Inspection on 16/03/06 for Rossendale Hall

This inspection was carried out on 16th 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rossendale Hall 09/01/09

Rossendale Hall 28/05/08

Rossendale Hall 30/05/07

Rossendale Hall 09/01/07

Rossendale Hall 08/08/06

Rossendale Hall 29/06/05

Rossendale Hall 23/11/04

Rossendale Hall 12/08/04

Similar services:

Ruskin Lodge

Clover House

Dystlegh Grange

The Good Companions

Cuerden Grange Rest Home

Springfield Cottage

Parkside

Park Lodge

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

CARE HOME ADULTS 18-65 Rossendale Hall Hollin Lane Sutton Macclesfield Cheshire SK11 0HR Lead Inspector Ms Julie Porter Unannounced Inspection 1:00 16 March 2006 th Rossendale Hall DS0000006617.V263225.R01.S.doc Version 5.0 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 Rossendale Hall DS0000006617.V263225.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 Adults 18-65. 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. Rossendale Hall DS0000006617.V263225.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Rossendale Hall Address Hollin Lane Sutton Macclesfield Cheshire SK11 0HR 01260 252500 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) Rossendale Trust Christian Blythe Care Home 30 Category(ies) of Learning disability (28), Learning disability over registration, with number 65 years of age (2), Physical disability (10) of places Rossendale Hall DS0000006617.V263225.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide care for a maximum of 30 service users including: Up to 30 service users in the category of LD(learning disabilities) Up to 2 sevice users in the category of LD(E) learning disabilities, 65 years and over) Up to 10 service users in the category of PD (physical disabilities) The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The registered provider must provide staff to meet the dependency needs of service users at all times and shall comply with any guidelines that may be issued through the Commision for Social Care Inspection. 29th June 2005 2. 3. Date of last inspection Brief Description of the Service: The Rossendale Trust was established in 1973 and provides both residential and day care for adults with learning disabilities. Rossendale Hall, registered to provide care for 30 people with learning disabilities, is a detached hall built in the 1930s situated in its own grounds in a rural location on the outskirts of Macclesfield. The home has been adapted and extended over the years and currently comprises of three self-contained units: the Hall, the short stay and the long stay. Despite their names, both of the latter two units provide permanent care. Accommodation is in single and shared bedrooms situated on the ground and first floors. The rooms are smaller than the sizes identified in the national minimum standards (Standard 25 of the National Minimum Standards for Care Homes for Younger Adults). However, as the home was registered and in use before 31 March 2002, the home does not have to meet this standard. Local amenities, in the village of Sutton and at other Rossendale Trust services, are a short drive away. Rossendale Hall DS0000006617.V263225.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The initial visit to the home for this inspection took place on 07 December 2005 and included a meeting with the Trustees of the service and staff. The inspection was concluded on 16 March and involved meeting with residents and staff, a further review of the records and the pre-inspection questionnaire completed by the manager of the home, and a tour of the premises. What the service does well: What has improved since the last inspection? What they could do better: Contracts for the residents detailing the terms and conditions of living in the home must be developed. The storage of information about the residents should be reviewed to ensure current information is available. The staff training plan must encompass all mandatory training and training relating to adult protection. The home must have a thorough and effective complaints procedure suitable for the needs of the residents and link this to a quality assurance process for the development of the home. Maintenance and repairs to the home must be undertaken in a timely fashion to cause the least possible disruption to the residents. Risk assessments and risk management strategies must be developed to ensure residents’ safety whilst the work is taking place. Residents must be provided with suitable equipment to meet their needs including beds. It is the responsibility of the Trust to provide adequate furniture for the residents, not the responsibility of the resident. Rossendale Hall DS0000006617.V263225.R01.S.doc Version 5.0 Page 6 The home must ensure staff are thoroughly checked before they start work at the home and that the information required under Schedule 2 of the Care Homes Regulations is available for each member of staff. 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. Rossendale Hall DS0000006617.V263225.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rossendale Hall DS0000006617.V263225.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 In the absence of contract and terms and conditions of living in the home, residents and families are not provided with full information regarding the service. EVIDENCE: Contracts between the home and the service user, detailing the terms and conditions of living in the home and what is included and what is not, were not available. A requirement was made at the last inspection that residents must have these contracts/statements of terms and conditions of living at the home. This requirement has not been met. See requirement 1 The manager confirmed that the residents’ needs and the cost related to meeting those needs have been under review for some time and agreements have recently been reached for an increase in fees. This should give the home the opportunity to develop the contracts referred to above, as the Trust will need to provide residents with information about the new fees and what these cover. Rossendale Hall DS0000006617.V263225.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 & 10 Although staff working in the home know the residents well there is a risk if the care plans are not kept up to date, in the absence of staff who know them, the residents may not receive the care they need. EVIDENCE: Information about the residents continues to be stored in a variety of places within each home and in the main office. Staff spoken with said that this can be problematic and means that often work needs to be duplicated, or is missed or the staff do not have immediate access to records. This was confirmed during a check of one of the residents’ files, as information in it was scant and not current. See requirement 2 and recommendation 1 The organisation is producing a newsletter called “Rossen-Tales”. Consideration needs to be given to the content to ensure that residents are assured of confidentiality and consent is given to the publication and reproduction of information and photographs. See requirement 3 and recommendation 2 Rossendale Hall DS0000006617.V263225.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 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 & 17 Staff practice has developed to ensure that residents’ privacy and dignity is maintained but further input is needed from a suitably qualified person to ensure residents are offered a nutritious, balanced diet. EVIDENCE: Staff confirmed that the intercom systems in place to monitor residents’ wellbeing are switched off when residents are being supported by staff, particularly when staff are providing personal care. This development is the result of a requirement made at the last inspection regarding dignity and privacy. Menu plans for a period of two weeks were included in the pre-inspection questionnaire. The meals identified for the period did not incorporate much fresh fruit and fresh vegetables. Contact should be made with a dietician to review menu planning to ensure residents are offered a healthy, balanced diet. See recommendation 3 Rossendale Hall DS0000006617.V263225.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 & 21 Improvements have been made relating to the administration of medication and covert medication administration so that residents are protected from the risk of not receiving their medication as prescribed. EVIDENCE: The home has reviewed its medication policy following a requirement made at the last inspection. The policy, dated 12 November 2005, now includes clear procedures in relation to covert administration of medication. Evidence was seen on one resident’s file that staff are following this guidance and the resident’s file included letters from the their GP and family, agreeing to the way the home administered the resident’s medication. The home has a policy regarding death and dying and has produced a procedure for staff to follow should somebody die whilst in the home. Rossendale Hall DS0000006617.V263225.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Without training for staff on protecting adults from abuse, residents continue to be at risk of harm or poor practice. The home’s complaints procedure is not effective and adequate records are not available so there is nothing to show that residents’ concerns and complaints are listened to and acted on. EVIDENCE: Staff at the home have still not completed adult protection training, as confirmed on the pre-inspection questionnaire. There are plans for future training but until that is completed, this requirement from the previous inspection remains unmet. See requirement 4 One resident spoken with was able to express if he was dissatisfied with any aspect of living in the home and confirmed he often spoke with the staff or the manager if things were wrong. A record of these conversations/complaints was not available. The home’s complaints procedure does not give consideration to how complaints are recognised and managed from people with limited verbal communication. This remains an outstanding requirement following the last inspection. See requirement 5 Rossendale Hall DS0000006617.V263225.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, 29 & 30 The home must ensure that improvements are undertaken and completed in a timely way and that the maintenance of the property is continuous to ensure residents live in a comfortable, safe environment. EVIDENCE: A tour of the premises, including the Hall, short stay and long stay, was undertaken during the inspection. In the Hall: the ongoing re-wiring programme has left the home in disarray. Carpets have been turned back to give access to the floor boards, some of the fire doors would not close as they were catching on the carpet, an inspection hole had been made in the ceiling, wallpaper has been removed from walls to enable the wiring to be channelled into the walls, and unwanted or unused items (including spare chairs, a table, glasses, lampshades, boxes and a radiator) had been left in the dome room, which was also very dusty. A new cooker has been installed in the kitchen. The kitchen of the home was found to be clean but worktops are damaged exposing chipboard, seals were broken and blackened and the paintwork discoloured. Rossendale Hall DS0000006617.V263225.R01.S.doc Version 5.0 Page 14 Some bedrooms are in need of decoration. Long stay: some improvements have been made to the environment; the lounge has been redecorated and furnished. The shower screen is broken and needs replacing. One resident has still not got a suitable bed and should be assessed by an occupational therapist to ensure the home purchases appropriate equipment. Short stay: the home was clean and fresh but some maintenance is required to the kitchen, ceiling in the lounge, bathrooms and patio doors in residents’ bedrooms. These are unmet requirements from the last inspection. See requirements 8 &9 A training room has been provided in the Hall. Access to this room is through the home and past residents’ bedrooms; consideration must be given to the scheduling of the training so as not to impact on the safety and privacy for residents. See recommendation 4 Rossendale Hall DS0000006617.V263225.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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, 32, 34 & 35 In the absence of robust recruitment processes and training for staff, residents are vulnerable to possible poor practice and harm. EVIDENCE: Job descriptions are available for all staff. Staff said that due to recent restructuring they were unsure of the lines of accountability. The organisation structure supplied to the Commission for Social Care Inspection confirms that the role of the registered manager has changed considerably since his registration. The organisation has a training leader and staff report that there have been some improvements in the availability of training. However, the three staff files that were checked at the inspection showed that staff had not received mandatory training. See requirement 10 The pre-inspection questionnaire identified that 10 staff started employment before their criminal record bureau disclosures had been received. This was evident on the three staff files checked during the inspection. In addition, two of the files contained only one reference and one file did not have a copy of the member of staff’s contract of employment. See requirement 11 Rossendale Hall DS0000006617.V263225.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 39 The extended responsibilities for the manager have reduced the time in which he is available to ensure that the home is run in the best interests of the residents. EVIDENCE: The roles and responsibilities of the manager have changed considerably since he was registered and the extra work has reduced the amount of time he has available to monitor the quality and performance of the home. Consequently requirements following the last inspection have not been met and further requirements have been made. See requirement 12 and recommendation 5 Internal quality monitoring systems, including monthly visits by a representative of the organisation that runs the home (Regulation 26 visits), and ways of obtaining the views of residents, relatives and staff about the home, need to be in place to enable the home to develop the service it provides. This requirement was made at the last inspection and has not been met. See requirement 13 &14 Rossendale Hall DS0000006617.V263225.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X 1 Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 X X 2 2 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 17 Standard No 31 32 33 34 35 36 Score 2 2 X 2 2 X 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Rossendale Hall Score X X 3 3 Standard No 37 38 39 40 41 42 43 Score 2 X 2 X X X X DS0000006617.V263225.R01.S.doc Version 5.0 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 YA5 Regulation 5 Timescale for action Residents must be given a 16/03/06 written contract or statement of the terms and conditions of residence at the home. These should include information about the accommodation provided and the method of payment of their fees Care plans must be reviewed 16/03/06 regularly and updated to reflect the residents’ current needs Staff must ensure that residents 16/03/06 are treated with dignity and respect at all times All staff must receive training on 16/03/06 protecting people from abuse and on adult protection procedures. Plans must be drawn up for each member of staff to receive training relevant to the role they perform, including all mandatory training. The complaints procedure must 16/03/06 be suitable for the residents’ needs and a record kept of all complaints made and action taken as a result. Requirement 2. 3. 4. YA6 YA17 YA23 15 12 18 5. YA22 22 Rossendale Hall DS0000006617.V263225.R01.S.doc Version 5.0 Page 19 8. YA24 23 9. 10 11 YA29 YA32 YA34 16 18 19 12 YA37 10 13. YA39 26 14. YA39 24 The home must have a planned schedule of maintenance to ensure the residents live in a safe comfortable & clean home. The problems identified in this report must be attended to as part of the planned schedule of maintenance Residents must be provided with furniture, including a suitable bed for their needs A rolling programme of staff training must include all mandatory training The registered person must ensure that full information regarding staff (as set out in Schedule 2 of the Care Home Regulation 2000) is available before they commence employment Taking into consideration the size and the nature of the service, the registered manager must be given the time to manage the home effectively. Visits to the home must be undertaken by a nominated person for the trustees at least once a month and a report produced Quality monitoring systems must be adopted to ensure service users views are sought 16/03/06 16/03/06 31/07/06 31/07/06 31/07/06 31/07/06 16/03/06 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 YA6 Good Practice Recommendations The storage of residents’ records should be reviewed to ensure staff have easy access to information, and information is kept updated. DS0000006617.V263225.R01.S.doc Version 5.0 Page 20 Rossendale Hall 2 3 4 5 YA10 YA17 YA24 YA37 Consideration should be given to confidentiality and consent relating to the publication of “Rossen-Tales” Advice should be sought from a dietician to ensure residents are offered a nutritious, balanced healthy diet. The provision of a staff training room in the home should not adversely affect the lives of the residents. The provider should review the organisation structure to ensure the registered manager for the home has the time to promote a quality, monitored service. Rossendale Hall DS0000006617.V263225.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Rossendale Hall DS0000006617.V263225.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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