Inspection on 01/05/07 for Rosehill House

This inspection was carried out on 1st May 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Rosehill House 21/04/09

Rosehill House 28/04/08

Rosehill House 02/05/06

Rosehill House 13/09/05

Rosehill House 09/06/05

Rosehill House 24/02/05

Rosehill House 02/06/04

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Larchfield Manor

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Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Rosehill House Keresforth Road Dodworth Barnsley South Yorkshire S75 3EB Lead Inspector Christine Rolt Key Unannounced Inspection 1st May 2007 11.30 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 DS0000018266.V331701.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. DS0000018266.V331701.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosehill House Address Keresforth Road Dodworth Barnsley South Yorkshire S75 3EB 01226 243 921 01226 297 978 NONE NONE Mr Azad Choudhry Mr Aurang Zeb Post Vacant Care Home 27 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) Category(ies) of Old age, not falling within any other category registration, with number (27) of places DS0000018266.V331701.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd May 2006 Brief Description of the Service: Rosehill House is situated on the outskirts of Dodworth Village. It is approximately three mile from Barnsley town centre and ten minutes drive from the M1 motorway. The home is a detached property within its own grounds, providing personal care for 27 elderly people. There is car parking space to the front, side and rear of the property. To the front of the property is a large patio/terrace with garden furniture. Ramps are provided to the main entrance at the side of the building and to the patio. Access to the patio can also be gained via the patio doors from the lounges. The accommodation is on two floors. A passenger lift is provided. The Service User Guide, the Statement of Purpose and the home’s last inspection report were displayed in the main entrance. The weekly fee was £327.50 per week. Hairdressing, chiropody, toiletries, newspapers and non-emergency taxi service were not included in the weekly fee and were charged separately. The manager supplied this information in the completed Pre-Inspection Questionnaire received March 2007. DS0000018266.V331701.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection and comprised information already received from or about the home and a site visit. The site visit was from 11.30 am to 5.30 pm on 1st May and from 9.30 am to 2.15 on 2nd May 2007. The acting manager provided assistance throughout the two days. The area manager visited on the first day and arrived for feedback on the second day. The majority of residents were seen and chatted with during the site visit. Three residents were tracked throughout the two days. Four members of staff and a relative were interviewed. Surveys and questionnaires were sent to 5 residents (2 returned), 5 staff (2 returned), 10 relatives (2 returned) and 5 health professionals (0 returned). Care practices were observed, a sample of records was examined and a partial inspection of the building was carried out. The inspector wishes to thank the residents, relatives, acting manager, area manager and staff for their assistance and co-operation. What the service does well: What has improved since the last inspection? DS0000018266.V331701.R01.S.doc Version 5.2 Page 6 The recruitment procedures ensured that all staff working in the home had undertaken the relevant identification checks and that the residents were in safe hands at all times. The CSCI was now receiving notification of incidents as required by regulation. Weekly fire safety checks were now being carried out 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. The summary of this inspection report can be made available in other formats on request. DS0000018266.V331701.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000018266.V331701.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents had sufficient information to make an informed choice and were assured that their identified needs could be met. EVIDENCE: This home does not provide intermediate care. Residents and relatives considered that they had received sufficient information about the home. The Service User Guide, the Statement of Purpose and the home’s last inspection report were displayed in the main entrance. The acting manager said that all residents had been issued with copies of the service user guide and these were in their bedrooms. The acting manager said that when prospective residents and their relatives visited the home they were given a tour of the building, they were given DS0000018266.V331701.R01.S.doc Version 5.2 Page 9 information about the home and questions were answered. A relative confirmed this and said that a pack of information was received prior to her relative’s admission to the home and her questions were answered. Assessments were carried out and letters were sent to confirm that the home could meet residents’ needs. These documents were seen on residents’ files during the site visit. DS0000018266.V331701.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents were treated with respect but their care needs were not fully reflected in their care plans and the medication procedure needs to improve to ensure that residents are protected. EVIDENCE: Residents and relatives considered that residents received the support and care they needed. One relative commented “Yes, all taken care of”. The acting manager supplied information in the Pre-Inspection Questionnaire of the health professionals involved in the home. The files for three residents were checked. These contained residents care plans and a range of risk assessments. Some moving and handling risk assessments contained conflicting information. Daily care records provided some information of physical needs being met but did not provide detail e.g. “turned regularly” without specifying what this meant. Health care information DS0000018266.V331701.R01.S.doc Version 5.2 Page 11 was recorded and this information cross-referenced to visits by health professionals. Some files contained activity information sheets but the information was sporadic and there was no consistent information of what each resident did each day. Residents were weighed monthly and records kept. Files contained information of residents’ personal possessions but there was insufficient information to enable identification. Accident forms were completed for residents who had had accidents or falls and 72 hour monitoring was implemented, which is good practice. However, these monitoring sheets were not being completed properly. The acting manager kept her own records of accidents to determine the frequency and patterns of accidents. Care plans were reviewed monthly but there were statements that care needs remained the same even where there was evidence that a resident’s needs had changed. There was no information to determine that the resident or their representative had been consulted about reviews. The care staff knew the residents and assisted them with their daily needs but they had very little input in the care plans. The acting manager was aware of this and said that she planned to encourage and enable carers to have greater involvement in residents care plans. The medication room was clean with a sink available. The medication trolley was clean and medication was securely stored. Medication was checked on a sample basis. The medication had not been booked in properly and several discrepancies with the medication were also found. An Immediate Requirement was issued for a full audit of all medication to be taken within 24 hours. The manager said that she would also be assessing staff competence for dealing with medication. Staff were observed to treat residents with respect. Residents and relatives said that residents were treated with respect and dignity and that staff listened and acted on what they said. DS0000018266.V331701.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The lifestyle within the home did not fully meet residents’ social interests and needs. The meals were good but residents weren’t always made aware of the choice of meals available. EVIDENCE: Residents said that they liked the home and were happy and could choose how to spend their days, but activities were not always available. Relatives comments were mixed “Not enough daytime stimulation for service users”, and “I think more can be done during the day to stimulate residents minds. I would like to see day trips introduced or members of staff walking residents around outside the building” but another relative said that her mother couldn’t join in activities but enjoyed “church service, concert, singers who come in, and staff talk to her”. The notice board provided information of the programme of activities and church services within the home and the acting manager said that she also encouraged staff to take residents out for walks in the local area. However the information of activities on residents’ files was sporadic and there DS0000018266.V331701.R01.S.doc Version 5.2 Page 13 was no information of residents’ daily routines. See also section on Health and Personal Care. Relatives said that they were helped to keep in touch, were informed of issues affecting the residents and were always made welcome in the home. Residents said that the food was good and a copy of the menu supplied prior to the site visit stated that choices were available at all meals. A relative commented that her relative thought the food was “Lovely – enjoys food”. Food preferences were listed on resident files and the acting manager said that the cook and the staff knew residents’ dislikes. Within the dining room a menu board was available but during the two days of the site visit this was blank therefore residents did not know what meals were available unless they asked. DS0000018266.V331701.R01.S.doc Version 5.2 Page 14 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents were protected from abuse and both they and their relatives were confident that their complaints would be dealt with to their satisfaction. EVIDENCE: Seven of the staff had undertaken adult protection training and future training was planned for the rest of the staff. In the meantime these staff had watched a video on this subject. The home had a complaints procedure. The complaints book was checked and this showed the action taken. Residents and relatives said that they knew how to complain and relatives said that they were confident that any complaint would be taken seriously and dealt with appropriately. The Commission for Social Care Inspection had received no complaints or allegations of abuse relating to this home. DS0000018266.V331701.R01.S.doc Version 5.2 Page 15 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 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well-maintained environment that is clean, pleasant and hygienic. EVIDENCE: The home was clean, well decorated and tidy. There were no offensive odours. A relative commented that the homeliness of Rosehill had helped her decide that this was the home for her relative. Aids and adaptations were available throughout the home. Bedrooms were personalised to residents’ preferences. No health and safety issues were noted. DS0000018266.V331701.R01.S.doc Version 5.2 Page 16 The acting manager and area manager were aware of two issues that were noted during the site visit i.e. poor water pressure in one part of the home and a damaged vanity unit, and provided information of the actions that had been taken to address these issues. An extractor fan that was not working was reported immediately. DS0000018266.V331701.R01.S.doc Version 5.2 Page 17 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home’s recruitment procedure, staffing levels and ongoing training ensure that residents are in safe hands at all times. EVIDENCE: Staff considered that the staffing levels within the home were sufficient to meet residents’ needs. Three staff files were checked to determine whether the recruitment criteria were in place. All three files contained the relevant information that ensured that residents were in safe hands at all times. Five staff had attained NVQ Level 2 or above (33 ) which was below 50 minimum. To address this shortfall another five staff were currently undertaking this training and when this qualification was attained, this would bring the level to 66 . Some staff had recently undertaken training in palliative care to enhance their skills. DS0000018266.V331701.R01.S.doc Version 5.2 Page 18 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, 33, 35 and 38 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home promotes the health, safety and welfare of residents and staff but quality monitoring systems could improve to ensure it is run in the best interests of service users. The acting manager has not applied for registration with the CSCI. EVIDENCE: Since the last inspection the registered manager had left and an acting manager had commenced employment. She had a nursing background and had commenced the Registered Managers Award. The need for her to apply for DS0000018266.V331701.R01.S.doc Version 5.2 Page 19 registration with the Commission for Social Care Inspection was discussed during the site visit. The home had a quality assurance monitoring system but this needed expanding to ensure that the home was run in the best interests of the residents e.g. questionnaires, meetings, environmental checks. The owner’s representative carried out the monthly regulatory visits to the home. She produced informative reports with details of actions to be taken. Residents’ personal allowances were stored safely. The acting manager dealt with all monies and obtained a second signature for transactions. Cash was held separately for each resident, the amounts checked tallied with the records and receipts were kept. The area manager carried out regular audits. Staff undertook mandatory health and safety training and the acting manager was able to supply the names of staff who had recently undertaken training and those nominated for future training. Eight staff had First Aid Certificates. For ease of reference, a staff training matrix was used to determine staff training needs. Fire drills were held regularly and fire equipment was checked weekly. Information was supplied in the Pre-inspection Questionnaire of the servicing and maintenance dates of systems and equipment within the home. DS0000018266.V331701.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 DS0000018266.V331701.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 12 Requirement Daily records must included details of residents’ daily routines to ensure that their health and welfare needs are met (i.e. Physical, health, social and emotional) Care plans, risk assessments and other relevant information must be taken into account when reviewing residents care. Residents or their representatives must be consulted about reviews Inventories of residents’ personal property must be recorded in sufficient detail to enable identification. Information and records on the monitoring of residents health needs via risk assessments and monitoring of accidents must be more detailed to ensure that residents are not put at risk. A full audit of all medication (to ensure recording, handling, safekeeping and safe administration of medication) must be undertaken. Immediate requirement issued. DS0000018266.V331701.R01.S.doc Timescale for action 01/07/07 2 OP7 15 01/07/07 3. OP7 17 01/07/07 3. OP8 13 01/07/07 4. OP9 13 03/05/07 Version 5.2 Page 22 5 OP12 16 6. 7 8 OP15 OP31 OP33 12 8 24 Arrangements must be made for residents to engage in activities to stimulate and motivate and daily records kept. . Records must be kept of residents’ daily routines and activities. Residents must be made aware of the meals on offer to enable them to make a positive choice. Application must be made to the CSCI for the registration of the manager. The home’s quality assurance system must be expanded to ensure that the home is run in the best interests of residents 01/07/07 01/07/07 01/07/07 01/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP38 Good Practice Recommendations Staff who deal with residents’ daily care needs should have more involvement in their care planning The introduction of a Fire Drill Matrix would provide a visual reference of staff who had not participated in a fire drill and who needed to be included in forthcoming fire drills. DS0000018266.V331701.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 DS0000018266.V331701.R01.S.doc Version 5.2 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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