Inspection on 27/06/05 for Rosewood Lodge

This inspection was carried out on 27th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Rosewood Lodge 03/09/08

Rosewood Lodge 23/08/07

Rosewood Lodge 08/08/06

Rosewood Lodge 03/01/06

Rosewood Lodge 28/12/04

Rosewood Lodge 05/07/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Rosewood Lodge 4 Southfield Hessle East Yorkshire HU13 0EX Lead Inspector Pam Dimishky Unannounced 27 June 2005 at 9:30 am th 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. Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Rosewood Lodge Address 4 Southfield Hessle HU13 0EX 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) 01482 641106 01482 627929 Jagata Nanda Kumar Adikaram Miss Victoria Maria Taylor CRH 21 Category(ies) of OP Old Age (21 registration, with number DE(E) Dementia - Elderly (21) of places Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th December 2004 Brief Description of the Service: Rosewood Lodge is a large traditional property in a residential area of Hessle. The care home is privately owned and is registered for 21 older people aged over 65 years of age, some of whom may have dementia. The home will also take people for respite care within this category. The property has an extension that includes ensuite bedrooms, a shower room and a conservatory which is used as a lounge. There is a patio and large garden which are easily accessed from the conservatory and there is a small car park. A further lounge and a dining room are situated in the main body of the building. Individual accommodation is provided in 18 single rooms and 1 double room (one double room is now only used as a single). Seven bedrooms on the first floor are accessed either by the staircase or stair lift. The home is close to the railway station and a short walk from the centre of Hessle where there are shops, cafes, banks and a library. Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over 8 hours (including preparation time). The inspection process included a review of documentation and a tour of the building. The inspector spent some time with the residents and spoke to nine, some of whom were in the lounge and some in their own room; the manager and two members of staff were also interviewed. What the service does well: What has improved since the last inspection? Improvements to the environment are ongoing and the programme for redecoration and replacement of furnishings and fitments has commenced. Staff training is very much in evidence covering areas appropriate to meeting residents’ needs. All the requirements made at the previous inspection have been met. Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_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 Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_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) 1,2,3, and 6 Prospective residents have the information they need to make a decision as to whether to come into the home. The admission procedure includes a proper assessment being made of residents moving into the service to ensure the home can meet their needs. However, the registered person has not provided confirmation in writing that the resident’s needs, in respect of health and welfare, can be met. EVIDENCE: Information about the home in the form of a welcome pack, is given to all prospective residents or their relatives. The information includes the statement of purpose, service user guide, complaints procedure, residents’ questionnaire, copy contract and the last inspection report; a copy is always available in the reception area although residents were not aware of the document. Contracts have been issued to all residents and three of these were checked. A further two recently admitted respite residents have not yet been given a contract as a decision has not yet been made whether they will be staying in the home. Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_Stage 4.doc Version 1.30 Page 9 For residents placed through social services, the home obtains a copy of care management’s care plan and needs assessment prior to coming into the home. From this information the manager makes a decision as to whether the home can meet the identified needs. Privately funded residents have their needs assessed by the manager before coming into the home; this includes information obtained from other involved professionals. The registered person has not confirmed in writing the home can meet the individual needs of residents, as required by regulation. The home is not registered for intermediate care. Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10 All residents have a care plan ensuring their assessed needs are being met. The systems for the administration of medication are good with clear arrangements being in place to ensure residents’ medication needs are met. Staff have a clear understanding of ensuring residents privacy and dignity is respected. EVIDENCE: Two residents admitted two weeks before the date of this inspection do not have a care plan developed by the home. However, the care delivered is based on the care plan and assessment provided by social services care management, until a decision is made as to whether they will be staying in the home. Five care plans were examined and found to be very comprehensive with good daily notes being recorded. Each care plan has a section which includes samples of the areas to be written up. The manager is to ensure oral health and foot care are included. The district nurse and community psychiatric nurse are also providing support. Residents stated they are treated well by the staff and staff demonstrated at interview, and by indirect observation, that residents privacy and dignity is respected. Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_Stage 4.doc Version 1.30 Page 11 Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15 Daily life and social activities generally meet the expectations and choice of the residents living in the home. Family and friends visit the home or maintain telephone contact and this enriches the lives of the resident. There is a choice of meals which are nutritious and offer a varied diet for residents. However it was not evident that residents are always given the meal of their choosing. EVIDENCE: Whilst some residents said there was nothing to do in the home and they could not go for walks alone, the records in the activities book indicated something was being offered almost every day and on the morning of the inspection the word game Scattergories was obviously being entered in to with some enthusiasm by the residents. Records indicated that on some days two activities took place and these included, card games, walk in the grounds, card bingo, floor snakes and ladders, one to one chats, hand and nail care, buffet tea with a sing-a-long. A visit to the Deep has been arranged for 6th of July, and ten residents are booked to go. A choice of meals are offered for both lunch and tea and this is recorded in the menu book. On the day of the inspection sixteen residents were listed under the heading of their choice, but on the previous four days there were only five, twelve, seven and six names entered. All the residents spoken to commented on how good the food is. Three residents have diabetes which is diet Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_Stage 4.doc Version 1.30 Page 13 controlled. Lunch on the day of the inspection was either steak and kidney pie or chicken casserole and looked very appetising. Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has a satisfactory complaints process with some evidence that residents feel that their views are listened to and acted upon. Staff are trained to protect residents from abuse. EVIDENCE: The home’s complaints procedure is displayed in the reception area and is included in the welcome pack. Four complaints have been recorded since the last inspection, all of which had been satisfactorily resolved. Staff interviewed have had vulnerable adults abuse awareness training and stated they would report to the manager any suspicions they may have. Senior staff have cascaded this training to other staff which involves answering a questionnaire based on a guidelines booklet from the course. Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,22 and 26 The standard of the environment within this home is generally good providing residents with an attractive and homely place to live. However to ensure the risk of infection is controlled more care must be made in ensuring soap, towels and toilet paper are always available in toilet areas. EVIDENCE: It is clear the provider is making progress towards the planned maintenance, redecoration and refurbishment programme for the home. The shared room now has new beds and furniture, a number of bedrooms and the corridor in the extension have been redecorated and a downstairs room has a new carpet and has also been redecorated. Residents are involved in choosing the colour for redecorating their room. A new washing machine has been installed in the laundry which operates to hospital standards and includes a sluice cycle. The home is generally clean and pleasant but despite the home’s best efforts one bedroom, where the resident chooses to self care, does have an odour problem. One resident informed the inspector she had to wait an hour on one occasion, and two hours on another, for staff to respond to the call bell which she understood to be not working. This was checked and was promptly Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_Stage 4.doc Version 1.30 Page 16 answered by a care assistant. The manager is to monitor whether there are any further problems. Staff confirmed the equipment and aids in the home are adequate to meet the needs of the residents. The headboard in one room is in need of repair or replacement. A record is now being kept for hot water temperatures in both bathrooms and the shower room. The manager is to discuss with the proprietor a variation to the registration to reduce the number of beds as one room, previously a double, is now only used for single use. Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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) 27,29 and 30 Staff are well trained and therefore competent to do their jobs. However, the procedures for the recruitment of staff are not robust and do not offer protection to people living in the home. The deployment and number of staff available Friday, Saturday and Sunday afternoons is not sufficient to meet the needs of the residents. EVIDENCE: The home employs sixteen care staff, one cook and one cleaner. Currently seventeen residents are cared for by three care staff on the early shift, two on the late and two at night. The manager is working four days a week at present and the provider and his wife spend four days in the home; all assist with the day to day running of the home. However, Friday, Saturday and Sunday afternoons the home does not benefit from this extra help and there is a need for an extra pair of hands at this time. Extensive training has taken place since the last inspection, including continence awareness, catheter care, moving and handling, basic food hygiene, basic health and safety, bereavement awareness and a three month programme commenced during April for infection control and decontamination. All staff have undergone training in first aid. One new member of staff has been appointed without a current Criminal Records Bureau check and only one reference obtained; another has not yet received induction training. Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_Stage 4.doc Version 1.30 Page 18 Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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) 31,33,34,37,38 The home is being managed properly and support is also given by the provider and his wife ensuring there is leadership, guidance and direction to staff. This generally results in practices that promote and safeguard the health, safety and welfare of the people using the service. However, death notifications were not notified as legally required and safety certificates were not available at the time of this inspection which may result in residents being put at risk. EVIDENCE: The manager is currently working four days a week, Monday to Thursday, and works extra hours when needed, eg covering shifts and absence of the cook. A senior carer works in the office Friday afternoon until the manager returns to full-time working. A report by the provider is forwarded to the Commission monthly; this includes consultation with residents and staff, and inspection of the premises and records. Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_Stage 4.doc Version 1.30 Page 20 Residents and family meetings are held three monthly and the next was advertised to take place on 30th June. Residents also complete a questionnaire twice a year about the services they receive. The results of these are published in the welcome pack. The provider has supplied information demonstrating effective and efficient management of the business. Notifications of deaths occurring in the home over the last six months were received by the Commission on 2nd June 2005; this is not in accordance with the legal requirements. Accident books for staff and residents were seen to be adequately recorded. Fire alarm and emergency lighting checks are taking place weekly. Certificates for a thorough examination of the hoists and stair lift were not available; a current landlords gas safety was seen dated 29th July 2004. (The manager later confirmed a further certificate was issued 28th June 2005 a copy of which is being sent to the Commission). The employers public liability certificate was displayed in the reception and is current to 5th March 2006. A health and safety notice is also displayed in the reception. Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_Stage 4.doc Version 1.30 Page 21 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 3 3 1 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 x x 3 x x x 1 STAFFING Standard No Score 27 1 28 1 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 3 x x 1 1 Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_Stage 4.doc Version 1.30 Page 22 NO 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 28 Regulation 14 Requirement The registered person must confirm in writing to the resident that having regard to the assessment, the home can meet their health and welfare needs Ensure toilet paper, soap and towels are available in toilet areas Ensure that at all times suitable persons are working in such numbers as are appropriate for the health and welfare of residents A criminal records bureau check must be requested for new staff employed to work at the home before they start work. Two references must also be obtained before starting work Provide the Commission with copies of the six monthly certificates for the thorough examination of the stair lift, bath hoist and mobile hoist Notifications of death must be notified to the Commission without delay Timescale for action On receipt of this report On receipt of this report On receipt of this report On receipt of this report 2. 3. 26 27 13,16 18 4. 28 12,19 5. 38 13,23 31/7/05 6. 37 37 On going Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_Stage 4.doc Version 1.30 Page 23 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 19 Good Practice Recommendations Bed headboards must be repaired/replaced as necessary (room 4) Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Rosewood Lodge J53_s37734_Rosewood Lodge_v225598_270605_Stage 4.doc Version 1.30 Page 25 - 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!