Inspection on 02/05/06 for Rosehill House

This inspection was carried out on 2nd May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Rosehill House 21/04/09

Rosehill House 28/04/08

Rosehill House 01/05/07

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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The Grove Waltham

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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 2nd May 2006 09:15 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 Rosehill House DS0000018266.V290906.R01.S.doc Version 5.1 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. Rosehill House DS0000018266.V290906.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Rosehill House Address Keresforth Road Dodworth Barnsley South Yorkshire S75 3EB 01226 243 921 01226 297 978 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) None Mr Azad Choudhry Mr Aurang Zeb Mrs Diane Kitchin Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Rosehill House DS0000018266.V290906.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 13th September 2005 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 weekly fee was £315 per week. Hairdressing, chiropody, toiletries and non-emergency taxi service were not included in the weekly fee and were charged separately. The manager supplied this information in the PreInspection Questionnaire dated April 2006. The home produces a Service User Guide and a Statement of Purpose. Copies of these are placed in residents’ bedrooms. Copies of these and a copy of the latest inspection report are available. The home also produces a newsletter. Rosehill House DS0000018266.V290906.R01.S.doc Version 5.1 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, contact with stakeholders in the community (i.e. health professionals, social workers and relatives) and a site visit. The site visit was from 9.15 am to 4.00 pm. The registered manager, Mrs. Diane Kitchin was present and provided assistance. The majority of the residents were seen during the site visit. Five residents were asked detailed questions about the home, and of these, three were tracked throughout the site visit. Two members of staff who were key workers for two of the tracked residents were interviewed. Six relatives were asked for their views during the site visit and a further 3 were contacted by telephone. Comment cards were sent to ten residents and of these four were completed and returned. Three social workers and a health professional were also contacted. A sample of records was examined and a partial inspection of the building was carried out. The inspector wishes to thank the manager, staff, residents, relatives and stakeholders for their assistance and co-operation. What the service does well: What has improved since the last inspection? Rosehill House DS0000018266.V290906.R01.S.doc Version 5.1 Page 6 A previous requirement to improve the décor and re-carpet a lounge had been done. Several visitors commented on how much better the lounge was and that it was much brighter. Since the last site visit, sluicing facilities had been provided for the hygienic cleaning of commodes. 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. Rosehill House DS0000018266.V290906.R01.S.doc Version 5.1 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 Rosehill House DS0000018266.V290906.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. The home does not provide intermediate care. Residents only move into the home after their needs have been assessed and been assured that the home meets their needs. EVIDENCE: The manager said that she visited prospective residents to assess their needs to ensure that the home could meet their needs. Copies of the assessments were seen on residents’ files. Residents said that they had trusted their families to choose the home for them and were satisfied with their choice. Relatives’ reasons for choosing the home were locality, size of the home, welcoming atmosphere and personal recommendation. Comments were “been here on respite and liked it”, “family live locally”, “came to look round”, “it’s comfortable”, “this home has the right atmosphere”. Rosehill House DS0000018266.V290906.R01.S.doc Version 5.1 Page 9 Relatives said that residents had contracts (terms and conditions) with the home and received information when fees were to be increased. Rosehill House DS0000018266.V290906.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service Residents’ health, personal and social care needs were set out in individual care plans and their changing needs were also reflected in their care plans. Residents’ health care needs were met. Medication procedures ensured that residents were protected. Residents’ privacy and dignity was, in the main, respected. Rosehill House DS0000018266.V290906.R01.S.doc Version 5.1 Page 11 EVIDENCE: Residents said that their care and health needs were met. Comments were “staff are helpful and make sure my hospital appointments are done”, “Staff look after us”. Visitors said that they were satisfied with the care provided to their relatives and that staff were helpful. Their comments were “They (staff) listen to what we say” and “They can’t do enough for her – brilliant”. Three care plans were checked and these provided details of individual care and recorded actions to meet care needs. There was also written evidence to show that care plans were reviewed regularly to meet residents’ changing needs. Mobility aids were provided for residents who needed them. The manager said that the community nurse visited twice per week and other health professionals were contacted when necessary. During the site visit a GP and the community nurse visited the home. Staff who dealt with medication had received training. The recording and storage of medication was checked on a sample basis. Records were up to date and tallied with the medication held. The medication trolley was clean and all medication was within date. Controlled medication was stored separately and the correct procedure for recording was being adhered to. The medication refrigerator was locked and refrigerator temperatures were recorded. Residents and relatives said that residents were treated with respect and dignity. Residents were called by their preferred name or title. A relative said that she had noted that residents were always neatly dressed and praised the staff for their extra care. In the main, residents were being treated with respect and dignity, but one member of staff was observed and heard to call out to a resident about the resident’s personal care needs whilst in a public area of the home. This was discussed with the member of staff and the manager at the time. Rosehill House DS0000018266.V290906.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15 Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service Residents’ lifestyle in the home, in the main, matched their expectations and preferences. They were encouraged to maintain contact with their family, friends and the local community as they wished and had choice and control over their lives. A good choice of menu was offered and special dietary needs were catered for. EVIDENCE: Residents were relaxed and said that they were satisfied with the home. The manager said that a member of staff arranged group activities but there were no group activities throughout the day of the site visit and a relative said, “there used to be painting and bingo but not over last few months”. Two residents said that church services were arranged in the home, which they enjoyed, and another resident said that gentle exercises classes had been held in the past. There was a constant stream of visitors throughout the day and members of staff chatted to residents and their relatives. Rosehill House DS0000018266.V290906.R01.S.doc Version 5.1 Page 13 Relatives said that staff were good at contacting them if they had any concerns about the residents. A relative said that “Yes, they let me know” Residents and visitors said that the food was good and comments indicated that special dietary needs were catered for “….. is on a semi liquid diet”. Staff knew residents’ likes and dislikes. The dining room was pleasant (but see Standard 19). The home’s three-week rolling programme of menus showed that residents had a choice at all meals. Rosehill House DS0000018266.V290906.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. 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 from evidence gathered before, during and after the visit to this service Residents and their relatives and friends were confident that their complaints would be taken seriously. Residents were protected from abuse. EVIDENCE: Residents and relatives were aware of who the manager was, and said that they would tell her or one of the senior members of staff if they had concerns or complaints. They all considered that any complaint would be dealt with properly. A relative commented, “The manager is always available to discuss any problems (not that there are any)”. The home had a complaints procedure and the manager said that residents had copies in their bedrooms. The manager was advised to update the information of the registering body i.e. amend “National Care Standards Commission” to “Commission for Social Care Inspection”. The manager said that an audio-cassette of the complaints procedure would be made available for anyone who was blind, although none of the current residents required this. The home’s complaint record showed what action had been taken to address complaints and concerns. The Commission had received no complaints or allegations of abuse. Staff had received adult protection training through Barnsley council. There were no allegations of abuse. Residents and relatives said that they liked the staff and the manager and all comments were positive. Rosehill House DS0000018266.V290906.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 26 Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. The home was clean, comfortable and generally well maintained. Service users were provided with an environment that was safe, accessible and homely and had the specialist equipment they required to maximise their independence. Rosehill House DS0000018266.V290906.R01.S.doc Version 5.1 Page 16 EVIDENCE: The home was welcoming and there were no offensive odours. Several relatives said that they had chosen this home because of these reasons. Residents said that they had pleasant bedrooms and some of these were seen during the site visit. They had been personalised to individual taste, were clean, well furnished and pleasantly decorated. Comments received included “Mothers room is always clean and tidy, bedding always fresh, clothes always washed. Public areas always clean and presentable”. Residents had the use of three lounges, one of which was noted at the previous site visit to be in need of redecoration and re-carpeting. This had been done and several relatives commented on the improvement. The dining room carpet was worn and stained. This was also noted at the previous site visit but had not been replaced. The manager said that new carpet had been purchased but was awaiting fitting. Mobility aids and equipment were provided to enable residents to maintain their independence. Since the last site visit, an obsolete shower room has been turned into a sluice for the hygienic cleaning of commodes. Rosehill House DS0000018266.V290906.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made from evidence gathered before, during and after the visit to this service. The numbers and skill mix of staff met residents’ needs. Staff were trained and competent to do their jobs. Residents were not supported and protected by the home’s recruitment practices, therefore residents were not in safe hands at all times. Rosehill House DS0000018266.V290906.R01.S.doc Version 5.1 Page 18 EVIDENCE: There was an outstanding requirement from August 2005 that staff files must contain a record of the employee’s full employment history and a recent photograph. The manager was able to describe her procedure for recruiting new staff, which demonstrated that she had the knowledge to do this. However, when two staff files were checked, they were disorganised and there was no evidence that either of the staff had undertaken a CRB disclosure. In addition to this, the Pre-inspection Questionnaire stated that each member of staff had undertaken Criminal Record Bureau disclosures, including the identified staff. The manager admitted that these had not been done and would ensure that they were done. The home’s application form did not request information on the history of employment therefore there was no system for highlighting gaps in employment. The manager said that a new application form was being introduced. One file had no references, photograph or identification documents and on the second file there was a statement by the applicant that required further enquiry by the manager, but there was no record of evidence that this had been discussed, therefore residents were not in safe hands at all times. All service users and relatives spoke positively about the staff’s attitude and care practices. Comments included “(Staff name) is a treasure”, “Staff look after me”, “Staff were superb”, and “Staff have never failed to act on requests and suggestion re my mother providing they are in her best interests” Staff said there were sufficient staff on each shift to meet residents’ needs. Staff training was ongoing. A training matrix was displayed which provided an easy reference guide to the training undertaken by staff. The variety of training included basic food hygiene, fire awareness, moving and handling, infection control, adult protection, emergency first aid, and National Vocation Qualifications. Just under half of the staff had NVQ level 2 or NVQ level 3 in care, and the manager said that six member of staff were currently undertaking NVQ level 2. Staff confirmed the training they had undertaken. Staff training ensured that they were competent to do their jobs. Rosehill House DS0000018266.V290906.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service. The home was run in the best interests of residents and managed by a person who was fit to be in charge of the home. Residents’ financial interests were safeguarded. Residents’ health, safety and welfare were not fully promoted. EVIDENCE: The manager said she had commenced the Registered Managers Award. All comments about the manager were positive e.g. “very helpful and cooperative”. Rosehill House DS0000018266.V290906.R01.S.doc Version 5.1 Page 20 The handyman carried out repairs and maintenance within the home but the records were incomplete, which gave the impression that some tasks were outstanding from the beginning of the year. The manager said that she carried out daily checks of the home but there were no records to verify this. The manager was advised to keep records of her environmental checks to highlight any problems and demonstrate her commitment to quality assurance. Residents and relatives said that they had not been asked for their opinions of the home and no residents’ or relatives’ meetings were held. The manager was advised to promote quality assurance. Mrs. P. Smith, the area manager, carried out the regulatory monthly visits to the home. Residents said that they could choose to look after their own personal allowances or have it looked after by the home. One of the three residents who were tracked, chose to look after their own personal allowance and signed for receipt. The other two residents who were tracked had their personal allowances looked after by the home. Cash was held separately for each resident and the amounts were checked against the records and were correct. Receipts for purchases were kept and all transactions were countersigned. Relatives said that if they brought money into the home for their parent, they were always given a receipt. Staff training, to promote safe working practices, was carried out on a rolling programme. See also Standard 30. Fire drills were held regularly. The manager was advised to formulate a fire drill matrix for ease of reference. This would ensure that all members of staff had participated in fire drills and were conversant with the procedure. The Fire Book was disorganised and it was difficult to determine whether all the fire safety checks had been carried out within the required time frames. The home is required by law to inform the Commission for Social Care Inspection of any death, serious illness, accident or incident that affects residents within the home. None had been received since November 2005. Clarification was given at the time of the site visit of what needs to be reported. The manager supplied the most recent service dates of systems and equipment within the home. Rosehill House DS0000018266.V290906.R01.S.doc Version 5.1 Page 21 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 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Rosehill House DS0000018266.V290906.R01.S.doc Version 5.1 Page 22 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 2 Standard OP10 OP12 Regulation 12 16 Timescale for action Residents must be treated with 02/05/06 respect and dignity at all times. Residents must be consulted 25/07/06 about their social interests and about a programme of activities and be provided with facilities for recreation. Staff files must contain a record 25/07/06 of the employee’s full employment history and a recent photograph. (Requirement outstanding since 4th August 2005) All staff must be deemed fit to 25/07/06 work at the home, by the provision of CRB enhanced disclosures, authenticated references, proof of identity and evidence that discrepancies have been discussed. The CSCI must be informed 02/05/06 without delay and on every occasion, of any death, serious injury, serious illness, outbreak of disease, theft, burglary, accident or any event in the care home which adversely affects the well being or safety of DS0000018266.V290906.R01.S.doc Version 5.1 Page 23 Requirement 3. OP29 19 4 OP29 19 5 OP38 37 Rosehill House 6 OP38 23 residents. Fire safety checks must be 25/07/06 carried out within the required time frames and records kept up to date. 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 3 4 5 Refer to Standard OP19 OP29 OP31 OP33 OP33 Good Practice Recommendations The dining room carpet should be replaced Staff files should be organised for ease of reference The registered manager should achieve the manager’s award. Formal monitoring of the environment should be introduced and an up to date record kept, ensuring effective quality assurance. The views of residents, their visitors and stakeholders in the community, should be sought to ensure that effective quality assurance and quality monitoring systems are in place 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. 6 OP38 Rosehill House DS0000018266.V290906.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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. 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