Inspection on 06/12/06 for Rosecroft Care Home

This inspection was carried out on 6th December 2006.

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 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 09/02/06

Rosecroft Care Home 28/10/05

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 09:00 6 & 7 December 2006 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.V308606.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. Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 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) rosecroftcarehome@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.V308606.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th February 2006 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. There are good bus routes to Grimsby and Scunthorpe. The home has large well-maintained grounds with ample car parking for visitors. The home was originally owned by the local authority but is now 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. Weekly fees range from £336 to £390 per week. Information on the service is made available to prospective and current service users via the statement of purpose, service user guide and inspection report. Copies of these documents can be obtained from the home. Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first key inspection of 2006/07. The inspection visit took place over 2 days in December 2006. Mrs Matun Wawryk, Regulation Inspector carried out the site visits. Prior to visiting the home the inspector sent out a selection of survey questionnaires to all the service users and staff and some professional staff. Comments received were analysed on their return and any issues identified were checked out during the inspection visit. Following the inspection visit questionnaires were also sent to the relatives of some service users. Some of the comments received by people have been included in the report. Information received by the Commission since the last inspection was also considered in forming a judgement about the overall standards of care provided by the home. Twenty-six service users were living in the home on the day of the inspection visit. The inspector had discussions with seven service users, the acting manager, a care co-ordinator, a senior care worker and two care workers and a district nurse and a friend of one of the service users. The inspector checked to see that service users privacy and dignity was maintained, that people could make choices about aspects of their lives and that the home ensured service users were safe and protected in their environments. Documentation in relation to the assessments people had prior to the admission to the home and support plans produced to meet assessed needs were examined. In addition the inspector also looked at a number of records in relation to medication practices, complaints management, staffing levels, staff training, induction and supervision. The inspector also looked at how the home monitored the quality of the service it provided and how the home was managed overall. What the service does well: There was a relaxed and homely atmosphere in the home, service users were observed to be settled and comfortable in their surroundings. All of the service users spoken to said they were very happy living at Rosecroft. Two service users spoken to said ‘we try hard to be as independent as possible, and it is so nice to be able to make decisions about the care being given and have the staff respect these’. Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 6 Visitors to the home are made welcome and the home encourages families and friends to join in with activities and other social events. Discussions held with the staff indicated that the staff are very committed to their role and take an interest in the welfare of the service users. Staff spoken to during the inspection talked about the service users in a sensitive and respectful way and understood the need to promote their dignity and independence. Staff stated that they felt the service was generally well managed and commented on the approachability of the manager and senior staff. Service users had good access to professional medical staff and were able to access external services such as dentists and opticians. What has improved since the last inspection? What they could do better: Following a check of the individual service user care plans; the inspector noted that one service user who had been in the home for a short time did not have a care plan. It is important that care plans are out into place as soon as an individual is admitted to the home. This is needed so that staff known what care and support people need and when they need it. Following a check on a sample of employment records for new staff the inspector noted that the home was not always following good practice when recruiting and selecting new staff and action must now be taken to address this. The home must now ensure all required checks on prospective employee are carried out before they start working in the home. Failure to do so could result in the service users being put at risk of harm. Not all staff had completed training in the protection of vulnerable adults from abuse. This was important, as all staff must know what to do and who to tell if Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 7 they suspect abuse has occurred. Also not all staff had up to date certificates in other important training for example moving and handling. The manager needs to make sure that all staff members have all important training to help them further develop the necessary skills to be able to do the job of caring for older people properly. The manager and senior staff were supervising staff on a 1-1 basis, but these supervisory meeting were not up to date for all staff. The manager must now ensure staff get more regular 1-1 supervision. This is important because staff need to be provided with necessary guidance; leadership and support to ensure service users living in the home are safe and well cared for. The inspector would like to thank everyone who completed a questionnaire and/or took the time to talk to her during the inspection visits. Their comments and input have been a valuable source of information, which has helped inform this report. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 8 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.V308606.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have their needs assessed prior to admission to the home and service users were offered the opportunity to visit the home prior to admission to sample the level of service provided. Thereby helping them to make decisions about the suitability of the home to meet their needs. EVIDENCE: The admission procedure was adequate to guide staff on the actions to be taken to ensure that prospective service users needs are properly assessed Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 10 and planned for. Discussion with the manager indicates that the home obtain a copy of the care management assessment and care plan for new service users. The inspector case tracked one service user admitted since the last inspection and looked at some records for one other service user. Records evidenced the service users had had their needs assessed prior to admission to the home. In the absence of a professional assessment the manager had completed a preadmission assessment. Two service users and the friend of one service user were questioned about what information was provided to them about the home and fees charged. All those spoken to were able to show a clear understanding of what they were required to pay and were satisfied that they had been given enough verbal information from the manager/staff before deciding to come into the home. One service user said ‘ I am quite satisfied that the home can meet my needs’. None these individuals spoken to could recall being given a copy of the service user guide prior to admission, although two said they had been made aware of the guide following their admission to the home. The manager stated that service users had the opportunity to visit the home prior to admission to meet other service users and to sample the levels of services provided by the home. Service users spoken to confirmed this, although most said their family or friends had chosen the home for them and that they had been happy for this to happen. Discussion with staff indicated that they are aware of the process of information giving to prospective service users, and they know where the statement of purpose and service user guide information is within the home. The home routinely provided statements of terms and conditions to both selffunding and local authority funded service users. However because the homes charges are above what the local authority would normally pay the inspector advises that contact detail who is responsible for paying the third party top up. The manager confirmed that none of the service users paid the top up out of their personal allowances. Six of the service users spoken to said they liked living in the home and described that staff as ‘kind, approachable and helpful’. All of the staff spoken to were very knowledgeable about the needs of the service users and were able to fully describe their care and support needs and routines for the way care should be given where this was needed. Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care and support each service user needs and receives is documented and care provided is based on assessment of individual needs and choices. EVIDENCE: Case tracking took place for four service users. The methodology used was a physical examination of care plans, written surveys to service users, staff, and some health and social care professionals, and direct observation on the day of the inspection visit. Individual support plans were in place for three out of the four service users selected for case tracking and these set out the health and personal care needs Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 12 identified for each person. Care plans were generally comprehensive and gave lots of information about the care needs of the individual and how they should be supported. One service user had been in the home for a short time did not have a care plan. The inspector discussed the need to complete a plan for this individual with the manager. At the second visit the inspector noted that a care plan had been written for this individual. The manager gave an assurance that in future care plans would be completed for new service users on admission. Plans looked at had been evaluated and discussions with staff indicated that they were aware of changes but had not always amended the care plans to reflect these. Specific examples were discussed with the manager during the visits. Risk assessments around moving and handling, pressure sores and nutrition had been carried out and were recorded within the individual plan. All high-risk areas identified had been reviewed and care plans were in place to support care provision. However some risk assessments particularly those for moving and handling did not always identify the specific risks and the actions staff must take to eliminate or minimise these. Specific examples were discussed with the manager during the visits. One service user was using bed rails, but there was no completed risk assessment in their file. Bedrails if not appropriate for the individual can be potentially harmful. The manager was advised to complete a risk assessment as soon as possible, which she agreed to do. All the service users spoken to said they have good access to their GP’s, chiropody, dentist and opticians, with records of their visits being written into their care plans. Information from the plans showed that individuals are able to access medical professionals as needed, including the Community Psychiatric Nurse, Speech therapist, Dieticians and the District Nurse. Some individual service user files looked at contained old care plans and risk assessments, the inspector advises that files could be improved by taking out all old or unnecessary paperwork and filing this. The home uses a Monitored Dosage medication system and information from the pre inspection questionnaire and discussion with the staff and manager indicate all those responsible for giving out medication have completed a distance-learning course for medication. Checks of the medication records and the system used showed that generally the home maintained good records, although documentation could be improved. Staff were handwriting medication onto the sheets (transcribing), but were not following best practice. In some cases staff were not always recording amounts of medication received or brought forward. The inspector advised the manager to ensure two staff sign the entry to indicate they have Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 13 both witnessed that the information on the sheet is correct and that quantities of medication, including balances where appropriate are recorded on the medication record sheet to ensure an accurate audit trail. Checks of the controlled drugs in the home showed these are held correctly in a locked cupboard and are recorded accurately in a Register. The medication policy for the home says that individuals can self-medicate if they want to and after a risk assessment has been completed and agreed. All of the service users spoken to preferred the staff to administer their medication. All of the service users who returned a questionnaire said they were satisfied with the care and support offered by the staff. Discussion with six service users revealed that they were also happy with the way in which personal care was given at the home, and they felt that the staff respect their wishes and choices regarding privacy and dignity. One person said ‘ the staff are very good to us, they are kind and we get the care we need.’ Three individuals said ‘we can talk to the staff about any problems we have and they or the manager will make sure our needs are met.’ ‘We can go to bed when we want and staff don’t get us up too early.’ ‘We have a laugh with some of the staff’. Two service users said they did not feel there was enough staff, they said call bells sometimes seemed to ring for a long time, particularly in the morning and that staff often seemed ‘rushed of their feet’. One individual highlighted an issue around bathing, expressing a wish to have more frequent baths, but problems with staffing levels sometimes prevented this from happening. These matters were discussed with the manager. Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided opportunities for social stimulation, and provided nutritional meals, flexible routines and enabled service users to make choices about aspects of their lives. EVIDENCE: Information gathered from the surveys and talking to service users, staff and manager indicated that activities within the home were generally satisfactory. The home employs an activity co-ordinator who works fours days a week; this individual is also responsible for supporting service users who attend for day care. One person described how they liked to be, ‘useful’ by helping to set tables. Two surveys indicated that people preferred not to join in activities whereas three stated that there were sufficient activities ‘mostly, three people said Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 15 there were sufficient activities sometimes’. This last statement may mean that the home have not got it quite right for everyone, although records showed a range of activities were provided including individual walks around the garden, trips to local shops and restaurants as well as group games and visiting entertainers. The inspector witnessed open visiting and service users confirmed their relatives were always made welcome and could visit at any time. Service user survey comments and feedback received during discussion with service users and staff indicated that overall there is a good level of satisfaction with the meals provided by the home. One individual said ‘the food is lovely, choices are good and there is plenty of it’, another commented that ‘all the food is home cooked, another service user said the food ‘alright’ another user said the meat was sometimes tough’. The cook was aware of this and assurances were given that steps had been taken to address this problem. Service users who choose to eat their meal in the sitting areas rather than the dinning rooms are provided with over bed tables. There were no menus on display in the dining areas although, a choice of meals is provided, with staff speaking to service users on a daily basis to check their choice of meal for the following day. The manager gave an assurance that specialist diets would be catered for. Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a satisfactory complaints system and staff and service users can be assured complaints and concerns will be listened to and acted upon. Adult protection systems need to be supported by a more consistent staff-training programme. EVIDENCE: The home has a clear complaints procedure in place. Service users spoken to said that they had no complaints about the home and felt confident to raise issues of concern if they arose. Individuals said they could express their opinions in the satisfaction surveys they completed each year and that the manager is always available for them to talk to if needed. Information from the Pre-Inspection Questionnaire and discussion with the manager indicates that the home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, management of challenging behaviours and management of service users money and financial affairs. Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 17 Staff spoken to displayed a good understanding of the vulnerable adults procedure. They were confident about reporting any concerns and certain that any allegations would be followed up promptly and the correct action taken. Discussion with the manager indicated that she has received training around Protection of Vulnerable adults along with some care staff. However some staff still need to complete this training. This training must now be provided. Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided a clean and safe environment for people who live and work there and service users were able to personalise their bedrooms. EVIDENCE: The home was clean and tidy. Out of the seventeen service user surveys eleven felt the home was clean and fresh, ‘always’ and the rest stated, ‘usually’. One person stated, ‘my room is cleaned every day’ and another said ‘standards are continuing to improve’. Service users spoken to were happy with their rooms and those examined were clean personalised to varying degrees. All the bedroom are single this means personal care and treatments Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 19 can carried out in private thereby ensuring the privacy and dignity of the service user. There are four lounge areas, all looked homely. The gardens were generally well maintained and staff said service users filled flower tubs as part of the homes activity programme. The manager stated that the home had a maintenance programme and that all bedrooms and communal areas had either been or would be redecorated within the next twelve months. The manager gave an assurance that service users had the choice of colours. The maintenance person carried out weekly and monthly environmental checklists as part of their role. Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A review of staffing levels is needed to ensure there are sufficient numbers of staff available at any one time. Although improvements had been noted in mandatory training there were still gaps to address and adjustments to be made to the recruitment process to promote the safety and welfare of service users. EVIDENCE: The roles and responsibilities of staff were clearly defined and in discussion with the inspector staff demonstrated understanding of the management and reporting structures for the home. Inspection of the duty rota and discussion with the manager indicates that the staffing levels at the home remain the same as at the last inspection. In general there are four staff during the morning and afternoon. Three staff are on duty through the night. In addition the homes employs an activity coordinator and various ancillary staff. Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 21 It was not clear from the information detailed in the pre-inspection questionnaire whether the home used the Residential Staffing Forum Guidance to calculate staffing hours. The inspector was not able to check whether the home was meeting the recommended guidelines because the manager was not using a recognised depenacy tool nor was she able to provide complete information on the dependency levels of service users in residence at the time of the inspection. . Feedback from discussion with four service users indicated they felt that there were sufficient numbers of staff on duty at any one time to enable their needs to be met. One service user said they felt staff were sometimes were rushed of their feet and that ‘more staffing was needed’. One service user said they were sometimes prevented from having more frequent baths because staffing did not always allow this to happen. Both these service users said ‘call bells’ particularly during the early morning and evening shifts sometimes rang for a ‘long time’ All but one of the staff spoken said staffing levels did not always enable service users to receive individualised care. Five staff returned a questionnaire. In response to the question do you feel there enough staff on duty to meet residents needs on all shifts? three said yes and two said no. Comments received indicate there were concerns about staffing levels in the home. A review of staffing must be carried out based on assessment of the dependency levels of service users, this is needed to ensure that there are sufficient staff on duty to enable service user needs to be met. Service users spoken to said the staff were nice, friendly, had a good approach and they got on well with most of them. One person stated that they have different personalities and you can have a laugh and a joke with some. The inspector observed good interaction between several staff members and service users. The manager had devised a basic training plan to incorporate mandatory training and updates. However records indicated that some staff were not up to date with all required training for example moving and handling. This training must now be provided. This is needed to ensure the health and safety of both service users and staff. The manager stated that all new staff had a formal induction and a pro-forma for recording induction training was in place. This included opportunities for new staff to work alongside more experienced staff (shadowing) as part of their induction. One staff member spoken to said her induction had been ‘very good’. On checking the induction records for a sample group of staff it was established that the content of induction training did not meet Skills for Care induction specifications. Action must now be taken to address this matter. Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 22 There was some evidence that some staff had had some training in conditions affecting older people. However there is a need for more specialised training to be offered that reflects the different care needs of older people for example; working with people who have had strokes, diabetes care or working with people with dementia. This is needed to ensure staff have the required skills and competencies to meet the changing needs of service users. The home employs six senior care workers and eight care workers, of these four had completed a National Vocational Qualification (NVQ) and a further three had enrolled to complete one. Employment records for a sample group of staff appointed by the home since the last inspection were examined; recruitment and selection practice was found to be generally satisfactory. However it was noted that one worker had undertaken two shadowing shifts in the home prior to receipt of a POVA 1st or Criminal Records Bureau Check (CRB). This was not acceptable because it potentially puts the service users at risk of harm. The manager assured the inspector that all future employees would not start working or carry out any shadowing shifts until all checks were completed and received. Advice was also given concerning the need to amend the job application form. Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home is satisfactory overall, but service users health, safety and welfare would be increased with improved staff supervision, staff training and attention to risk assessments for bedrails, moving and handling and a review of staffing. EVIDENCE: The registered manager left the home in July 2006 and an acting manager was managing the home. This individual had worked in the home for several years and had also previously managed the home in the absence of a registered Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 24 manager. The manager said that she keeps her skills up to date through attending regular training sessions relevant to her role. There is a need to employ a permanent manager for the home, who must then submit an application to register with the Commission. Staff spoken to and those who returned a questionnaire said the home was run in the best interests of service users. Staff confirmed that moral was good and staff said there was a good team approach to care delivery at the home. Evidence from staff interviews and staff surveys indicated the staff consider the manager to be approachable, staff said she takes issues raised seriously and takes prompt action to resolve matters. The home had a range of mechanisms in place to monitor the quality of services provided including regular audits of the homes environment, regulation 26 visits and reports, a staff survey questionnaire and individual service user reviews. Certificates on the wall of the home and discussion with the Provider and Manager indicate that the North Lincolnshire Council has awarded the home its Gold Standard for Quality Assurance, this award was achieved in 2002 and has been reaffirmed by the council since this time. Feedback is sought from the service users and relatives through regular meetings and satisfaction questionnaires. A staff supervision programme was in place and each staff member had an allocated supervisor. The owner of the home had also facilitated a training session for supervisors. Staff supervision files showed that individuals were receiving supervision, but that supervision meetings were not up to date for all staff. Discussion with the manager and care co-ordinator indicated that they were aware of this problem and an assurance was provided that the supervision process would be up dated and carried out on a more frequent basis. This will be looked at the next visit. General health and safety was maintained via adherence to policies and procedures, staff training and the maintenance of equipment. Information provided in the pre inspection questionnaire indicates servicing of equipment was up to date. However it was noted that one service user using bedrails did not have a risk assessment for this. One must now be completed. Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 25 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 2 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 x x x x 3 x 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 X 3 2 X 2 Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 26 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 OP36 Regulation 18(2) Requirement The registered person must ensure staff are provided with formal supervision as a minimum of six times a year. Timescale of 31/12/05 and 31/3/06 not met The registered person must ensure staff are provided with an annual appraisal. Timescale of 31/3/06 not met The registered person must ensure that staff receive induction and foundation training to meet NTO targets. Timescale of 31/3/06 not met The registered person must ensure that all staff complete moving and handling training and other essential training. The registered person must ensure that mandatory training is kept up to date. Timescale of 31/3/06 not met Timescale for action 21/03/07 2 OP36 18 31/03/07 3 OP36 18 31/01/07 4 OP38 18 31/01/07 Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 27 5 OP18 18 The registered person must ensure staff are provided with adult protection training. Timescale of 30/4/06 not met The registered person must ensure bedrail risk assessments are completed. Assessments must be completed in line with guidance issued by the Medical Devices Agency. An audit must be carried to check that all service users using bedrails have appropriate risk assessments in place The registered person must ensure that no prospective employee works in the home, this includes ‘shadowing’ more experienced workers until all records as set out in Regulation 19 have been received. This includes receipt of a POVA 1st check pending receipt of a CRB check The registered person must carryout a review of staffing to ensure there are sufficient staffing numbers and skill mix of staff to meet the assessed needs of the service users, the size, layout and purpose of the home at all times, and additional staff are on duty at peak times of activity during the day. The registered person must ensure that there is a training programme in place that ensures staff fulfil the aims of the home and meet the changing needs of the residents. Specialist training on the elderly and diseases relating to old age must be included in the training programme. The registered person must appoint a permanent manager to DS0000045639.V308606.R01.S.doc 31/01/07 6 OP38 13 14/01/07 7 OP29 19 14/01/07 8 OP27 18 31/01/07 9 OP30 12, 18 31/03/07 9 OP32 8 31/03/07 Page 28 Rosecroft Care Home Version 5.2 run the home. Once appointed the manager must submit an application to register with the Commission. 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 OP25 Good Practice Recommendations The registered person should consider the replacement of fluorescent lighting in some lounges and corridors. The registered person must continue the programme of NVQ training to ensure 50 of care workers obtain an NVQ or equivalent. The inspector advises that the application form as well as asking for information concerning conviction should ask for information on any cautions received The registered person should ensure a second member of staff should witness all hand written annotations on Medication Administration Record charts. The registered person should consider detailing the name of the person responsible for paying third party top ups 2 OP28 3 4 OP29 YA20 5 OP2 Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Rosecroft Care Home DS0000045639.V308606.R01.S.doc Version 5.2 Page 30 - 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. 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