Inspection on 24/05/05 for Rosedale

This inspection was carried out on 24th May 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rosedale 29/04/08

Rosedale 21/05/07

Rosedale 27/06/06

Rosedale 08/12/05

Rosedale 21/12/04

Rosedale 02/11/04

Rosedale 05/09/02

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

CARE HOME ADULTS 18-65 Rosedale 42a Manchester Road Haslingden Lancashire BB4 5ST Lead Inspector Lynn Mitton Unannounced 24 May 2005 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Rosedale F57 F57 S9612 Rosedale V221317 May 24th 2005 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Rosedale Address 42a Manchester Road Haslingden Lancashire BB4 5ST 01706 222066 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) Mrs Bridget Mary Healy Mrs Sarah Jane Taylor CRH 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (MD) 6 both of places Rosedale F57 F57 S9612 Rosedale V221317 May 24th 2005 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st December 2004 Brief Description of the Service: Rosedale is registered to provide accommodation and social care for 6 adults with a mental illness. The house is a Victorian building and offers spacious accommodation with small garden areas to the front and rear of the house. It is situated in the centre of Haslingden town centre, surrounded by all local amenities. Accommodation is provided on two floors in six single bedrooms. There is a lounge and a snooker/dining room on the ground floor. There are designated smoking areas for service users and support staff. Rosedale F57 F57 S9612 Rosedale V221317 May 24th 2005 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 4 hours. At the time of the inspection the home was fully occupied. A tour of the premises took place. Two of the care staff on duty were spoken to, the registered manager and four resident’s also contributed to the inspection process. What the service does well: What has improved since the last inspection? What they could do better: A completed written contract explaining the terms and conditions of residents stay at Rosedale would clarify the responsibilities of both parties. Further improvements to the décor and furnishings were needed in order to improve the standard of the home. Serious potential risks to the health & safety of residents and care staff, such as the closure of internal fire doors, the locking of external fire doors must be given high priority and resolved as a matter of urgency. At least 2 staff must be on duty from 9am until 10pm every day in order to ensure that residents needs, as identified in their care plan, can be met throughout the day. A copy of the complaints procedure should be available to all residents and visitors to the home. Rosedale F57 F57 S9612 Rosedale V221317 May 24th 2005 Stage 4.doc Version 1.20 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Rosedale F57 F57 S9612 Rosedale V221317 May 24th 2005 Stage 4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Rosedale F57 F57 S9612 Rosedale V221317 May 24th 2005 Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 5 Not all written contract fully explained the terms and conditions of residents stay at Rosedale. EVIDENCE: Whilst case tracking it was noted that one resident did not have a fully completed contract. Although signed and dated it did not have the placement funding details completed and who would pay this. Rosedale F57 F57 S9612 Rosedale V221317 May 24th 2005 Stage 4.doc Version 1.20 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 The social care needs of the resident case tracked were identified and met. Appropriate risk assessment and management strategies were in place to ensure residents were safe from harm. Access to resident’s information must always be available to the commission. EVIDENCE: The inspector looked at 1 residents’ care plan. On this was information about social care and a safety profile. There was also risk management documentation. These had been reviewed within the past month. Daily records with detailed content were seen. Some information also required to be kept by the Commission could not be seen due to keys not being available. There was information completed by other professionals regarding the residents’ mental health and wellbeing. One resident said “ I’m happy here, I am - this is the best place for me” From observations and by speaking to the residents the inspector felt that the care staff on duty had a good understanding of the needs of residents. Each resident had a key worker allocated. Rosedale F57 F57 S9612 Rosedale V221317 May 24th 2005 Stage 4.doc Version 1.20 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 & 15 Residents were able to make decisions about their lives, and had some opportunities to fulfil their potential. Residents were able to maintain family links, and had regular access to their local community. Residents were respected and valued as individuals. EVIDENCE: One resident told the inspector about her planned activities for the forthcoming week. She works 2 days per week at a Café. She also had very regular contact with her family and planned to visit her mum unsupported in a nearby town. She also told the inspector how much she valued going out shopping on her own. The inspector was advised that a house meeting was held each Monday when a plan was made of the forthcoming weekly activities and menus were planned. Very old copies of these were found on the communal notice board in the dining room. Rosedale F57 F57 S9612 Rosedale V221317 May 24th 2005 Stage 4.doc Version 1.20 Page 11 The inspector was advised that it was intended that most residents would be going on holiday to Morecambe for 2/3 nights and perhaps to Wales later on in the year. The inspector was advised that one resident had not been registered on the electoral roll and therefore had not received a voting card, however, no residents had voted at the recent general election. Rosedale F57 F57 S9612 Rosedale V221317 May 24th 2005 Stage 4.doc Version 1.20 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 20 There was no evidence available on the day of the inspection that the resident case tracked had their health needs met at Rosedale. Residents could, with appropriate risk management strategies in place administer their own medication. Policies and practices for the safe administration of medication were incomplete and did not ensure that residents were safe from harm. EVIDENCE: There was evidence that residents mental health needs were given consideration on the health plan, however the resident case tracked did not have any information available to show that other health needs were being met. The inspector was advised that no further action had been taken to update the policies since the Commissions pharmacist visited in December 2004. The inspector noted that there were gaps in two residents’ medication administration records. The inspector also advised that any handwritten records (in the case of a new admission) should be countersigned and doublechecked by a second staff member. Rosedale F57 F57 S9612 Rosedale V221317 May 24th 2005 Stage 4.doc Version 1.20 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 A copy of the complaints procedure should be on display to advise residents and visitors to the home of options if they feel their complaints have not or cannot be resolved by talking to a member of the care staff team. EVIDENCE: The inspector spoke to residents about what they would do if they wanted to make a complaint. Most agreed that they would talk to a staff member if they had an issue with another resident. One resident said “I’d talk to staff and keep out of the other persons way”, another said “ I’d talk to staff and tell them about it” There was not a copy of the complaints procedure on display in any of the communal areas. Rosedale F57 F57 S9612 Rosedale V221317 May 24th 2005 Stage 4.doc Version 1.20 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 30 Further improvements to the décor and furnishings are needed in order to improve the standard of the home. The standard of cleanliness and hygiene was satisfactory. Serious potential risks to the health & safety of residents and care staff must be given high priority and resolved as a matter of urgency. EVIDENCE: Despite assurances at the last inspection in December, there was still bare plaster on the ceiling and peeling wallpaper in the front lounge. There was only one light bulb working in the only light fitting in the dining room. The inspector was advised that the residents’ payphone was not working. The attic door was not locked shut and posed a risk to residents. The carpet in the landing and entrance foyer was in need of cleaning. There was no light shade fitted in room 5. The inspector and registered manager discussed the side exit door, which was also a fire exit – this door was locked shut and also fitted with bolts. The inspector advised that further advice should be sought from the fire service with regard to this door being fit for purpose. The registered manager and inspector also discussed all fire doors being wedged open, and advised that this practice must cease forthwith. Further Rosedale F57 F57 S9612 Rosedale V221317 May 24th 2005 Stage 4.doc Version 1.20 Page 15 advise should also be sought with regards to appropriate alternatives if it is important for the flow of the home that these doors are kept open. The inspector was advised that a maintenance man was available to the home and it was suggested that he be called to the home as soon as possible. Rosedale F57 F57 S9612 Rosedale V221317 May 24th 2005 Stage 4.doc Version 1.20 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 35 Staff spoken to and observed by the inspector demonstrated a good understanding of the needs of residents. There were insufficient staff members on duty at all times of the day to ensure the needs of all residents could be met. Staff should continue to complete their NVQ training. EVIDENCE: One resident told the inspector “there’s always someone to listen to us, the staff are good workers and kind”. The inspector observed residents and staff having positive and supportive interaction. The inspector was unable to case track a care staff member’s file due to not having access to the locked filing cabinet. The inspector was advised that there were 5 staff working at Rosedale. There was 1 full time vacancy, and 1 new full time staff member due to begin work once CRB/POVA clearance and references have been received. There were 2 staff on duty from 9am – 5 pm, five days out of seven. However, it was noted that, according to the staff rota the waking day was considered to be from 9am until 5pm and after that time there was only one care staff on duty. This may prevent some residents from accessing the community after 5pm, and compromise the safety and welfare of residents and staff members. Rosedale F57 F57 S9612 Rosedale V221317 May 24th 2005 Stage 4.doc Version 1.20 Page 17 The inspector was not satisfied that this arrangement was in the best interests of the residents, and that it was reasonable that the waking day for these residents would be 9 am until 10pm every day. From 5pm until 9am there was one care staff on duty and a senior staff member on call. The inspector was advised that one staff member had just received notification that she had obtained the NVQ2 qualification. The registered manager advised that she too had completed the care component of NVQ 4 and was due to start the management component in September. Two care staff were due to start their NVQ 2 training in September. There was a training matrix in place. 2 staff were undertaking 2 hours per week training regarding managing challenging behaviour. 2 senior staff had completed medication management training in June 2004. Rosedale F57 F57 S9612 Rosedale V221317 May 24th 2005 Stage 4.doc Version 1.20 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 & 42 The evidence that residents were consulted in the residents survey should be published. The health and safety of residents and care staff should be of paramount importance, and all action needed taken to safeguard this as a matter of highest priority. EVIDENCE: The registered manager is midway through her NVQ 4 qualification. The inspector was advised that a residents survey had been completed about 2 weeks ago, however, this information had not yet been collated nor published. The inspector was advised that residents meetings were held on a weekly basis, minutes of these meetings were not seen. See evidence for standard 42, in regard to standard 20. Other elements of this standard were not examined at this inspection. Rosedale F57 F57 S9612 Rosedale V221317 May 24th 2005 Stage 4.doc Version 1.20 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x 2 Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 2 Standard No 11 12 13 14 15 Rosedale x 3 3 x 3 Standard No 31 32 33 34 35 36 Score x x 2 x 2 x Version 1.20 Page 20 F57 F57 S9612 Rosedale V221317 May 24th 2005 Stage 4.doc 16 17 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 2 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 2 x x 1 x Rosedale F57 F57 S9612 Rosedale V221317 May 24th 2005 Stage 4.doc Version 1.20 Page 21 Yes 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 YA5 Regulation 5(1b) Requirement All residents must have terms and conditions in respect of accomodation to be provided including the amount and method of payment of fees. Records identified in this Regulation must be available at all times to the commission. Make and promote proper arrangements for the health and welfare of residents. Safe arrangements must be made regarding the safe keeping, recording, handling, safe administration and disposal of medicines received into the home. The complaints procedure must be available to all residents, and any person acting on their behalf. The registered person must ensure at all times suitably qualified competent and experienced persons are working at the home in such numbers as are appropriate for the health and welfare of residents. Persons working in the care home must receive training appropriate to the work they Timescale for action 5th August 2005 2. 3. 4. YA7 YA19 YA20 17(1a) Schedule 3 12(1) 13(2) 24th May 2005 24th May 2005 24th May 2005 5. YA22 22 (5) 24th May 2005 24th may 2005 6. YA33 18 (1) 7. YA35 12,17,18 &19 20th December 2005 Page 22 Rosedale F57 F57 S9612 Rosedale V221317 May 24th 2005 Stage 4.doc Version 1.20 perform. 8. YA42 12(1) Make and promote proper arrangements for the health and welfare of residents. 24th May 2005 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 YA20 Good Practice Recommendations The registered manager should ensure that policies and procedures for medicines management be reviewed in line with the current Royal Pharmaceutical Society of Great Britain guidelines It is recommended that at least 50 of support staff have obtained an NVQ level 2 in Care Award/or equivalent by April 2005. In addition each staff member is required to have a written personal development and training plan in place. To fully meet the criteria of this standard the registered manager should obtain a NVQ at level 4 in both management and care by 2005. It is recommended that there is continuous selfmonitoring, using objective, consistently obtained and reviewed and verifiable method, involving service users, and an internal audit takes place at least annually. 2. YA35 3. 4. YA37 YA39 Rosedale F57 F57 S9612 Rosedale V221317 May 24th 2005 Stage 4.doc Version 1.20 Page 23 Commission for Social Care Inspection 1st Floor, Unit 4 Clayton-Le-Moors Accrington Lancashire. BB5 5JB 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 Rosedale F57 F57 S9612 Rosedale V221317 May 24th 2005 Stage 4.doc Version 1.20 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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