Inspection on 23/08/05 for Rosemary Lodge

This inspection was carried out on 23rd August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Rosemary Lodge 10/12/08

Rosemary Lodge 12/02/07

Rosemary Lodge 21/02/06

Rosemary Lodge 25/10/04

Rosemary Lodge 05/05/04

Rosemary Lodge 27/11/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Rosemary Lodge 191 Walsall Road Lichfield Staffordshire WS13 8AQ Lead Inspector Robert Hewston Unannounced 23 August 2005 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Rosemary Lodge E51-E09 Rosemary Lodge UI (OP) s4996 v.246047 23.08.05 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Rosemary Lodge Address 191 Walsall Road Lichfield Staffordshire WS13 8AQ 01543 415223 01543 415012 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Abivue Limited T/A Rosemary Lodge Residential Home Susan Nelhams CRH 24 Category(ies) of (OP) Old age (31) registration, with number PD(E) Physical Disability - over 65 (1) of places Rosemary Lodge E51-E09 Rosemary Lodge UI (OP) s4996 v.246047 23.08.05 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 25 October 2004 Brief Description of the Service: Rosmary Lodge is an older peoples home which provides care for people with a physical disablity and over sixty five years in age. The home is operated by Abivue Limited and can accommodate up to 24 people with varying dependency needs. Located in Lichfield, the home is a two-storey property providing all single bedrooms. There are four separate living areas, each having a lounge-dining room, with adjacent bedrooms, bathroom and toilets. First floor accommodation is accessed by a lift. Externally there is a car park and the rear garden offers an enclosed area for residents. The location of this home ensures that there is a wide range of community facilities nearby that can be readily accessed. Rosemary Lodge E51-E09 Rosemary Lodge UI (OP) s4996 v.246047 23.08.05 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on a Tuesday from 2.30pm to 8.30pm. During the inspection a number of service users were spoken with. Four staff were also spoken to about training and care practice within the home. The registered manager was present throughout the inspection. What the service does well: The home continues to maintain an attractive/homeley environment for service users. The feedback from service users and relatives was very positive about the support service users receive from staff. Visitors say that they can visit when they want and that they are made to feel welcome. They also said that staff always keep them informed about any changes or developments in their relative’s care needs. The views from service users and relatives about the food within the home were also positive. The decoration in the lounge and dining areas provide service users with a homely environment. The health and medication needs of service users are also well met in this home. The complaints procedure was satisfactory however their were specific matters as to how this needed to be improved to reflect use by service users. Rosemary Lodge E51-E09 Rosemary Lodge UI (OP) s4996 v.246047 23.08.05 stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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. Rosemary Lodge E51-E09 Rosemary Lodge UI (OP) s4996 v.246047 23.08.05 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Rosemary Lodge E51-E09 Rosemary Lodge UI (OP) s4996 v.246047 23.08.05 stage 4.doc Version 1.40 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 standard(s) 3 The home has not established clear assessments of service user’s individual needs. Risk assessments were not specific in details in service users needs prior to admission. EVIDENCE: A sample of three service user’s care files were inspected. Appropriate and comprehensive care management assessments were not in place. Care needs and potential risks were outlined although not specific in individual’s requirements and identified care planning. The proprietor stated that she had recently implemented a new care plan package that ensures that Rosemary Lodge House can meet prospective service user’s care needs. It will be a requirement of this report that all service uses care plans and risk assessments are reviewed and replaced with the proposed new care package. Rosemary Lodge E51-E09 Rosemary Lodge UI (OP) s4996 v.246047 23.08.05 stage 4.doc Version 1.40 Page 9 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 standard(s) 7,8,9 Care plans do not fully of reflect how staff are meeting service users needs on a daily basis. The systems for the health monitoring and the administration of medication are generally good with clear and comprehensive arrangements being in place to ensure service users health and medication needs are met. EVIDENCE: The three care files checked contained care plans however, the plans did not consistency set out in detail the action which needs to be taken by staff to ensure that all aspects of the health, personal and social care needs of the service users are met. There was evidence that care plans are reviewed but this process generally involved no changes to the existing care plan. In discussions with staff all care staff spoken with demonstrated an understanding of the importance of care planning but some felt the process of reviewing was repetitious and that the plans were not always clear and easy to read. Health needs were recorded within service user’s files. Information about the outcome of health appointments was recorded in a separate file. There was Rosemary Lodge E51-E09 Rosemary Lodge UI (OP) s4996 v.246047 23.08.05 stage 4.doc Version 1.40 Page 10 documented evidence that regular contact with health professionals takes place as and when needed. Medication is stored appropriately in a locked cabinet in a locked room. The manager stated that all senior staff who administer medication have completed or were in the final stages of completing medication training. A good medication administration system is in place with appropriate safeguards and policies. A random sample of medication administration records (MAR) sheets and medication were inspected and found to be in order. Appropriate systems are in place for receiving medication from the pharmacist and there was also evidence that a pharmacist visits the home on a quarterly basis. The manager demonstrated a good and thoughtful value base regarding the use and potential misuse of medication with evidence that she advocates strongly on behalf of service users when there are outstanding or concerning issues regarding medication. Rosemary Lodge E51-E09 Rosemary Lodge UI (OP) s4996 v.246047 23.08.05 stage 4.doc Version 1.40 Page 11 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 standard(s) 15 The meals in this home are good offering both choice and variety and catering for special dietary needs EVIDENCE: Three service users were spoken to about the food within the home all confirmed that they enjoyed the food and that there was always enough. The menus indicate that in general toast and cereals are offered for breakfast apart from Sunday where there is also a cooked alternative. Hot meals and a dessert are offered at lunchtime with a mixture of salads, sandwiches or an alternative light meal for tea. A member of the care staff stated that although there was a set meal service users who did not want or did not eat what was offered would be offered an alternative. The cook demonstrated a good understanding of special diets and health and safety arrangements within the kitchen. The main food supplies for the home are stored within the kitchen the cook confirmed that beverages, fruit, biscuits and yoghurts are available at all times for service users. Rosemary Lodge E51-E09 Rosemary Lodge UI (OP) s4996 v.246047 23.08.05 stage 4.doc Version 1.40 Page 12 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 standard(s) 16 The home has a satisfactory complaints system but further work is needed to ensure that service users feel that their views are listened to and acted upon. EVIDENCE: An examination of the complaints system showed it to be satisfactory. Speaking to some service users they were unaware of the complaints procedure and would not know who to speak to about their concerns. One service user had brought to the attention of the staff team a complaint of being roughly handled. There are no records of the complaint being registered within the complaint log or the management being made aware of the complaint. The proprietor confirmed that she would investigate and review the service users concern. The manager must review, in a way that is appropriate for the needs of the service users at Rosemary Lodge, the complaints procedure to ensure that service users are able to voice their concerns. Rosemary Lodge E51-E09 Rosemary Lodge UI (OP) s4996 v.246047 23.08.05 stage 4.doc Version 1.40 Page 13 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 standard(s) 19 The location and layout of the home meets the criteria of the statement of purpose. EVIDENCE: Rosemary Lodge is a detached building located on the outskirts of Lichfield. The houses were appointed providing individual bedrooms for the service uses and ample living spaces. Externally there is a parking area, storage shed and mature gardens. The standard of repair, redecoration and refurbishments has remained at a high standard. There is evidence of continuing staff investment in the care and development of the physical environment. Discussion took place regarding an administrative area/desk situated in the dining area. The need for effective administration is appreciated. However this detracted from the homely appearance of the dining room. Rosemary Lodge E51-E09 Rosemary Lodge UI (OP) s4996 v.246047 23.08.05 stage 4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: Rosemary Lodge E51-E09 Rosemary Lodge UI (OP) s4996 v.246047 23.08.05 stage 4.doc Version 1.40 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: Rosemary Lodge E51-E09 Rosemary Lodge UI (OP) s4996 v.246047 23.08.05 stage 4.doc Version 1.40 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 x x x x x x x x x x Rosemary Lodge E51-E09 Rosemary Lodge UI (OP) s4996 v.246047 23.08.05 stage 4.doc Version 1.40 Page 17 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 ch33 Regulation 26 Requirement Timescale for action 01/12/05 2. 7 15(1) 3. 16 22(2) The registered provider must ensure a monitoring system based on seeking the views of service users, meeting the aims, objectives and statement of purpose To review the plans of care in to 01/12/05 ensure sufficient information is recorded for all aspects of care needs The manager must review the 01/12/05 complaints procedure within the home to ensure that it is understood by and accessible to the service users accommodated at Rosmary lodge 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 7 Good Practice Recommendations Staff should receive care planning training when the new care plan system is introduced. Rosemary Lodge E51-E09 Rosemary Lodge UI (OP) s4996 v.246047 23.08.05 stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Rosemary Lodge E51-E09 Rosemary Lodge UI (OP) s4996 v.246047 23.08.05 stage 4.doc Version 1.40 Page 19 - 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. 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