Inspection on 18/04/07 for Rosemary Retirement Home

This inspection was carried out on 18th April 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 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 Retirement Home 17/04/08

Rosemary Retirement Home 06/03/06

Rosemary Retirement Home 21/03/05

Rosemary Retirement Home 07/12/04

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 Retirement Home 65 Vicarage Road Wollaston Stourbridge West Midlands DY8 4NP Lead Inspector Mrs Jean Edwards Unannounced Inspection 18th April 2007 09:00 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 Rosemary Retirement Home DS0000024975.V333517.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. Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosemary Retirement Home Address 65 Vicarage Road Wollaston Stourbridge West Midlands DY8 4NP 01384 397298 01384 393506 rosemary@yescomputers.co.uk 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) Rosemary Limited Mrs Kathleen Oakley Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (15), Physical disability over 65 years of age (8) of places Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th September 2006 Brief Description of the Service: Rosemary Retirement Home is registered to provide residential care for up to 23 people over the age of 65, including 8 with a physical disability. The property is a large detached house located in Wollaston within a residential area close to shops and easily accessible by local public transport. Parking is provided at the front of the property with landscaped gardens at the rear. Ramps enable easy access for wheelchair users. Accommodation is provided over 3 levels. Access at the front is to the ground floor where there is a conservatory, dinning room, main lounge area, kitchen, laundry room, single toilet, and bathroom with single toilet, office, staff toilet and bedrooms. The lower ground floor is accessed via stair or open lift and forms part of the new extension. This comprises a small open lounge, shower room and toilet, and six bedrooms with en-suit facilities. The remaining bedrooms, bathroom with toilet and walk in bath and toilet are on the 1st floor accessed by stairs or vertical lift. The level of fees for this home is currently between £370.00 and £430.00 per week, including a range of individual third party top up fees. Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is an unannounced key inspection visit for 2007 - 8, undertaken by an inspector from the Commission for Social Care Inspection (CSCI), starting at 9:00 am and finishing at 7:30pm. All Key National Minimum Standards have been assessed at this visit. The range of inspection methods to obtain evidence and make judgements includes: discussions with the proprietor / manager and staff on duty during the visit, examination of records and documents and discussions with residents, and relatives. Other information was gathered before this inspection visit from the pre inspection questionnaire submitted, notification of incidents, accidents and events. Twenty service user surveys and relatives surveys were sent to the home by the CSCI and an analysis of the 2 service user survey forms and 7 relatives survey forms returned is contained throughout this report. Comments have been generally positive, particularly about the environment and staff. There are currently 22 people living at the home. During the visit the inspector has spoken to the majority of residents. Longer discussions have taken place with the residents whose care was looked at in depth. Comments indicate that staff are friendly, helpful and welcoming. There has been a tour of the premises, including the grounds, communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and residents’ bedrooms, with their permission. What the service does well: Relatives, residents continue to express high levels of satisfaction with the service provided. There is easy to read information available about the home, which helps people to make decisions about where to live. In answer to the questions on the CSCI service user survey forms all responses indicate that they have received satisfactory information to help them make decisions and the majority state that they have a contract / terms and conditions of residency from the home. Comment are, After visiting a number of care homes I feel the right decision was made when choosing Rosemary Retirement Home, and the standard of care given is exemplary Residents are very complimentary about the care and support from the proprietor, manager and staff. The majority of people feel they always receive prompt attention at the time they need it and comments support this view, This is an excellent home where all the staff show kindness and consideration to all residents. Respect is at all times uppermost in the carers attitude, and both my sister and I are extremely satisfied with the care given to our mother. Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 6 Visitors are warmly welcomed to the home and are offered refreshments, support and appropriate information, for example a relative states, we can visit at any time, and are made to feel welcome. The home provides wholesome, nutritious meals and residents are very complimentary, commenting that they really enjoy the meals and especially the afternoon snacks. The warm, home cooked sausage rolls served on the afternoon of the inspection visit are very tasty. Hot and cold drinks are available throughout the day and carers know how each person prefers their drinks, such as weak tea with plenty of milk. There is a proactive approach towards any concerns or complaints, and efforts are made to listen and improve the service. Comments from the CSCI surveys states, the home soon sort things out, if not right and have never had cause to complain but know any problem would be dealt with. The Proprietor and manager are proud of the homely environment at Rosemary Retirement Home and they actively introduce improvements. The laundry has been renovated, there are new floor coverings and carpets in a number of areas, and rear gardens have landscaped since the last inspection. Rosemary Retirement Home is warm, clean and homely. A comment from the CSCI survey is, The home is spotlessly clean in all areas and always smells nice. Residents are encouraged to personalise their own rooms and the registered manager has asked the family of a new resident to bring more personal possessions to make the bedroom more homely to help her to settle in. The family are also going to bring an organ into the home, which she enjoys playing. This inspection was conducted with full co-operation of the Registered Proprietors, Registered Manager, Administrator, staff and residents. The atmosphere through out the inspection was relaxed and friendly. The Inspectors would like to thank the proprietors, manager, staff, and residents for their hospitality during this inspection visit. What has improved since the last inspection? The registered proprietor and manager have updated and improved the homes statement of purpose and service user guide. The useful information about the home is made available to residents, relatives and other visitors. Residents are given a comprehensive contract with terms and conditions of residence, including details of fees, rights and responsibilities. The way the home plans each persons care is improving with the introduction of new assessment processes, care plan and risk assessment formats. There is also improved use of health screening so that residents needs are identified at Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 7 an early stage and all care needs are met. The records to show that residents have access to dental care, opticians, chiropodists and other services have improved. Each persons dietary needs are looked at and their weight is monitored, with advice requested from GPs and dieticians as needed. All residents who wish to exercise their democratic right to vote have received their voting papers and will be assisted to vote in the May 2007 local elections. There are improvements to individual staff training records showing that they are receiving training to improve their skills and knowledge in areas such as infection control measures, food safety and protecting vulnerable people. The home continues to improve the level of activities on offer for residents, with outings advertised on a notice board in the reception area. Comments from the CSCI service users surveys states, there are craft class on Wednesday mornings and keep fit on Thursday mornings. There are also examples around the home of handicrafts made at the home, such as glazed decorated plant pots, innovated note pads and decorative soap in holders. The registered manager must improve recruitment processes and staff personnel records as a priority, making sure no staff are employed at the home until essential clearances from the Protection of Vulnerable Adults (POVA) Register and Criminal Records Bureau (CRB) are obtained. There are a number of areas of record keeping and compliance with health and safety, which have improved, however there are a small areas still to be improved, which have been identified at this visit. What they could do better: The new care plans need further development and fuller health care screening and assessments must be put in place to make sure that all residents needs are well met. The homes system for the management and administration of residents medication needs improvement in a number of areas so that it is a safe as possible. Examples are that staff receive more comprehensive training from an accredited trainer, that medication storage and records are reviewed and improved in accordance with advice. As highlighted at the previous inspection in November 2006 the improvements to provide more activities and outings must be built on and all residents must be asked about their preferred individual activities. The information collected must then be used to devise, advertise and offer a regular programme of a variety of group and individual activities, with each persons participation or refusal noted. There are comments such as could provide more activity I suppose but only if the residents want to do the activity and that they have a choice if they want to do it or not and implement more activities for residents. Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 8 Although the registered managers hours have been separated allocated and not counted as care hours staffing levels have not been increased and care staff still do some cooking and laundry, especially on late shifts, which detracts from time to directly attend to residents care needs. The registered manager must submit staffing proposals, demonstrating compliance with Department of Health guidance, to the CSCI office, Halesowen for consideration. The responses to the CSCI surveys indicate that residents and relatives do not feel that there are always enough staff available to respond to residents needs. There are areas of staff recruitment, which need further improvement, such as fuller employment histories on application forms to make sure there are no unaccounted for gaps in employment. The registered persons must put in place a robust quality assurance system to measure and monitor the homes performance, using questionnaires and other means to seek the views of residents, relatives and other professionals in the wider community. There are a number of records and areas of health and safety, which must be improved to safeguard the residents. For example the registered manager must analyse accidents to identify any trends or unforeseen risks and to put additional controls in place to minimise risks where possible. 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. Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 9 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 Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 10 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): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an easy to read statement of purpose and service user guide and residents have a contract / terms and conditions of occupancy, which provides residents and their advocates with information about how care will be provided, their rights and entitlements, and any agreed restrictions. The home uses comprehensive assessment tools, which means that residents’ needs are thoroughly assessed to ensure that care needs will be met. The home actively encourages introductory visits and there is evidence to demonstrate that people have been given the opportunity and time to make decisions, which are right for them. The home does not provide intermediate care; therefore standard 6 is not applicable. EVIDENCE: Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 11 The home has an up to date comprehensive statement of purpose and service user guide written in a friendly and welcoming style. These documents provide clear information about the home and plans are continuing to develop a web site. There are copies of the service user guide in each residents bedroom and copies are made available to residents, families, and other interested parties, including the CSCI. The majority of residents have been provided with a contract or statement of terms and conditions, which include clear details of fees and third party top up arrangements. As identified at the previous inspection visit in November 2006 the document currently in use needs to be reviewed to demonstrate compliance with guidance issued by the Office of Fair Trading. Evidence from examination of residents records and discussions confirm that pre-admission assessments are conducted professionally and sensitively and family or representative of the resident have been involved. The staff are aware of residents needs, and the home is now recording individual preferences such as rising, retiring, likes and dislikes, preferred gender of staff to give assistance with personal care, which reduces risks of reliance on verbal communication between staff. There is written confirmation from the registered manager to confirm the persons admission to the home. There is evidence that the home offers introductory visits, so that residents and families can feel sure the home is right for them. Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 12 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. The improved care planning and monitoring provides staff with the information they need to adequately meet residents needs. There is good multi disciplinary working taking place on a regular basis, which results in the health needs of residents being generally well met. The home is committed to make progress to improve the arrangements for administration of medication, which reduces potential risks to residents. Residents are treated with respect. EVIDENCE: Each resident has a care plan using a new and improved format. Assessment of the care plans two residents admitted recently and an existing resident with complex needs show evidence of the good practice of involving residents and their relatives in the development and review of the plans. However the plans do not contain signatures of residents or their representatives, which are needed to indicate their agreement. Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 13 The care plans generally include essential basic information necessary to meet the persons care and includes some, though not all risk assessment elements. Medication regimes need to be more fully recorded though plans now more accurately reflect each persons current situation. Where residents have been prescribed antibiotics for chest or urinary tract infections or have developed pressure sores there are short-term care plans in place. The format for recording comprehensive care for people with diabetes is in place, and fuller information relating to skin care, eye care, foot care and diet is more fully recorded for staff guidance and to ensure these areas are not overlooked. There are is a resident, who has been observed to show disturbed behaviour and there are no documented risk assessments or risk management strategies to guide staff as to how to deal with these situations. The manager has sought advice from the GP following the last inspection and discovered this person was diagnosed with Dementia in 1997 and this information had been lost in the notes and in the medical system. The manager has sought advice and input from the Alzheimers society. The staff have been observed to be very patient with this lady, who at times has been very distressed, she later sat in the lounge happily singing to herself. All residents have good access to health care services to meet their assessed needs both within the home and in the local community. Some residents are able to choose their own GP within the limits of geographical borders and there is evidence of access to dentists, opticians, chiropodists and other community services, and these are now well documented. Following discussions and advice at the last inspection visit in November 2006 all residents are offered regular dental checks, whether they have their own teeth or not, for screening and the early diagnosis of soft tissue problems. Since the last inspection visit the registered manager has made progress to introduce health care assessments and screening, such as use of nutritional tools and tissue viability and falls assessments, though these are at an early stage of implementation. The manager generally seeks professional advice on health care issues, acts upon it and is able to access the aids and equipment recommended. Observations and discussions show that pressure relieving equipment is in place or is under review with district nurse but this is not currently recorded. Similarly staff are able describe preventative measures for example a resident who is developing pressure sores is encouraged to have legs elevated, changes of position and support for mobility but these measures are not recorded as part of the persons plan and personal care records. The home has a basic medication policy which is accessible to staff. As identified at the last inspection visit the medication policy and procedures must be expanded to reflect all good practice guidance. Information was sent to the home following the last inspection visit and some guidance has been implemented. Medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded. There are Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 14 currently a small number of residents who wish to administer some part of their own medication, for example creams and sprays, and risk assessments are in place to monitor that this practice is conducted in safety. Where medication systems are in need of action the registered person is willing to work towards improvements. The areas still to be improved include accredited training for all care staff involved in the administration of medication and a more efficient use of senior staff time when administering medicines. The system continues to present risks where the carer takes the medication from a locked cupboard in its secure location to the residents on an unsecured open trolley. An approved medication trolley would be safer and save staff time and effort. A separate fridge has now been provided. The registered manager is urged to use the CSCI web site or contact the CSCI Pharmacist for further advice. From observations and discussions staff are aware of the need to treat residents with respect and they show consideration for personal dignity when delivering personal care. The manager and staff arrange for residents to enjoy the privacy of their own rooms as they wish. The residents say that are happy with the way that the staff care for them. A relative has commented, the staff show kindness and consideration to all residents. Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. There is some progress to make planned and spontaneous activities available on a regular basis, which would give residents improved opportunities to take advantage of and develop socially stimulating activities. The majority of residents are able to maintain good contact with family and friends. Dietary needs of residents are catered for with a balanced and varied selection of food that meets residents tastes and choices. EVIDENCE: Residents have the confidence to informally say what makes them happy and to make comment where improvements can be made. The proprietor, manager and staff take residents feedback seriously and make changes where possible. Evidence from the service user survey forms indicate that staff listen to residents and make considerable effort to provide a flexible service, which enables them to enjoy a better quality of life. As highlighted at the last inspection visit the manager and care workers need to formally consult residents to identify preferences regarding their interests Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 16 and hobbies and use the information to plan additional activities, which residents will enjoy. The home also needs to develop a system for displaying information and drawing attention to community events and activities in userfriendly formats. Although there are some organised activities, such as weekly craft and exercise sessions and musical entertainment brought into the home, there is a good understanding for the need to increase the level of activities and access to social stimulation. The staff show an understanding that some people prefer to spend their time on their own in their own bedrooms, with individual interests. A resident with visual impairment and very limited mobility has been offered access to talking books and services from the Blind Institute but has declined preferring to listen to the radio in his own room. A number of residents go out with their families; there are currently no outings organised by the home. The home does arrange access to the Ring & Ride service for any residents wishing to attend church. For example one resident attends services at the local Roman Catholic Church every Sunday and one Wednesday each month. There have been a number of visitors to the home during this inspection visit and it is evident from the banter and cheerful repartee that family and friends of the residents feel welcome and know they can visit the home at any time. People are very positively about the care and attention provided by the home, with the management and staff always friendly and ready to listen and help. The visiting policy and visitors book is located in the reception area. All visitors are greeted and requested to sign in and out of the home for safety and security reasons. Residents are able to have personal possessions in their room, but may be not always be able to bring large items of furniture due to space restrictions or health and safety considerations. As indicated at the previous inspection visit the registered manager must ensure that there are inventories of residents personal possessions, which are signed and dated by the member of staff and resident or their representative. Residents enjoy flexibility of meal arrangements and are able to eat in their own room if they wish, though residents are generally encouraged to socialise at mealtimes and there is a chatty atmosphere. It is notable that regular warm and cool drinks are offered and staff are always willing make drinks at any time and there are plentiful supplies of cool drinks, with easy access for residents to help themselves, around the communal areas of the home. The food in the home is good quality, well presented and generally meets the dietary needs of residents. The staff make sure residents have drinks and food according to their preferences, for example one person prefers very weak tea and there is a choice of brown and white bread. The registered manager has undertaken an audit of residents food preferences and plans to incorporate some of the suggested dishes when preparing the new menus. Some suggested options are, pigs feet, black pudding, tongue, Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 17 spam, spaghetti bolognaise and savoury rice as well as traditional roast dinners. The contact details of the community dietician have been given to the registered manager to seek advice from the community regarding the nutritional content of menus and especially the use of powdered milk only. The staff are trained to help those residents who need help when eating and they are sensitive in their approach. Fuller records of daily food intake are needed for residents assessed as being nutritionally at risk. Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 18 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, 17, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is evidence that any complaints and concerns are listened to and action is taken to look into them, and there are systems to record any investigations and outcomes. Arrangements for protecting residents are improved with the introduction of policies, procedures, guidance and staff training to provide better safeguards for residents from potential abuse. EVIDENCE: The home has complaints procedure displayed in various areas throughout the home. Information supplied as part of the pre-inspection questionnaire indicates that the home has not received any complaints since the last inspection in November 2006 and this has been confirmed during this inspection visit. From the results of the service users survey, all respondents indicated that they are aware of how to raise concerns and use the homes complaints procedure. The recommendation that the complaints procedure should be produced in alternative formats suitable for residents, such as large print, has not yet been acted upon. The registered manager states she has plans to introduce alternative formats for written information. Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 19 The new care planning formats have a section for recording each persons preferences for voting, and these have now been completed, which means that any resident wishing to exercise their democratic right to vote, is empowered to do so. There is evidence that all residents who wish to vote have received their postal voting papers for the May 2007 local elections. The home has not received any allegations relating to abuse of vulnerable residents. There is a copy of the multi-agency procedures for the protection of vulnerable adults, Safeguard and Protect at the home. The homes policies and procedures regarding protection of residents are generally satisfactory and the process of review and revision to be generally in line with regulations and other external guidance is taking place. The home is making progress to provide all staff with adult protection training from a recognised training organisation. Staff are generally able to explain how they would respond to any allegation of abuse and are aware of the need to contact outside agencies. Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 20 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, 21, 24, 25, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There continues to be significant and positive changes to the décor and furnishings. The incremental improvements contribute to creating a pleasing and pleasant environment for residents to live in. The grounds are maintained to provide a safe and pleasant outdoor environment for residents. EVIDENCE: Rosemary Retirement Home is homely and domestic in style and has a bright and cheerful interior. There are attractive gardens and garden furniture for the residents comfort and enjoyment. Parts of the rear garden have been landscaped to make the borders more interesting and a number of residents enjoyed their afternoon tea on the rear patio in the warm spring sunshine. The tour of the building identified that a number of improvements have been made and a programme of redecoration and refurbishment is in progress. Residents bedrooms are well maintained and individually decorated providing pleasant Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 21 personal living space, especially in the new wing. These bedrooms have en suite facilities and patio windows onto the pleasant landscaped and paved area of garden. The registered manager does not yet have a formal documented maintenance programme in place, which would provide additional assurance that there are plans to ensure high standards for the environment. The first floor bathroom, with the medic bath remains unused for bathing purposes and is still being used as storage, though most of the clutter has been removed. The registered proprietor has submitted a bid for funding from the Department of Health one off grant for improvements to the first floor bathing facilities for residents. There is a walk in shower room in the new wing on the ground floor, which is currently little used. The resident who made use of this facility has left the home. Residents say that they like living here and are comfortable. The home is clean, warm, well ventilated, and well lit. At the previous inspection visit it was noticed that there were a number of areas of exposed hot water pipe work, mainly in bathing and en-suite facilities. The registered manager has undertaken an audit of the home to identify all areas of exposed hot water pipe work accessible to residents, and work is in progress to make sure that they are guarded, boxed or covered appropriately. The kitchen area is generally well organised, clean and tidy and food safety has been improved. The cook is knowledgeable and has started to implement the recommended guidance from Dudley MBC Environmental Services, using documentation from the manual Safer Food, Safer Business. The refurbishment and extension of the laundry has been completed, with new more effective equipment. The registered manger must fully implement guidelines for effective infection control in the home, which must include documented cleaning schedules for the kitchen and laundry. Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 22 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 adequate. This judgement has been made using available evidence including a visit to this service. Staff morale and confidence is good. There are improvements to staffing levels to provide additional dedicated care staff during the day, reducing the risk that residents may not have all care, support and needs for stimulation met. There are improvements to staff recruitment processes, which reduces the potential for residents to be exposed to risks of harm. The registered manager now has more managerial sufficient time to develop staff training, support and development strategies. EVIDENCE: There are currently 22 residents accommodated, with a variety of dependency levels and diverse needs. Following discussions the registered manager has agreed to regular review residents dependencies and occupancy levels, and review staffing levels, making appropriate adjustments, with the use of a recognised staffing tool, such as the Department of Health Residential Forum staffing Tool. A staffing proposal must be forwarded to the CSCI for consideration. Currently the registered manager, Kathleen Oakley has been allocated the majority of her time for managerial hours, with a small number of hours dedicated to covering any care staff shortfalls, and Kevin Franklin continues to undertake the administration and business tasks. On the day of this inspection Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 23 visit the registered manager is extra to 4 care staff on duty from 08:00 till 13:30/14:00 hours and there are 3 carers from 14:00 until 22:00 hours. During the night there are 2 waking staff on duty. The cook works from 09:00 to 13:30 hours during the weekdays only, and domestic staff are employed to cover 7 days each week from 07:00 till 12:00 hours. The care staff continue to undertake catering and laundry duties during the afternoons, which depletes care hours available for residents. The structure of the staff team is: registered proprietors, registered manager and administrator, 18 care staff and 3 ancillary staff. There are no designated senior staff for supervisory tasks to be delegated to, though there are named designated persons in charge of the home, on a day-to-day basis when the manager is off duty. The registered manager has not yet been able to implement a formal staff supervision system. It is unlikely she will have sufficient time to personally implement one-to-one documented meeting with each of the 18 care staff for the minimum 6 times each year. Assessment of the pre-inspection questionnaire submitted, staff files and staffing rotas during the visit show that two staff have left the homes employ since the last inspection visit in November 2006. There is evidence that 9 care staff have an NVQ 2 care award, which means the home has the minimum ratio of 50 care staff trained to the required level. Five care staff are additionally registered as candidates to undertake the NVQ 2 award at Dudley College. Assessment of three staff personnel files at this visit indicate that recruitment procedures have improved and essential recruitment checks and clearances are in place, although there are still unexplained gaps in employment histories on application forms. Examples are that one person had not completed the homes application form with starting or leaving dates of previous employment, therefore this does not constitute a full employment history and any gaps would not be noticed. Another new employee has not completed a full employment history. The third new employee has attached a full comprehensive CV, which demonstrates good practice. The homes training needs analysis and training plan and individual staff training profiles are improved and show an improved commitment to staff training and development. The staff show that they are knowledgeable about residents needs and how to meet them. There is a warm rapport with both residents and visitors. There is a good team spirit and staff can demonstrate that they are aware of their responsibilities, what is expected from them. Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 24 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): 31,32,33,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager now has additional time and opportunity to develop effective leadership, direction, and ensure there is good communication. There are still not sufficient systems for resident consultation at Rosemary Retirement Home, though there is some evidence that indicates that efforts are made to ensure that residents’ views are informally sought and acted upon. The standard of record keeping and health and safety compliance has improved, and has reduced the potential for risks of harm for residents. EVIDENCE: Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 25 Kathleen Oakley is the registered manager at Rosemary Retirement Home. She has worked at the home for many years and she has now been allocated dedicated managerial hours to implement improvements to demonstrate compliance with the Care Homes. She is now able to devote the majority of her time monitoring care delivery and developing the care staff. She now has a relevant job description and takes overall managerial responsibility for the running of the home, with assistance from the homes administrator, Kevin Franklin. The registered manager is continuing her personal development, undertaking the Registered Managers Award (RMA), which see commenced on 4 August 2006, with Dudley College. She hopes to achieve the award within 12 months. The home has purchased a quality assurance system, Mulberry House policies and procedures and limited progress is being made with implementation. Discussion has taken place about the new requirement to submit a completed Annual Quality Assurance return to the CSCI upon request. The registered manager has agreed to forward collated results of questionnaires issued to obtain feedback from residents, visitors, and other stakeholders i.e. GPs and Social Workers, along with an annual development plan and minutes of recent staff meetings. One residents meeting has taken place since the last inspection visit in November 2006. There is insufficient evidence of regular residents meetings and the registered managers needs to devise and display a schedule of residents meetings, together with agendas and minutes of meetings to encourage participation. The registered manager has not yet implemented a structured formal staff supervision system, with a minimum of 6 recorded one-to-one meetings with each member of staff, each year. She states she plans to commence the system in the near future. It is advised that the home needs to consider senior care assistants as part of the staffing structure to make the supervision and development of staff workable. It is stated that the home is not responsible for residents finances and does not hold any monies on their behalf. Invoices are sent monthly for any purchases such as hairdressing or chiropody. The registered manager now obtains individual receipts from the hairdresser and independent chiropodist for each residents financial transaction in compliance with the Data Protection Act. There are some improvements to records, which include comprehensive preadmission proformas, care plans, and daily records, though there are still records requiring further improvement such as risk assessments, tissue viability assessments, falls risk assessments, nutritional assessments, medication records and staff records. The random assessment of a sample of health and safety and service maintenance records examined shows that they are generally satisfactory. The Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 26 home has obtained a Legionella risk assessment and has an in house Asbestos risk assessment. The water temperatures are not recoded for all outlets every month; these must be consistently maintained. The visual checks of wheelchairs have lapsed; these must be resumed. There is evidence that mandatory training is being sourced and provided for all staff on an on-going basis. There have been 24 recorded accidents involving residents since November 2006, which is a considerable reduction on the previous 6 months. The registered manager has not yet introduced a system for auditing, analysing and evaluating accidents involving residents. This must show effective measures, for example falls risk assessments implemented and reviewed, particularly where residents have frequent falls or accidents. Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 27 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 2 3 3 3 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 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 2 X 2 X X 3 2 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X N/A 2 2 2 Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 28 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 Standard OP2 Regulation 5(1) Requirement To review the contract / terms and conditions taking account of the revisions to the Care Homes Regulation 5 and the publication from the Office of Fair Trading relating to Contracts and terms & conditions in Care Homes (Timescale of 01/12/06 Not Fully Met) 1) To complete care plans for short term care needs such as need for infections, antibiotics etc. (Timescale of 01/11/06 Not Fully Met) 2) To ensure care plans contain - Up to date list of medication / medication regime 3) To ensure there are signatures on care plans to demonstrate that they are developed and agreed with the active involvement of residents and / or their representatives (Timescale of 01/11/06 Not Met) Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 29 Timescale for action 01/06/07 2 OP7 15(1) 01/06/07 4) To ensure daily notes reflect progress or otherwise related to goals and needs identified in the care plan (Timescale of 01/11/06 Improved - Not Fully Met) 3 OP8 13(1) To ensure that the following are documented as part of each residents case file / care plan 1) Tissue viability assessment (such as a Waterlow Score) (Timescale of 01/11/06 Not Fully Met) 2) Record of any pressure relieving equipment (Timescale of 01/11/06 Not Fully Met) 3) Plan of any pressure relieving prevention, such as turns, change of position, mobilising (Timescale of 01/11/06 Not Fully Met) 4) Nutritional screening assessment and referrals to GP and / or community dietician as needed (Timescale of 01/11/06 Not Fully Met) 5) Falls risk assessment, and record of any referral to the Dudley Falls Service, with any preventative / protection measures in place (Timescale of 01/11/06 Not Fully Met) 4 OP9 13(2) 1) To seek advice from the pharmacy provider about provision of an approved medication trolley, which must be secured to the wall, when not in use (Timescale of 01/11/06 Not Met) DS0000024975.V333517.R01.S.doc 01/06/07 01/06/07 Rosemary Retirement Home Version 5.2 Page 30 2) To obtain a drugs fridge and thermometer to record daily minimum and maximum temperatures to safely store significant amounts of medication currently held the homes domestic fridge (Timescale of 01/11/06 Not Fully Met) 3) To provide all staff involved in medication administration with accredited medication training (and provide documentary evidence of the current training providers accreditation) (Timescale of 01/11/06 Not Fully Met) 4) To revise and expand the medication procedure taking account of current guidance from the Royal Pharmaceutical Society of Great Britain (Timescale of 01/11/06 Not Fully Met) 5) To ensure staff signatures are obtained to demonstrate awareness and compliance with medication policy and procedures (Timescale of 01/11/06 Not Fully Met) 6) To ensure that staff record variable dosages of medication administered on MAR sheets, for example one tablet or two (Timescale of 01/11/06 Not Met) 7) To ensure that any handwritten entries on MAR sheets are dated, signed and witnessed by 2 appropriately trained staff (Timescale of 01/11/06 Not Met) Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 31 8) To clarify as directed dosages with the prescriber or pharmacist (Timescale of 01/11/06 Not Met) 9) To record carried forward balances of medication on MAR sheets (Timescale of 01/11/06 Not Met) 10) To undertake documented random audits of medication stocks, with any corrective measures identified (Timescale of 01/11/06 Not Met) 11) To ensure all medication is appropriately recorded as received into the home 12) To request regular quarterly audits and reports from the pharmacy provider in compliance with their contractual obligations to the home and PCT (Timescale of 01/11/06 Not Fully Met) 5 OP12 16(2)(n) Implement a plan of daily 01/07/07 activities based on consultation with residents and their individual needs. (Timescale of 01/05/06 and 01/12/06 Not Met) 01/07/07 The registered person must undertake a documented audit of residents preferences regarding activities, from which a structured weekly programme must be devised and displayed in appropriate formats to encourage participation and introduce weekly activity planners for each person to record planned and spontaneous activities, refusals and evaluation of activities offered (Timescale Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 32 6 OP12 16(2)(n) of 01/05/06 and 01/12/06 Not Met) 7 OP14 17(2) To ensure that residents 01/07/07 property inventories property are fully completed on admission with clothing, furniture, valuables, hearing aids etc. and thereafter kept up to date, signed and dated by staff, resident and / or relative. (Timescale of 01/05/06 and 01/12/06 Not Met) 1) To ensure the daily food / fluid intake recorded and monitored is recorded in sufficient detail to demonstrate a nutritious daily diet for any resident assessed as nutritionally at risk (Timescale of 01/12/06 Not Met) 2) To seek advice from the community dietician regarding the nutritional content of menus and especially the use of powdered milk only (Timescale of 01/12/06 Not Met) 3) To undertake a documented audit of residents preferences for the type of milk, for example fresh, full fat, semi skimmed, skimmed etc. (Timescale of 01/12/06 Not Met) 4) To develop and display menus in formats suitable to the residents capabilities and include supper time options (Timescale of 01/12/06 Not Met) 9 OP16 22 1) To revise the homes complaints procedure, to include clear stages and timescales and taking account of the changes to DS0000024975.V333517.R01.S.doc 8 OP15 13(1) 01/06/07 01/07/07 Rosemary Retirement Home Version 5.2 Page 33 the CSCI stance regarding complaint investigations (Timescale of 01/12/06 Not Met) 2) To produce the complaints procedure in alternative formats suited to residents needs and capabilities (large print etc.) (Timescale of 01/12/06 Not Met) 10 OP18 15(1) 13(4)(6) Behaviour care plans must be put in place to guide staff to understand behaviour triggers for individual residents and how to manage behaviour that challenges, such as agitation, wandering etc. (Timescale of 01/12/06 Not Met) 01/06/07 11 OP19 16(2) 23(2) The home must develop and 01/06/07 implement a plan for the renewal of furniture, fittings and decoration, which is operated alongside the repairs book. (Timescale of 02/09/05 and 01/06/06 and 01/12/07 Not Met) To undertake an audit of the home to identify all areas of exposed hot water pipe work accessible to residents, especially en suites, toilets and bathing facilities and ensure that they are guarded, boxed or covered appropriately (Timescale of 01/12/06 Not Met) To devise and implement documented cleaning schedules for the Kitchen, laundry and general areas in the home (Timescale of 01/11/06 Not Fully Met) DS0000024975.V333517.R01.S.doc 12 OP25 13(4) 01/06/07 13 OP26 13(4) 01/06/07 Rosemary Retirement Home Version 5.2 Page 34 14 OP27 18(1)(a) 1) To submit revised staffing 01/06/07 proposals, with staff rotas to the CSCI Office, Halesowen, together with details of current residents occupancy and dependency levels, (taking account of ancillary duties undertaken by care staff) demonstrating that staffing levels are adequate to meet care needs (Timescale of 01/11/06 Not Fully Met) 2) To increase the number of care staff to provide sufficient numbers of suitably qualified, competent and experienced care staff at all times that is: 08:00 hrs - 14:00 minimum of four carers, and 14:00 - 22:00 three carers one to designated as senior carer (wakeful day); and 22:00 hrs - 08:00 hours (night hours) two wakeful carer assistants, one of whom is designated as a senior carer. (Timescale of 01/11/06 Not Fully Met) 15 OP29 19(1) 17(2) Schedules 2 and 4 1) To ensure any gaps in employment history are fully explored and reasons documented and checked wherever possible (Timescale of 01/11/06 Not Fully Met) 2) To check the authenticity of references, ensuring that there is a reference from the last care employer or documenting reason why not possible and request that referees print their name and use company paper or company stamp (Timescale of 01/11/06 Not Fully Met) 01/06/07 16 OP30 18(1)(c) Staff must be provided with training in: DS0000024975.V333517.R01.S.doc 01/07/07 Rosemary Retirement Home Version 5.2 Page 35 1) Nutrition (Timescale of 01/12/06 Not Met) 2) Disability Awareness (Timescale of 01/12/06 Not Fully Met) 3) Behaviour that challenges the service (Timescale of 01/12/06 Not Fully Met) 17 OP33 24 To devise and display a schedule of residents meetings, together with agendas and minutes of meetings to encourage participation (Timescale of 01/12/06 Not Met) To forward copies the following to the CSCI office, Halesowen 1) The annual development plan for the home (Timescale of 01/12/06 Not Met) 2) The collated results of the homes service user surveys (Timescale of 01/12/06 Not Met) 3) The collated results of the homes relatives surveys (Timescale of 01/12/06 Not Met) 4) The collated results of the homes stakeholder surveys (Timescale of 01/12/06 Not Met) 5) The minutes of staff meeting held since March 2006 (Timescale of 01/12/06 Not Met) Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 36 01/07/07 18 OP33 24 01/07/07 19 OP36 18(1)(c) 1) To progress the implementation of the staff supervision system, ensuring that each member of staff has a minimum 6 formal recorded supervision sessions in each 12 months (Timescale of 01/12/06 Not Met) 2) To devise an annual schedule of supervision sessions, displayed to encourage participation (Timescale of 01/12/06 Not Met) 01/07/07 20 OP37 17(1)(2) 1) To ensure all records are compliant with the Data Protection Act, for example no communal information held relating to residents or lists on public display (Timescale of 01/12/06 Not Met) To seek advice from Dudley Environmental Services and undertake and implement a risk assessment and risk management strategy for staff climbing into lounge cupboard for incontinence products as an immediate priority, as an interim measure (Timescale of 27/09/06 Not Met) 1) All policies and procedures as required by the National Minimum Standards for Older People must be specific to the home. Once implemented (signed and dated by the manager) they must be read and understood by all employees commensurate to their duties. (Timescale of 2/09/05 and 01/06/06 Not Fully Met) 2) Risk assessments on the building and staff/service users 01/06/07 21 OP38 13(4) 01/06/07 22 OP38 13(4) 17(1)(2) 01/07/07 Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 37 activities must be completed and reviewed every 12 months. (Timescale of 2/09/05 and 01/06/06 Not Fully Met) 3) Health and safety checks must be made on a regular basis to identify any areas of concern. (Timescale of 2/09/05 and 01/06/06 Not Fully Met) 23 OP38 13(4) 17(1)(2) 1) To provide accredited / 01/07/07 approved risk management training for the registered manager and any other person undertaking risk assessment processes at the home or engage the services of a ‘competent’ person to provide documented risk assessments, with control measures and risk management strategies. (Timescale of 01/12/06 Not Met) 2) To provide documentary evidence that approved risk assessment awareness training has been arranged for all staff to be delivered within an identified timescale. (Timescale of 01/12/06 Not Met) 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 OP37 Good Practice Recommendations That a checklist matrix be used to record and monitor personal care provided Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 38 2 OP1 It is recommended that residents or representatives signatures are obtained for receipt of their copies of the homes statement and purpose, service user guide and complaints procedure That staff signatures are obtained to demonstrate that they have read and have an awareness of the homes and the multi-agency procedures for the protection of vulnerable adults Safeguard & Protect 3 OP18 Rosemary Retirement Home DS0000024975.V333517.R01.S.doc Version 5.2 Page 39 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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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