff are provided with an annual appraisal. 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 Refer to Standard OP11 OP25 Good Practice Recommendations The manager could consider formulating a palliative care plan that can be individualised and swung into action when the service user becomes terminally ill. The registered person should consider the replacement of fluorescent lighting in some lounges and corridors. Rosecroft Care Home DS0000045639.V260730.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Rosecroft Care Home DS0000045639.V260730.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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