Inspection on 01/07/05 for Rosemount

This inspection was carried out on 1st July 2005.

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

Rosemount 17/03/08

Rosemount 18/09/07

Rosemount 03/08/06

Rosemount 19/01/06

Rosemount 19/11/04

Rosemount 20/05/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Rosemount Sunningdale West Monkseaton Whitley Bay NE25 9YF Lead Inspector Suzanne McKean Unannounced 1 July 2005 09:30 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. Rosemount B53-B03 S28819 Rosemount V231589 010705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Rosemount Address Sunningdale West Monkseaton Whitley Bay Tyne & Wear NE25 9YF 0191 251 0856 0191 251 0866 rosemount@fshc.co.uk Cotswold Spa Retirement Hotels Ltd 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) vacant CRH 60 Category(ies) of OP Old Age (59) registration, with number PD Physical Disability (1) of places Rosemount B53-B03 S28819 Rosemount V231589 010705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 19 November 2004 Brief Description of the Service: Rosemount is a purpose built care home of traditional brick build design on one level, there is a car park to the front of the building which allows level access to the home. it is situated in the residential area of West Monkseaton, Whitley Bay. The home is easily accessed by metro, bus and car. All accommodation is provided in single, ensuite bedrooms and there is a selection of communal facilities, including lounges, dining rooms and a conservatory. Rosemount B53-B03 S28819 Rosemount V231589 010705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over a period of 5 hours on one day by the inspector. The manager was on holiday and the Deputy Manager assisted in the inspection this allowed the examination of records which were being stored securely in line with the homes policy on confidentiality. Eight residents were spoken to during the visit and five relatives and the inspector also spoke to seven of the staff. The records examined included, five care plans and medication records, the training records, the fire log as well as complaints and accident records. The inspector also viewed three staff files including the process for their recruitment and selection. What the service does well: What has improved since the last inspection? What they could do better: Individual care planning is undertaken and the care is being delivered in line with these plans. However these were not all fully up to date resulting in them Rosemount B53-B03 S28819 Rosemount V231589 010705 Stage 4.doc Version 1.30 Page 6 containing out of date or inaccurate information. It is a requirement for these to be improved so that the home can demonstrate the care being delivered. The environment of the home is now in need of improvement to return it to the standard it previously maintained. This includes both decoration of the bedrooms and communal areas and deep cleaning or replacement of carpets as necessary. A requirement to provide a detailed list of the work needed and the timescales for them being completed has been made. Control of infection strategies must be improved to meet current guidelines including laundry equipment (the use of disposable red laundry bags so that staff do not have to handle soiled linen) as well as improvement in the cleaning routines for which a requirement has been identified. The use and storage of topical medications must be improved and medicine trolleys must always be stored safely. The Manager must undertake health and safety assessments of the home to make sure that the environment is safe for both the residents and the staff. This is particularly regarding equipment and furniture in the bedrooms. 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. Rosemount B53-B03 S28819 Rosemount V231589 010705 Stage 4.doc Version 1.30 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 Rosemount B53-B03 S28819 Rosemount V231589 010705 Stage 4.doc Version 1.30 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) 2, 3, 6 The assessment undertaken prior to admission is detailed and the care plans are being developed from them to identify the needs of the residents in the home. The company has not yet issued the amended contract so that the homes can implement it, this is outstanding from previous inspections. A requirement has been made regarding this issue. The home is not registered for, and therefore does not provide, intermediate care. EVIDENCE: Five care plans were examined and each has comprehensive pre-admission assessments, which were undertaken by the Manager or the senior staff in the home. The residents also have a care management assessment, which is provided, to the home on admission and from these documents an individual care plan is produced. Rosemount B53-B03 S28819 Rosemount V231589 010705 Stage 4.doc Version 1.30 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 Individual care planning is undertaken and the care is being delivered in line with these plans. However these were not all fully up to date resulting in them containing out of date or inaccurate information. Care is being delivered to the residents to a satisfactory level however this is not recorded effectively in the care plans. A requirement has been made regarding this issue. EVIDENCE: Each resident has an individual plan of care, which is based on the admission assessment and is then added to during the placement. Five care plans were examined all of which contained a large amount of information regarding the care of the resident and there was evidence that relevant risk assessments are available for the nutrition, wound care, moving and assisting, and continence promotion. However the plans showed that they were not being regularly reviewed and updated resulting in them containing some out of date and inaccurate information. The care plans showed that the residents have access to all NHS services and facilities. There was a good range of pressure relieving mattresses in use for the prevention of pressure sores. Rosemount B53-B03 S28819 Rosemount V231589 010705 Stage 4.doc Version 1.30 Page 10 Although the standard in relation to medication was not fully examined it was noted during the inspection that the Medication trolleys were being stored inappropriately although this was a short term measure immediate action was requested to ensure their safety. Also during the inspection it was noted that there were pots of prescribed topical lotions in the on suites of the residents bedrooms, some of which were out of date and some were not the ones prescribed for that individual resident, an immediate requirement was made regarding this issue. Interviewing the Deputy and other care staff provided information that the staff are aware of the needs of the service users and the residents spoken too were complementary about the way the care is being delivered. Rosemount B53-B03 S28819 Rosemount V231589 010705 Stage 4.doc Version 1.30 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 food being served is being prepared safely by knowledgeable staff and offers choice to the residents. The home offers the resident a balanced diet and there is sufficient quantity of both food and fluids to meet their needs. Staff are aware of the importance of a balanced diet and the way it is served. EVIDENCE: The kitchen was clean and well organised, the recording of food, fridge, and freezer temperatures were in place and completed appropriately. There was an ample supply of frozen, tinned, dried and fresh food available all of which was appropriately stored. The kitchen staff were aware of residents specialist needs including how to fortify foods for those who have poor appetites or those who have lost weight. The residents are offered a choice of three meals a day and residents on the day were seen eating heartily one asked said that the “food is really nice”. The meal being served was ample portion size, hot and well presented. Residents were offered assistance in a discreet manner. Residents were offered second helpings and alternatives to the main and dessert course were available. A variety of cold drinks were available throughout the meal and hot, cold drinks and biscuits were available throughout the day. Rosemount B53-B03 S28819 Rosemount V231589 010705 Stage 4.doc Version 1.30 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 ensures that the residents and relatives are made aware of the complaints policy and that it is available in a variety of places. There is a system for managing and dealing with complaints, which makes it possible for them to be investigated and action taken to address any issues identified. EVIDENCE: The complaints procedure is available in the service users guide and a copy is available at the front entrance as well as being displayed in the home. The records of the complaints made to the home was examined, there has been two complaints recorded and the records of one of these was detailed including the response to the complainants and the action taken in response to the issues raised. One of the complaints identified was handled by a more senior member of the company so the complete record was not held in the home, however it was available on request. Two of the residents spoken to were asked how they would have any problems dealt with, were able to identify the way this would be done. Three relatives spoken to were aware of the complaints procedure and had used it in the past. The Manager and Deputy Manager confirmed that relatives use the relative meetings and informal opportunities to express their concerns and that they are working to address the issues raised. (see environment section) Rosemount B53-B03 S28819 Rosemount V231589 010705 Stage 4.doc Version 1.30 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, 26 The bedrooms are all single occupancy and are decorated and equipped in a homely and personalised way. The home is generally well decorated, however it is now becoming in need of redecoration in some of the bedrooms and areas of high use including the need for the carpets to be replaced if they cannot be cleaned effectively. A requirement has been made regarding this issue. There are risks evident in the home for which risk assessments have not been undertaken. A requirement has been made regarding this issue. The home must improve the methods of reducing the risk of cross infection. A requirement has been made regarding this issue. EVIDENCE: A tour of the premises was conducted with the Deputy Manager and alone and it was noted that there are now a number of bedrooms which require redecoration and replacement of the carpets. The communal areas are also in need of redecoration in places. An audit must be carried out to identify the areas of the home which should be a priority and action taken to undertake the necessary work. Rosemount B53-B03 S28819 Rosemount V231589 010705 Stage 4.doc Version 1.30 Page 14 The home is one domestic short of its company requirement and the other staff are attempting to cover the short fall as a consequence some of the tasks are not being done as frequently as necessary. This is supported by interview with the staff and from resident/relative meeting records. In some areas tablets of soap were being used instead of the liquid soap, so increasing the possibility of cross infection. Although there is liquid soap and disposable paper in the on-suites there are no waste bins so staff are not able to dispose of them without leaving the room. Wheelchairs were not being cleaned according to the company policy, bath mats were dirty and were not being cleaned effectively. Appropriately coloured aprons were not available to allow staff to follow appropriate control of infection policies, and staff did not understand the procedures they should follow. Red dissolvable laundry bags were not available and staff were handling soiled linen prior to it being washed. Rosemount B53-B03 S28819 Rosemount V231589 010705 Stage 4.doc Version 1.30 Page 15 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) 27 The home is staffed according to the recently proposed levels put forward by the company to the CSCI which have been agreed subject to ongoing monitoring and assessment of adequacy. This is a change from those set by previous regulatory organisation in that there is now one less qualified nurse on duty in the morning and one additional carer in the afternoon. There was two qualified nurses on duty during the inspection and nine care staff. This was adequate for the needs of the residents on the day. EVIDENCE: The staffing rota was examined and it confirmed that there was two qualified nurses on duty during the inspection and nine care staff all of which were seen during the visit. This was adequate for the needs of the residents on the day. The Deputy provided written evidence of the information given to the care staff outlining the expectations the managers have of the way they should work. The residents on the day were appropriately dressed in clean well laundered clothing suggesting that they were being given an adequate level of personal care and the residents who were asked were positive about the staff working in the home an example was “the staff are really nice” and “they are extremely kind”. During the visit it was noted that the medication round took a significant amount of time and involved the nurse being unable to undertake any other tasks for the majority of the morning, the cause of this was not determined. Rosemount B53-B03 S28819 Rosemount V231589 010705 Stage 4.doc Version 1.30 Page 16 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) 31, 38 Mrs Huntingdons application to be registered as the manager is being processed. The company has policies and procedures in place to ensure that the home is managed effectively taking into account the needs and wishes of the residents and there is evidence that she is working in line with these. Recent problems have arisen in the home due to the management changes and a period when there was some uncertainty. Some aspects relating to the health and safety and welfare issues of residents and staff are not adequately promoted and protected. EVIDENCE: The records of the arrangements to ensure that persons working at the care home receive suitable training in fire prevention and by means of fire drills and training in the procedures to be followed in the case of fire were examined and were adequate. There is a system in place to review health and safety in the home involving the staff for which records are available, however there was a glass fronted cabinet which was unstable and had a large glass ornament on Rosemount B53-B03 S28819 Rosemount V231589 010705 Stage 4.doc Version 1.30 Page 17 top, this presented a possible risk to both staff and resident and an immediate requirement was made for it to be risk assessed and appropriate action taken. Also a television was on a broken stand next to a resident who was being nursed on the floor for which immediate action was necessary. During the visit the fire alarm was activated and the staff generally took appropriate action, however it was noted that although there was a visitors “signing in” record there was no way of identifying the staff on the premises except for the staffing rotas. Records were examined of the staff meetings which take place regularly and the contents of these suggest that there is a broad spectrum of relevant issues discussed. The Manager also facilitates meetings with the relatives and residents as appropriate which she is using to consult the residents, relatives and other interested parties to review the service provided. Rosemount B53-B03 S28819 Rosemount V231589 010705 Stage 4.doc Version 1.30 Page 18 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 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 3 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 3 x x 2 x x x x x x 2 Rosemount B53-B03 S28819 Rosemount V231589 010705 Stage 4.doc Version 1.30 Page 19 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 OP2 Regulation 5 (1) (b) Requirement The updated statement of terms and conditions must be submitted to the CSCIand be provided to new service users on moving into the home. Outstanding The Manager must ensure that each of the residents care plans are detailed, up to date and reflect the care being delivered. The home must undertake a detailed audit of the redecoration required including bedrooms and areas of high use. The need for the carpets to be replaced if they cannot be cleaned effectively must be identified. this audit must be sent to the C.S.C.I. with timescales of completion dates included. The home must improve the methods of reducing the risk of cross infection. There are risks evident in the home for which risk assessments have not been undertaken. An immediate requirement was made. Prescribed topical medication must be dated when opened and disposed of within the Timescale for action 01.09.05 2. OP7 15 01.09.05 3. OP19 16 (2) (c) 23 (2) (d) 01.09.05 4. 5. OP26 OP19 OP38 13 (3) 13 (4) 01.09.05 Immediate 6. OP9 13 (2) Immediate Rosemount B53-B03 S28819 Rosemount V231589 010705 Stage 4.doc Version 1.30 Page 20 7. OP31 9 (1) (2) recommended time scale. only medication prescribed for the individual resident must be administered to them. The Manager must undertake the 01.10.05 necessary fitness process so that she can be registered. She must demonstrate her ability to make the necessary improvments required as identified in the other requirements identified. 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 OP9 OP38 Good Practice Recommendations It is recommended that the Manager review the way the medicines administration is organised to ensure that it is organised in the most appropriate way. It is recommended that the is in place a record of the staff on the premises which could be used in the event of a fire. Rosemount B53-B03 S28819 Rosemount V231589 010705 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Northumbria House Manor Walks, Cramlington Northumberland NE23 6UR 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 Rosemount B53-B03 S28819 Rosemount V231589 010705 Stage 4.doc Version 1.30 Page 22 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!