Inspection on 17/01/07 for Roseleigh Care Home

This inspection was carried out on 17th January 2007.

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

The inspector 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

Roseleigh Care Home 15/12/05

Roseleigh Care Home 20/06/05

Roseleigh Care Home 03/02/05

Roseleigh Care Home 26/07/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Roseleigh Care Home Lytton Street Middlesbrough TS4 2BZ Lead Inspector Ania Swann Key Unannounced Inspection 17th January 2007 10:00 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 Roseleigh Care Home DS0000056173.V326666.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. Roseleigh Care Home DS0000056173.V326666.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Roseleigh Care Home Address Lytton Street Middlesbrough TS4 2BZ 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) 01642 656122 01642 659700 roseleigh@mimosahealthcare.com Mimosa Healthcare (No 9) Ltd Mrs Susan Abdi Care Home 50 Category(ies) of Dementia (26), Old age, not falling within any registration, with number other category (24) of places Roseleigh Care Home DS0000056173.V326666.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To allow two named individuals under 65 years of age to reside at the home. 15th December 2005 Date of last inspection Brief Description of the Service: Roseleigh is a care home for older people and also for people suffering with dementia. The home can accommodate up to 50 residents. All rooms are single and have en-suite facilities with a WC and hand basin. There are two separate units in the home; the ground floor accommodates older people and the first floor accommodates people suffering with dementia. It is situated in an urban area and overlooks a greenbelt and play area for children. The garden is enclosed and has a paved area where people can sit outside. The home was purpose built and is owned by Mimosa Healthcare. At the time of inspection the fees range from £338 to £376 per week. Roseleigh Care Home DS0000056173.V326666.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection lasting a total of eight inspection hours. The inspector had discussions with five residents, four care staff and the manager. A range of records and documents were looked at including staff files, medication record sheets and residents care plans. Nine completed service user surveys and six relative comment cards were returned to the inspector. A tour of the premises formed part of the inspection, and the inspector found the staff very helpful and co-operative. What the service does well: What has improved since the last inspection? The home has been redecorated in some of the communal areas and several of the bedrooms. A downstairs room that was previously under used has been transformed into a games room. This gives the residents the opportunity to socialise and mix with other residents, and provides a good range of games such as dominoes, a pool table and darts. The staff told the inspector that there has been a noticeable change in the morale of the staff for the better since the new manager took over. They report that there is a good atmosphere among the staff, and that the staff are happy. Roseleigh Care Home DS0000056173.V326666.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Roseleigh Care Home DS0000056173.V326666.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 Roseleigh Care Home DS0000056173.V326666.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, 2, 3 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have the information needed to choose a home that will meet their needs. Residents or their representatives are given a contract with clear information. A full assessment of needs is done before going to live in the home, and residents and their families have the opportunity to visit the home before moving in. EVIDENCE: The statement of purpose was updated in November 2006 and is very detailed. There is a philosophy of care and residents charter, and the aims and objectives of the home are clearly set out. The ‘welcome pack’ or service user guide is written in a very clear and easy to understand way. Roseleigh Care Home DS0000056173.V326666.R01.S.doc Version 5.2 Page 9 The service user surveys returned to the inspector confirm that the residents receive a contract. There is also a copy of the contract evident in the residents file. Six sets of resident’s files were examined and confirmed that they have had a full assessment of needs done through Care Management arrangements prior to moving in, and an assessment by the home on admission. A group discussion with three of the residents highlighted the fact that all had visited the home before moving in and had the chance to look around. They all said they received an information pack and that they all had a clear understanding of what to expect when they moved in. Roseleigh Care Home DS0000056173.V326666.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 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each resident has a care plan in place but in some cases this only includes the basic information necessary to plan the individual’s care. The healthcare needs of the residents are met. The staff do not fully put into practice the homes medication policy and procedures and they must ensure that the residents are protected by good practice in administering and recording medication. Residents feel they are treated with respect and their privacy is maintained. Roseleigh Care Home DS0000056173.V326666.R01.S.doc Version 5.2 Page 11 EVIDENCE: The inspector looked at six sets of residents files and they all contained a care plan. The quality of these was very variable; some contained very limited individual information, and others were very good and specified particular needs or likes and dislikes. The care plans need to be developed to identify individual needs or issues such as changing behaviour and how this is to be managed. The risk assessments also need to be reviewed, as in some cases they are very general and not specific to the individual resident. The home provides organised keep fit sessions for the residents and one of the residents told the inspector she particularly “enjoys the keep fit”. The residents have access to dentists, opticians and other community services. The home has a medication policy that is detailed but it is not always put into practice. On the day of inspection the medication administration record sheets were examined. There were incidents where medication had not been signed for as given. There were discrepancies between what the records showed and what was evident in the medication packs. Where medication had been significantly increased by a health professional, there was no details recorded of who prescribed the increase and why. The manager must ensure that staff who administer medication are reminded of the correct procedures to follow and the importance of filling in the record sheets correctly. One resident told the inspector that “the staff always knock on the door and say who they are before coming in”, and the staff were observed treating the residents with consideration and respect. Roseleigh Care Home DS0000056173.V326666.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 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The social, cultural and recreational activities meet resident’s expectations. Family and friends are welcomed into the home and residents are actively encouraged to have visitors. Residents make positive choices how they spend their day. The home provides a varied balanced menu in pleasant surroundings. EVIDENCE: The service has an activities co-ordinator /care worker who divides her activity time between the residential and dementia unit. On the day of the inspection the residents in the dementia unit were observed to be playing cards and there was good interaction between the staff member and the residents. Music was playing in the background and some residents were singing along. There was a group of residents on the ground floor enjoying the facilities in the games room, taking part in a game of dominoes and playing pool. Roseleigh Care Home DS0000056173.V326666.R01.S.doc Version 5.2 Page 13 A wheel chair user commented that she appreciates being able to move around the room freely and use the equipment like anyone else. The inspector observed good relations between the residents, and two of the residents told the inspector that a really good friendship had developed through socialising in the games room. The manager told the inspector that family and friends are welcome in the home. “Staff always stop and have a chat” remarked a relative. Families often sit outside and enjoy the garden together. The hairdresser visits regularly and many of the residents use this service. The residents are encouraged to have their personal possessions in their rooms and where possible, they exercise choice about how they wish to live in the home. The downstairs dining room has been completely redecorated and overlooks the garden at the rear of the home. This provides the residents with very pleasant surroundings in which they can enjoy nicely presented and wholesome food. The residents told the inspector “ the meals are very good” and “you get a choice of two meals and if you don’t like them, you can ask for something else”. The menus were evident on the notice boards on both floors of the home. Roseleigh Care Home DS0000056173.V326666.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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents and their representatives have access to a robust, effective complaints procedure and are confident that any complaint would be dealt with appropriately. Residents are protected from abuse. EVIDENCE: There is a robust complaints procedure that outlines clearly the steps to take in making a complaint. Residents and their family members confirmed in the surveys and comment cards returned to the inspector, and in discussions on the day of inspection, that they knew how to make a complaint and who to go to. One relative confirmed that when they had made a complaint, it had been acted upon straight away. Discussion with some of the staff confirmed that they know how to report any concerns and how to make a complaint. They also showed that they know the process of referral if there is any suspicion that a resident is at risk of abuse. Roseleigh Care Home DS0000056173.V326666.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, 20, 21, 23, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Roseleigh provides homely and comfortable surroundings for its residents. The residents own bedrooms suit their needs and are comfortable. They can choose to have their own possessions around them. The home is well lit, clean and tidy. EVIDENCE: There is evidence that the home has had several areas redecorated in the last twelve months. It has a programme of improvements including a plan to replace the hallway and corridor carpet during the next year, as it is worn. Roseleigh Care Home DS0000056173.V326666.R01.S.doc Version 5.2 Page 16 The lounge downstairs has been redecorated including new carpet. There is a ‘quiet’ lounge on the first floor where residents can sit and read. The garden is well maintained and provides outdoor space that is accessible to those in wheelchairs. The bathrooms on the first floor are large and have plenty of room for wheelchair users. There is a toilet on the ground floor for disabled users. The resident’s bedrooms that the inspector saw had several personal items and furniture evident. The residents in the dementia unit had different means of identifying which was their bedroom, by pictures and handmade ‘name plates’. One of the staff commented that “the home is a nice place to work and a nice place to live. I think the residents do feel like it is their home”. On the day of inspection the home was observed to be clean and odour free. One of the residents told the inspector “the home is very well cared for, and I am very house proud!”. There are policies and procedures in place for control of infection. Roseleigh Care Home DS0000056173.V326666.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff are in sufficient numbers to meet the needs of the residents. The staff receive training, but the registered person must ensure that all staff have mandatory training, and where appropriate, staff receive specialist training in dementia care. Residents are protected by the home’s recruitment policy and practices. EVIDENCE: Many of the staff at Roseleigh have worked in the home for some time, and there is not a high turnover of staff. Discussions with some of the staff showed that the staff themselves feel there are enough staff to met the needs of the residents. One member of staff is on the rota to start at seven ‘o’ clock in the morning to assist upstairs at one of the busiest times of the day. One resident told the inspector “the staff are good – they help you in whatever way they can”. Roseleigh Care Home DS0000056173.V326666.R01.S.doc Version 5.2 Page 18 The manager delegates the responsibility of co-ordinating training for the staff to one of the team leaders. The home’s training matrix shows the staff have yearly mandatory training in moving and handling and fire safety awareness. There is no evidence to show that all staff have had the necessary training, and the registered manager should ensure that this mandatory training does take place and reflected in the home’s training records. The inspector had discussions with some of the staff who work in the dementia unit. They showed a degree of understanding of the condition and that there are different behaviours; “what you do for one person isn’t the same as what you do for another”. The staff also acknowledged that it can be quite demanding caring for these particular residents who have challenging behaviours. Staff told the inspector that they have “been shown a few videos but it would be good to have some more training. The registered manager should, where it is appropriate, arrange for all the staff that work in the dementia unit to have specific training in dementia care. This would equip the staff with the knowledge and skills to meet the changing needs of these residents. Four staff files were examined and showed that the necessary pre-employment checks are carried out including checks of the Protection of Vulnerable Adults register and Criminal Records Bureau. There is photographic identification of the staff member in the file and confirmation that an identification badge has been issued at the start of their employment. The inspector also saw evidence that the staff have had a full induction programme when they started work at the home. Roseleigh Care Home DS0000056173.V326666.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home is based on openness and respect, and there are effective quality assurance systems in place. The resident’s financial interests are protected. Staff are appropriately supervised, and induction and supervision arrangements are put into practice. The safety and welfare of the home’s most vulnerable residents has been compromised, and the registered persons must ensure that the safety and security of the home’s most vulnerable residents is safeguarded. Roseleigh Care Home DS0000056173.V326666.R01.S.doc Version 5.2 Page 20 EVIDENCE: The current manager worked as a senior carer and deputy manager in Roseleigh before taking on the position of manager, and has a good working knowledge of the residents and the staff. In discussions with staff, they comment that the managers’ good background knowledge of the home is beneficial to the smooth running of the place. It is evident from talking to the manager that she is working at improving services for the residents. The staff state that they have a “good working relationship with the manager – she is very approachable and can always go to her. She is always available”. “The last year there has been a good atmosphere – the girls are happy, and happy with the manager”. “The morale is better now – everyone gets on better. She does a lot for the residents, organising trips out, parties, karaoke for the residents”. There are residents meetings every month; the most recent minutes evidenced were dated 20th November 2006. The home also gives out residents and visitors satisfaction surveys. There was evidence of a large number of responses; “warm and friendly home”, “staff always helpful and welcoming”. Staff confirmed to the inspector that they have supervisions every two months, and an annual appraisal. There are regular Team Leader and staff meetings, and the staff stated that they know they can ring any of the team leaders or the manager if they have any queries. One of the staff told the inspector she feels “well supported by the manager”, and that the manager “will act on issues highlighted in the staff meetings”. The inspector looked at four residents personal allowances. All of the personal allowance record examined were dated and signed with the correct balances. Receipts were also evident and there was evidence that the records are audited by the manager every two months. Roseleigh Care Home DS0000056173.V326666.R01.S.doc Version 5.2 Page 21 The home has an ‘open door’ during the day – the inspector walked straight into the home without anyone challenging their identity. During the tour of the premises on the first floor, a resident was observed wandering into the lift and was fortunately prevented from going downstairs by some visitors to the home. There was no keypad lock at the lift entrance to prevent any of the residents in the dementia unit getting into the lift and potentially out of the home. There was no keypad lock on the main front door to further prevent the most vulnerable residents getting out of the home. The lack of security on the main door also had the potential for undetected access into the home by intruders. The safety and security of the most vulnerable residents was compromised and the registered persons must ensure that measures are taken to make sure all the residents in the home are safe and protected from harm. The manager acknowledged the potential risks, and agreed that risk assessments must be completed for the residents, identifying those that require increased supervision until the essential work to fit the keypad locks is completed. Roseleigh Care Home DS0000056173.V326666.R01.S.doc Version 5.2 Page 22 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 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 x 3 3 x 2 Roseleigh Care Home DS0000056173.V326666.R01.S.doc Version 5.2 Page 23 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 15 Requirement Timescale for action 30/04/07 2. OP9 13 (2) 3. OP30 OP38 18, 23 (4(d)) 4. OP38 13 (4) The registered manager should ensure that the residents care plans are developed further, to include more specific detail that is relevant to the individuals needs. The registered manager must 20/01/07 ensure that the medication administration records are completed correctly and that staff who administer medication are aware of the potential risks of their actions if they do not comply to the medication procedures. The registered manager should 30/04/07 ensure that all staff are trained in the mandatory areas of fire safety awareness and manual handling, and that this training is updated. Where appropriate, the manager should ensure that staff who care for the residents with dementia, have the specific training in dementia care. The registered persons must 31/01/07 ensure that the safety and security of the home’s most vulnerable residents is DS0000056173.V326666.R01.S.doc Version 5.2 Roseleigh Care Home Page 24 safeguarded. There must be arrangements made to secure the main door and also the entrance to the lift on the first floor. While the work is being completed the registered persons must make sure that risk assessments are done for the residents, and a strategy is in place to safeguard the residents and give reassurance to the Commission that the safety of the residents is maintained. 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 OP19 Good Practice Recommendations The carpet in the hallway and corridors is worn and should be replaced as planned. The manager should make sure that this does happen. Roseleigh Care Home DS0000056173.V326666.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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. 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