Inspection on 08/12/05 for Rosedale

This inspection was carried out on 8th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 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 24/05/05

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 Mrs Lynn Mitton Unannounced Inspection 09:30 8 December 2005 th Rosedale DS0000009612.V256249.R01.S.doc Version 5.0 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 Rosedale DS0000009612.V256249.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 Adults 18-65. 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. Rosedale DS0000009612.V256249.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Rosedale Address 42a Manchester Road Haslingden Lancashire BB4 5ST 01706 222066 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) Mrs Bridget Mary Healy Mrs Sarah Jane Taylor Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Rosedale DS0000009612.V256249.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th May 2005 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 DS0000009612.V256249.R01.S.doc Version 5.0 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 communal areas of the premises took place. Two of the care staff on duty were spoken to, the registered manager and three resident’s also contributed to the inspection process. Throughout the report there are various references to the “tracking process”, this is a method whereby the inspector focuses on a small representative group of staff member and service users. Records pertaining to these people were inspected. Policies and practices were also looked at. There were 6 service users living at Rosedale at the time of the inspection. What the service does well: What has improved since the last inspection? There were risk assessments and management strategies in place, and these had been recently reviewed. Policies and practices for managing and administering medication were largely in order. There was a clear complaints procedure and evidence that resident’s views were sought and acted upon. Over half of the staff team had completed their NVQ training. Rosedale DS0000009612.V256249.R01.S.doc Version 5.0 Page 6 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. Rosedale DS0000009612.V256249.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Rosedale DS0000009612.V256249.R01.S.doc Version 5.0 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 the following standard(s): YA2 & YA5 Needs assessments were not in place identifying the care needs of residents so that support staff would have a clear understanding of how they needed to support them. Contracts did not fully explain what residents could expect, and what was expected of them in order for them to live at Rosedale. EVIDENCE: There had been no new admissions to the home since the last inspection. The most recent admission to the home was in March 2005. There was no assessment documentation for this person available to ascertain their needs prior to their admission. Resident’s contracts were seen. These did not fully explain the terms and conditions of their residence at Rosedale. In particular there were no costings of the placement. Rosedale DS0000009612.V256249.R01.S.doc Version 5.0 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 the following standard(s): YA7 Information on care and health plans meant that some resident’s needs were known to support staff. The risk assessment and management framework supported residents to take responsible risks. EVIDENCE: One residents care plan was examined. There was some information about the level of support needed for staff to ensure continuity of care. This had been recently reviewed. The registered manager and inspector discussed how this documentation could be further improved to include more detail and residents input. There were risk assessments and management strategies in place, and these had been recently reviewed. Rosedale DS0000009612.V256249.R01.S.doc Version 5.0 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 the following standard(s): YA16 & YA17 Resident’s privacy was respected and they were valued as individuals. They were each given opportunities to maintain their independence. Individual dietary needs were catered for. Residents were encouraged to participate in shopping, planning and preparation of meals. EVIDENCE: Residents said that they felt their rights and wishes were respected and gave examples of how and when this had happened. The inspector observed residents being spoken to with respect and being encouraged to take responsibility for their day-to-day living arrangements. The inspector saw one resident making his own lunch. The inspector suggested making a record of what each resident eats on their daily records. Residents made their own meals with staff support as required, except tea, which was usually a communal meal. Residents were advised individually about nutritionally balanced diets. The inspector witnessed menus being discussed during a residents meeting. Rosedale DS0000009612.V256249.R01.S.doc Version 5.0 Page 11 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 the following standard(s): YA18, YA19 & YA20 Personal support was offered in accordance with resident’s needs and wishes. There was insufficient evidence that the service users case tracked had all their health needs identified and how they would be met documented. Policies and practices for managing and administering medication were largely in order. EVIDENCE: The inspector was advised that the residents at Rosedale only needed prompting to maintain their own personal care. Whilst case tracking, there was very limited evidence that service users mental health and physical health needs were being given due care and attention. The inspector and registered manager discussed the development of a health check. The home used Boots MAR system. Administration records seen by the inspector appeared in good order. The inspector was advised that all staff members were undertaking safe administration of medication training. Policies and practices for managing and administering medication were in place. No residents were self-medicating or taking controlled drugs. Rosedale DS0000009612.V256249.R01.S.doc Version 5.0 Page 12 The inspector and registered manager discussed dispensation of medication for residents during periods of home leave and taking over the counter remedies (e.g. cough mixture or painkillers) alongside their other medication. These practices once in place should also be recorded in the medication policy. The inspector advised that staffs over the counter medication should be removed from the medication cabinet. Rosedale DS0000009612.V256249.R01.S.doc Version 5.0 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 the following standard(s): YA22 & YA23 There was a clear complaints procedure and evidence that resident’s views were sought and acted upon. Staff spoken to had an understanding of adult protection issues, ensuring that any allegations would be dealt with appropriately. EVIDENCE: The Commission had received no formal complaints. Policies and practices regarding concerns complaints and protection were in place. The inspector attended a residents meeting and those present were asked if they had any concerns or complaints. A copy of the complaints procedure was on display in the homes dining area and each resident had a copy in their room. One staff spoken to by the inspector knew what to do should they have any concerns about resident’s wellbeing. They were also aware of whistle blowing, and said they would have no hesitation in doing so should they need to. Rosedale DS0000009612.V256249.R01.S.doc Version 5.0 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 the following standard(s): YA24 & YA30 Overall the standard of décor and furnishings provided an acceptable environment for residents. Further improvements as identified below would further enhance the resident’s environment. EVIDENCE: The inspector conducted a tour of the communal areas. The inspector noted that the bare plaster in the front lounge had been decorated. A new lock had been fitted on the attic door. Magnetic safety fire door devices had been fitted to all communal thoroughfare fire doors. The inspector advised that a magnetic safety fire door device must also be fitted to this door. The carpet in the entrance hall had been cleaned. The office’s purpose had been changed to a games room and a pool table installed. The office had been relocated to the rear of the staff room. The registered manager and inspector discussed the visit by the fire officer since the last inspection and the change in use of the side door. The inspector was advised that the front door, which is now kept locked, could be opened without a key in the case of emergencies. The maintenance man had visited the Rosedale the previous day to undertake general maintenance of the home. Rosedale DS0000009612.V256249.R01.S.doc Version 5.0 Page 15 The inspector advised that the front garden area would benefit from clearing of litter. The resident’s payphone was still out of order. The registered manager advised that the main telephone line had yet to be moved from the old office location to the new one. Rosedale DS0000009612.V256249.R01.S.doc Version 5.0 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): YA32, YA33, YA34 & YA35 Staff spoken to and observed by the inspector on the day demonstrated an understanding of the needs of the residents. There were insufficient staff numbers on duty during the waking day to meet the resident’s needs. Staff records seen demonstrated appropriate checks had been taken to ensure that service users were safeguarded. Some staff had completed their NVQ training. Other training needs identified should be implemented as a priority. EVIDENCE: There were no staff vacancies at the time of the inspection. According to the rota, there were usually only two staff members on duty from 9am – 5pm and one or two staff members from 5 – 10pm. One staff member slept in overnight. One staff member worked for 27 hours each week without a break. There were a number of occasions where there was only one staff member on duty from 5pm onwards. The inspector and registered manager discussed having a “security net” of bank or agency staff to cover for sickness and leave, especially as the staff team only consisted of 5 people. The Christmas and New Year rota was also discussed, as it had not been completed. Rosedale DS0000009612.V256249.R01.S.doc Version 5.0 Page 17 The inspector case tracked one staff file. This file contained information that demonstrated appropriate checks had been taken to ensure that service users were safeguarded. However it was also noted that there was no evidence of induction training on this newly recruited staff member. Of the 5 care staff, 3 had completed NVQ 2 training, a further 1 was undertaking this training, and the 5th staff member was due to start this training in January. All staff were undertaking an external safe administration of medication training course. 3 staff members had undertaken health and safety training. Food Hygiene, 1st Aid and Fire Safety training had yet to be arranged. The inspector was advised that all staff had completed in house challenging behaviour training. One staff member spoke to the inspector. Rosedale DS0000009612.V256249.R01.S.doc Version 5.0 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): YA37, YA39, YA42 An experienced and appropriately trained manager ran the home. Residents were consulted about the day-to-day running of the home. Significant concerns were raised with regard to the safety and welfare of the staff and residents. EVIDENCE: The registered manager had completed her NVQ4 training in care and management, and was awaiting certification. The accountability within the home and with the registered person was discussed with the registered manager. Weekly discussions with the registered person usually took place. Managers meetings were held three monthly. A residents meeting took place on the day of the inspection. The inspector observed this meeting and noted that all residents were invited to contribute to discuss how the home was run on a day-to-day basis. Rosedale DS0000009612.V256249.R01.S.doc Version 5.0 Page 19 A residents and staff survey was conducted in September 2005. The results had not yet been collated. The inspector and registered manager discussed developing a survey for family/visitors to the home. The inspector advised that for the safety of the home, metal bins should be provided in communal areas where residents smoke. The fire register was seen the last test had been 6/12/05. The last fire drill was 21/11/05. There had been a health and safety inspection completed by Rossendale Council in May 2005 when no issues had been identified. Identified staff training regarding ensuring the health and safety of the staff and service users was discussed and is reported on in this report. The inspector noted that the hot water temperatures in the shower and bath were between 61 degrees and 71 degrees centigrade. The inspector advised that this issue must be resolved as a matter of urgency. Rosedale DS0000009612.V256249.R01.S.doc Version 5.0 Page 20 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. 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 2 X X 2 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 2 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 2 3 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Rosedale Score 3 2 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 1 X DS0000009612.V256249.R01.S.doc Version 5.0 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 YA2 Regulation 14 Requirement The registered person shall not provide accommodation to a service users at the home unless their needs have been assessed, and their has been appropriate consultation. All residents must have terms and conditions in respect of accommodation 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. Residents care plans must contain all information to ensure that all support needs are known. Make and promote proper arrangements for the health and welfare of residents. The registered person must provide appropriate telephone facilities. The registered person must provide training appropriate to the work they are to perform. The registered person must ensure at all times suitably qualified competent and DS0000009612.V256249.R01.S.doc Timescale for action 31/03/05 2 YA5 5(1b) 31/03/05 3 YA7 17(1a) Schedule 3 31/03/05 4 5 6 7 YA19 YA24 YA32 YA33 12(1) 16(2) 18(1) 18 (1) 31/03/05 31/03/05 31/03/05 31/01/05 Rosedale Version 5.0 Page 22 8 YA35 12,17,18 &19 12(1) 9 YA42 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 perform. Make and promote proper arrangements for the health and welfare of residents. 31/03/05 31/03/05 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 Rosedale DS0000009612.V256249.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington 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 DS0000009612.V256249.R01.S.doc Version 5.0 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!