Inspection on 06/03/06 for Rosemary Retirement Home

This inspection was carried out on 6th March 2006.

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

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

Other inspections for this house

Rosemary Retirement Home 17/04/08

Rosemary Retirement Home 18/04/07

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 Mike Kirton Unannounced Inspection 10:00 6 March 2006 th 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.V285631.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Rosemary Retirement Home DS0000024975.V285631.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Rosemary Retirement Home Address 65 Vicarage Road Wollaston Stourbridge West Midlands DY8 4NP 01384 397298 01384 393506 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) Mrs Rosemarie Joyce Smith Mr Norman Smith 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.V285631.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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 1st floor where there is a conservatory, dinning room, main lounge area, kitchen, laundry room, single toilet, bathroom with single toilet, office, staff toilet and bedrooms. The 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 2nd floor accessed by stairs or vertical lift. Rosemary Retirement Home DS0000024975.V285631.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 5 hours and included interviews with Kevin Franklin (Administration Manager) Kathleen Oakley (Registered Manager) and Rosemarie Smith (Registered Provider) Informal discussions also took place with the service users and staff members on duty. Additionally records relating to health and safety, 2 service users and 2 staff files were examined. What the service does well: 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 Retirement Home DS0000024975.V285631.R01.S.doc Version 5.1 Page 6 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.V285631.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 2nd September 2005. Rosemary Retirement Home DS0000024975.V285631.R01.S.doc Version 5.1 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 2nd September 2005. Rosemary Retirement Home DS0000024975.V285631.R01.S.doc Version 5.1 Page 9 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 A good choice and standard of meals are provided tailored to individual’s preferences and requirements. Visitors are made to feel welcome and reported to be very pleased with the home. Whilst some activities are provided, this could be improved with the use of a weekly plan and more choice for example 1:1 sessions. EVIDENCE: On the day of the inspection a music session (planned on a monthly basis) was taking place in the main lounge. Keep fit sessions (armchair exercises) and hairdressing are held weekly and unplanned activities such as sing-a-longs were reported to be undertaken by staff and visitors. The proprietors also spend a lot of time at the home and several pets were seen including 2 dogs and a cat. There was however no information displayed about future events or planned activities. The home has an open visiting policy and staff were observed making them feel welcome i.e. offering a cup of tea. Residents are able to see their friends Rosemary Retirement Home DS0000024975.V285631.R01.S.doc Version 5.1 Page 10 and relatives in either the lounge areas or the privacy of their own room. These can be furnished with their own possession subject to health and safety requirements. External advocates including solicitors are accessed when needed. Meals are planned in advance and are based on feedback sought from residents (evidence was seen). Every morning the cook speaks individually to them offering a choice of 2 cooked midday dinners. Personal preferences and dietary requirements are taken into account and hot and cold drinks are available at set times or upon request. Sweets are also provided in the main lounge. Rosemary Retirement Home DS0000024975.V285631.R01.S.doc Version 5.1 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Rosemary has a clear and concise complaints procedure in place. Further work is required to implement adult protection procedures and ensure all staff members are suitably trained. EVIDENCE: The home has a complaints procedure, which contains all the required information including contact details for the Commission. Copies are given to each resident on arrival. No complaints have been received. Dudley Social Services adult protection procedures have been obtained and the home has their own policy including whistle blowing. This along with all other documents has not yet been implemented (see standard 16). Similarly not all staff have received training and evidence of induction was not available (see standard 30) Rosemary Retirement Home DS0000024975.V285631.R01.S.doc Version 5.1 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 2nd September 2005. Rosemary Retirement Home DS0000024975.V285631.R01.S.doc Version 5.1 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The current staffing levels mean that there are only 2 care staff on duty during the afternoon and evening. They are also required to prepare the evening meal and the lunch on the weekends. The manager must continue to review staffing levels to ensure all resident’s needs are met. Very poor recruitment procedures are being followed and staff are working without the required level of training and experience. Procedures must improve to ensure the health and safety of residents and care staff is protected. EVIDENCE: Kathleen Oakley (Registered Manager) spends the majority of her time in a caring role whilst Kevin Franklin completes the administration tasks. Whilst the registered proprietors are reported to be there most days their hours are not shown on the duty rota. On the day of the inspection there were 3 care staff on duty from 08:00 till 13:30/14:00 hours and 2 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, whilst domestics are employed to cover the whole week 07:00 till 12:00 hours. As with all other documents the homes recruitment procedures have not yet been implemented (see standard 16). Files for 2 recently appointed staff Rosemary Retirement Home DS0000024975.V285631.R01.S.doc Version 5.1 Page 14 members were examined. Both had commenced employment before notification had been received that their name were not on the list of people who may pose a risk to vulnerable adults (POVA). References had not been received or proof of identification kept for one and neither had gaps in their employment history explained. The inspector was informed that all staff receive 3 days training and follow the Black Country induction and foundation course folder. No evidence of this was available for inspection. Similarly individual staff training records were not being maintained. The past duty rota’s showed that action had been taken to ensure newly appointed night staff worked with someone more experienced however their training records were incomplete. Rosemary Retirement Home DS0000024975.V285631.R01.S.doc Version 5.1 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 There is sufficient evidence that the home is being poorly managed and that action is not being taken to ensure the health and safety of residents is protected. EVIDENCE: As previously stated the Kathleen Oakley, registered manager, spends the majority of her time in a caring capacity whilst other managerial duties are undertaken by Kevin Franklin. It is the responsibility of the registered manager and provider to ensure that standards and regulations are met. The home has started a quality assurance procedure and questionnaires prepared to obtain feedback from residents, visitors, and other stakeholders Rosemary Retirement Home DS0000024975.V285631.R01.S.doc Version 5.1 Page 16 i.e. GP and Social Worker. This system now requires updating in line with the current standards and published on an annual basis along with an action plan for improvements. The home is not responsible for residents finances and do not hold any monies on their behalf. Invoices are sent monthly for any purchases such as hairdressing. Records required to ensure the health and safety of staff and service users were inspected. Fridge, freezer, water and cooked meat temperatures were recorded. The homes gas certificate and 5-year electrical wiring test was in date. All equipment is regularly serviced and tested as required including portable electrical equipment. A fire risk assessment and evacuation plan is in place however not all staff have received fire training at least twice a year. Risk assessments on the building and staff/service users activities was not completed or reviewed every 12 months. The Commission had not been notified of reportable events that have occurred in the home i.e. the death of a resident or incidents requiring medical treatment. A tour of the premises resulted in several issues identified, which placed resident’s health and safety at risk. This included a cupboard on the first floor, which was not secured and could easily fall over, fire doors not closing correctly and one with a hole in. A portable heater in the front conservatory, which was identified as a potential risk of causing a burn injury at the last inspection, was still being used. The upstairs bathroom was also being used as a storage facility. Rosemary Retirement Home DS0000024975.V285631.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 1 Rosemary Retirement Home DS0000024975.V285631.R01.S.doc Version 5.1 Page 18 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 OP1 Regulation 5 Requirement The home must produce a Service User Guide. This is an outstanding requirement from 21st March 2005. All residents must have a completed contract signed by them or their representative. This is an outstanding requirement from 2nd September 2005. A care plan must be implemented upon on arrival detailing exactly how residents assessed needs will be met. This must be reviewed every month or earlier if required. This is an outstanding requirement from 2nd September 2005. Risk assessment with appropriate actions must be completed for prevention of falls, pressure sores, nutrition (including weight gain and loss and fluid intake) and safe moving and handling of residents. Further assessments for violence and aggression and DS0000024975.V285631.R01.S.doc Timescale for action 01/06/06 2. OP2 4,5,6 01/05/06 3. OP7 14,15 01/04/06 4. OP8 14,15 01/04/06 Rosemary Retirement Home Version 5.1 Page 19 5. OP9 12,13 6. OP12 16(2)(n) 7. OP19 16,23 8. OP26 16,23 9. 10. OP27 OP29 18 18 mental health may also be required. This is an outstanding requirement from 2nd September 2005. There must be no gaps in the record sheets used to record whether residents have taken their prescribed medication. This is an outstanding requirement from 2nd September 2005. Implement a plan of daily activities based on consultation with residents and their individual needs. The home must develop and implement a plan for the renewal of furniture, fittings and decoration, which is operated alongside the repairs book. This is an outstanding requirement from 2nd September 2005. Portable heaters must be removed unless the home can demonstrate they are safe. A clear policy and procedure for the washing of laundry must be implemented and the room removed of unnecessary storage items. This is an outstanding requirement from 2nd September 2005. The manager must continue to review staffing levels to ensure all resident’s needs are met. The home must implement a policy for the recruitment and employment of staff. This is an outstanding requirement from 21st March 2005. Staff must not commence employment before a clear POVA check and satisfactory references have been received. DS0000024975.V285631.R01.S.doc 21/03/06 01/05/06 01/05/06 21/03/06 21/03/06 21/03/06 Rosemary Retirement Home Version 5.1 Page 20 11. OP30 18 12. OP31 9 13. OP33 24 14. OP38 12,13 15. OP38 37 Individual staff training records must be maintained and evidence available that they have undertaken a period of induction. The Registered manager must ensure they are in control of the management of the home and that all regulations are met. The registered person must implement and effective quality assurance and quality monitoring system including an annual development plan, internal audit of the service provision, views of service users and their relatives and a review of policy and procedures. This is an outstanding requirement from 21st March 2005. All policies and procedures as required by the minimum standards must be specific to the home. Once implemented (signed and dated by the manager) they must be read and understood by all employees where relevant to their duties. This is an outstanding requirement from 2nd September 2005. Risk assessments on the building and staff/service users activities must be completed and reviewed every 12 months. Health and safety checks must be made on a regular basis to identify any areas of concern. All staff must received fire training at least twice a year. All fire doors must be maintained and close correctly. The registered person must notify the Commission of any reportable incidents that occur. 21/03/06 21/03/06 01/06/06 01/06/06 21/03/06 Rosemary Retirement Home DS0000024975.V285631.R01.S.doc Version 5.1 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP10 OP37 Good Practice Recommendations Bedrooms with a window in the door should be considered for having obscured glass or a curtain fitted to prevent people seeing inside. Care staff should provide more information in the daily records and avoid using only the word fine. Rosemary Retirement Home DS0000024975.V285631.R01.S.doc Version 5.1 Page 22 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: 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 Retirement Home DS0000024975.V285631.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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