Inspection on 07/11/05 for Rosewood Lodge

This inspection was carried out on 7th November 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 28/07/06

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Rosewood Lodge 491 Clifton Drive North St Annes Lancashire FY8 2QX Lead Inspector Mrs Lillian McMullen Unannounced Inspection 7th November 2005 10:30 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 Rosewood Lodge DS0000064309.V260357.R01.S.doc Version 5.0 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. Rosewood Lodge DS0000064309.V260357.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Rosewood Lodge Address 491 Clifton Drive North St Annes Lancashire FY8 2QX 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) 01253 721601 Lakeview Rest Homes Ltd Mrs Agness Woods Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Rosewood Lodge DS0000064309.V260357.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection The service is registered to accommodate a maximum of 24 service users in the category OP (older persons 65 and over). 20 June 2005 Date of last inspection Brief Description of the Service: Rosewood Lodge is situated on the main bus route not far from the centre of St Annes and a short distance from the sea front. The home is registered to provide residential care for twenty-four service users of both sexes, above the age of sixty-five years. All the service users are accommodated in single rooms with en-suite facilities; the rooms are well decorated and furnished to a high standard. The property is a two storey detached house which provides ample and varied lounge space including a lounge for smokers. The home has a well-maintained garden with a gazebo and seating areas. Rosewood Lodge DS0000064309.V260357.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 10.30am and took place over 7 hours. At the time of the inspection there were 24 residents in the home. The Inspector spoke to 3 residents, 2 staff members and the manager. Comment cards were sent out prior to the inspection, however no completed ones were returned. What the service does well: What has improved since the last inspection? What they could do better: The pharmacy inspector inspected the medication procedures. A number of requirements and recommendations were made and these will be addressed with the registered manager via a separate letter. Rosewood Lodge DS0000064309.V260357.R01.S.doc Version 5.0 Page 6 Risk assessments need to be put into place for all identified environmental hazards. The procedure for staff recruitment needs to be more robust staff should not commence employment until two written references have been received. Following employment all new staff must received supervised induction. 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 DS0000064309.V260357.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Rosewood Lodge DS0000064309.V260357.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: None of the above standards were assessed at this inspection. Rosewood Lodge DS0000064309.V260357.R01.S.doc Version 5.0 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 the following standard(s): 9 Health needs are closely monitored. Medication procedures need to be more robust for the benefit of service users. EVIDENCE: Residents spoken to all stated that they are well cared for and that the staff do everything they can to make sure they are comfortable. Staff spoken to had a good understanding of the care needs of the residents and confirmed that they have good management support. The inspector observed staff assisting residents and was pleased to see they had good relationships with residents and carried out all tasks in a friendly and sensitive way. In particular the more frail residents looked extremely comfortable and were given appropriate one to one care. The Pharmacy inspector conducted an inspection of the medication procedures. A number of requirements and recommendations were made and these will be addressed with the registered manager via a separate letter. Rosewood Lodge DS0000064309.V260357.R01.S.doc Version 5.0 Page 10 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): EVIDENCE: None of the above standards were assessed at this inspection. Rosewood Lodge DS0000064309.V260357.R01.S.doc Version 5.0 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 and 18 Good practices and policies are in place to enable concerns to be raised and responded to and to protect residents from abuse. EVIDENCE: Rosewood Lodge has a comprehensive complaints procedure, which is also adopted by the other two homes within the company. The complaints procedure is contained in the Service User Guide and provided to residents and their relatives upon admission a copy is also displayed in the home. The Commission for Social Care Inspection has received no complaints within the last year and there have been no vulnerable adult referrals to Social Services. The registered manager is pro active in encouraging residents and their relatives to voice any concerns they may have. This was evidence during the inspection when the registered manager discussed an area of concern that a relative had raised. It was evident that the registered manager had thoroughly investigated the concern and had arranged a personal meeting between herself and the relative to provide feedback and resolve the matter. One resident spoken to felt that if she had any concerns they would be taken seriously, saying, “the manager keeps her eye on the staff to make sure they do their job”. The home has an abuse policy in place, which includes guidance on whistle blowing, abuse of residents and advice for staff on what could be perceived as abusive practice. This policy is easily accessible by staff. Criminal Records Rosewood Lodge DS0000064309.V260357.R01.S.doc Version 5.0 Page 12 Bureau clearances were checked. The home maintains records of details of staff applications and clearances received and liaise well with the Commission in respect of POVA (Protection of Vulnerable Adults) clearance. Rosewood Lodge DS0000064309.V260357.R01.S.doc Version 5.0 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 the following standard(s): 19 and 26 The internal and external environment at the home is maintained to a good standard which provides residents with a safe and comfortable in which to live. A planned programme of maintenance is in place. EVIDENCE: Rosewood Lodge is decorated and furnished to a good standard, with the decoration and furnishings being of a good standard. Furniture and lighting is domestic in character, which creates a homely environment. All bedrooms are single with full bathroom en suite facilities. A resident spoken to stated that she was very comfortable in her bedroom and would not like to live anywhere else. Observation of resident’s bedrooms revealed that all rooms were personalised with resident’s own belongings, which created a sense of home and belonging. Maintenance personnel are employed and a maintenance record is maintained. Staff are encouraged to be vigilant and report any minor repairs or areas of Rosewood Lodge DS0000064309.V260357.R01.S.doc Version 5.0 Page 14 concern they have noted. A system of recording any minor works required in the maintenance book, which is then acted upon on a daily basis by the maintenance men. Future plans for Rosewood Lodge include a total refurbishment, which will result larger bedrooms and improved facilities being created. The home is clean and free from offensive odours. Policies and procedures for the control of infection and safe handling of clinical waste are in place. All staff receives mandatory training in respect of infection control. The home has a separate laundry area that does not intrude on residents and is sited away from food storage and preparation. However some work is required on the laundry room walls to ensure that they are impermeable and readily cleanable. Rosewood Lodge DS0000064309.V260357.R01.S.doc Version 5.0 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 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 and 30 The policies and procedures for the recruitment of staff are required to be more robust to ensure safeguards and the protection of residents. EVIDENCE: There is a settled staff group at Rosewood Lodge with very few staff changes since the last inspection. Observation of a number of staff files revealed that all staff are interviewed prior to employment with written references being sought and Criminal Records Bureau checks being carried out. However it became evident that two staff members had taken up employment on the basis of verbal references and prior to written references being received. It was pleasing to note that all staff had been cleared through the Criminal Records Bureau or were in receipt of a POVA first check. The registered manager was informed that to fully protect residents new staff must not take up employment until satisfactory written references have been received. In addition staff that have a POVA first check must work supervised until the full Criminal Record Bureau check has been received. The registered manager said she would ensure that the recruitment process in future would be applied more stringently. Once employed all staff receive induction, which should involve shadowing an experienced member of staff. However on the day of the inspection the inspector observed a new member of staff being allocated ‘tasks’ and then Rosewood Lodge DS0000064309.V260357.R01.S.doc Version 5.0 Page 16 being left alone whilst she performed her tasks. As this was the new staff members first day the inspector advised that this was not acceptable and in the initial stages of induction new staff members should work along side an experienced member of staff at all times. As part of the induction process the registered manager provides training in relation to the standards of care required at Rosewood Lodge. This training is based on the TOPSS (Training Organisation for Personal Social Services) standards for induction and records observed revealed that this training is provided over a period of time and the record is signed by the staff member and the registered manager. Staffing levels were sufficient for the number of residents living at the home. Residents said they were happy with the care they receive from the home and were well treated by the staff. Residents spoken to say they had ‘no complaints’ and confirmed that in their opinion there was always sufficient staff on duty. Staff spoken to said they were clear about their role and work well as a team to ensure the individual and collective needs of residents are met. A number of staff have completed their NVQ training and it is pleasing to note that the home has now achieved 75 of the staff group trained to a minimum of NVQ Level 2. In addition short courses are arranged to ensure staff have the necessary knowledge and skills to meet the needs of the residents living at Rosewood Lodge. A training matrix is maintained which shows what mandatory training staff have attended. The inspector advised that all training provided be recorded on the training matrix. Certificates of achievement are retained in the individual staff file. Rosewood Lodge DS0000064309.V260357.R01.S.doc Version 5.0 Page 17 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): 35 and 38 The management and staff at the home are competent and the health, safety and welfare of residents are strongly promoted. EVIDENCE: As the registered provider does not manage the home she is required to carry out monthly visits in order to satisfy herself the home is being run in the best interests of the residents and that satisfactory standards are being maintained. The findings of these visits must be recorded and a copy of the record forwarded to the Commission for Social Care Inspection. The registered manager is competent and well experienced. In order to ensure best practice the registered manager pursues further training and has recently completed a Diploma in Management Course. Rosewood Lodge DS0000064309.V260357.R01.S.doc Version 5.0 Page 18 Records are kept of routine maintenance and servicing of equipment. COSHH regulations are adhered to and substances hazardous to health are stored securely. All staff are made aware of their responsibilities for health and safety. Training in health and safety and fire safety is provided through the induction of all new staff and refresher courses are held at regular intervals. The home has comprehensive policies and procedures in relation to health and safety these take the form of individual policies in relation to safe working practices. The inspector advised that all policies should be reviewed on an annual basis. At present the home’s risk assessments are not in sufficient detail to fully protect residents and staff. The registered manager was strongly advised that risk assessments in relation to all working practices must be in place. All risk assessments must include the identified hazard together with the details of the action to be taken in order to minimise the hazard. Once in place all risk assessments must be under constant review and signed by staff once they have read and understood the content. There is a system in place for recording resident’s personal money residents are encouraged to retain responsibility for their own finances. To reduce the involvement of staff in managing residents personal money the home operates an invoicing system in that any expenditure spent on behalf of the resident, i.e. hairdressing and chiropody, will be paid by the home and the resident invoiced accordingly. All expenditure is receipted and receipts are retained on individual files. Rosewood Lodge DS0000064309.V260357.R01.S.doc Version 5.0 Page 19 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 2 Rosewood Lodge DS0000064309.V260357.R01.S.doc Version 5.0 Page 20 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 2 3 4 Standard OP30 OP29 OP38 OP38 Regulation 18 19 26 23 Requirement All staff must be supervised through their induction period. Two written references must be obtained prior to employment. The registered manager must conduct Regulation 26 visits. Risk assessment must be in place for all safe working practices and environmental issues. Medication procedures require reviewing. Timescale for action 30/11/05 30/11/05 30/11/05 31/12/05 5 OP9 13 30/11/05 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 OP38 OP26 Good Practice Recommendations Policies and procedures should be reviewed an annual basis. The laundry room walls should be repainted. Rosewood Lodge DS0000064309.V260357.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 DS0000064309.V260357.R01.S.doc Version 5.0 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. 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