Inspection on 08/08/06 for Rossendale Hall

This inspection was carried out on 8th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 15 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 16/03/06

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 Key Unannounced Inspection 8th August 2006 10:00 Rossendale Hall DS0000006617.V296550.R01.S.doc Version 5.2 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.V296550.R01.S.doc Version 5.2 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.V296550.R01.S.doc Version 5.2 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.V296550.R01.S.doc Version 5.2 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 service 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 Commission for Social Care Inspection. 16th March 2006 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, which has been named Riverside since the last inspection; and the long stay, now named Hillside. 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. Information provided by the manager on 17 July2006 identified that fees ranged from £375.00 to £519.75 per week. Rossendale Hall DS0000006617.V296550.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit to the home, which was part of the key unannounced inspection for this service, took place on 08 August 2006 and feedback was given to the manager of the service on 21 August 2006. The manager had provided CSCI with information about the service on 17 July 2006. CSCI survey forms had been sent to home for residents and families none had been completed and returned. One health care professional had completed CSCI comment cards about the home and no concerns were raised. All residents of the home were available on the day of the visit and spoken with. Two residents were spoken with at length regarding their feelings of living in the home. Three residents’ care plans were inspected and a number of the home’s records were seen. The visit included a tour of the premises. What the service does well: What has improved since the last inspection? The information available for prospective residents is informative and has been improved by the addition of photographs to make it easier to understand. East Cheshire Advocacy service has been working with residents of the home to ensure their views about life in the home are known. The completion of the re-wiring in The Hall has significantly improved the safety of the environment from hazards relating to carrying out this work. Information stored on staff personnel records is more structured so it is easier to track that all necessary checks and staff development are taking place. Senior management meetings (the registered manager and house managers) are taking place regularly to improve communication and consistency of approach to the care of the residents. Rossendale Hall DS0000006617.V296550.R01.S.doc Version 5.2 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. Rossendale Hall DS0000006617.V296550.R01.S.doc Version 5.2 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.V296550.R01.S.doc Version 5.2 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): 1, 2, 3, 4, & 5 Quality in this outcome is poor. This judgement has been made using the available evidence including a visit to the service. Although improvements have been made to the information that is available for potential residents, the lack of initial assessment of residents’ needs means that they may not get the care and support they require. EVIDENCE: A statement of purpose and service user guide is available and was informative regarding the home and life in the home. Improvements have been made by including photographs to assist with understanding. Two residents’ files were inspected. Both residents had been admitted to the home within the last six months as emergency placements. The files contained limited information regarding their assessed needs. The manager said that there had been difficulties in obtaining the assessments from the residents’ social workers. The home had not yet completed their own assessment of the needs of the residents. Neither of the residents had had the opportunity to spend time visiting the home before they moved there because of the circumstances around their admission. The manager confirmed that their residency had been confirmed but in the absence of an assessment of their needs and a care plan the home could not demonstrate that their needs could be met. Rossendale Hall DS0000006617.V296550.R01.S.doc Version 5.2 Page 9 One resident spoken with did not recall if any meeting had taken place with him to confirm whether he was happy with the arrangements for living in the home. There was no evidence to suggest that existing residents had been consulted regarding the new admissions to the home. Contracts/statements of the terms and conditions living in the home were not available on the residents’ files. Rossendale Hall DS0000006617.V296550.R01.S.doc Version 5.2 Page 10 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, 7, 8 & 9 Quality in this outcome is poor. This judgement has been made using the available evidence including a visit to the service. Risks relating to daily living and activities have not been assessed and therefore the residents may not be adequately safeguarded. EVIDENCE: Three residents’ care plans were inspected during the visit. Two plans provided only limited information about the residents’ care needs. The third care plan gave a full picture of the residents’ life but the plan was not signed or dated. Risks in respect of daily living and activities had not been identified. The manager confirmed that somebody has been commissioned to undertake work within Rossendale Trust regarding risk and assessment of risk and will also deliver training to staff. Residents are encouraged to make decisions regarding their daily living, for example what activities they want to take part in. These decisions were not recorded accurately on the residents’ care plans and could lead to confusion for staff unfamiliar with the residents’ routines. Rossendale Hall DS0000006617.V296550.R01.S.doc Version 5.2 Page 11 The manager confirmed that the residents of the home are not involved in making decisions about the day-to-day running of the service. East Cheshire Advocacy service has recently surveyed all the residents of the home to establish their views regarding the service offered to them. This is seen as a positive move towards resident involvement. Rossendale Hall DS0000006617.V296550.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14, 15, 16 & 17 Quality in this outcome is good. This judgement has been made using the available evidence including a visit to the service. Residents are supported to make choices so they maintain control over their lives within their individual abilities. EVIDENCE: Rossendale Trust offers a range of daytime activities for the residents. They have a day centre in the village hall in Sutton. A horticulture centre operates adjacent to the home and two of the residents in the home have work placements. During the visit, residents were seen watching TV and videos; one resident spoken with has SKY TV in his bedroom. The resident said that he enjoys spending time in his room watching football and the music channel. One resident’s record of his finances identified that £510 had been used for a recent holiday. The manager said that the Trust was not able to fund a sevenday break for residents as part of the contract price and all residents needed to fund their own holidays. Rossendale Hall DS0000006617.V296550.R01.S.doc Version 5.2 Page 13 One member of staff and a volunteer had been accompanied the resident on holiday, but there was no evidence to show that thorough checks, including CRB disclosures, had been obtained for the volunteer. (See standard 34) Staff in the home offer residents the necessary support to maintain relationships with their families. One resident received an invitation to a family party during the visit and staff were seen offering support to use the telephone to accept and making the necessary arrangements to attend. During the visit staff were seen chatting with residents; the atmosphere was friendly and relaxed. Two bedrooms in the Hall have an interconnecting door. The residents’ views should be explored to ensure they are happy with this arrangement. It is recommended that a lock should be fitted to give residents privacy but if this door is part of a fire escape route, the fire officer should be consulted. During the first visit to the home, one resident spoken with at length said that he had asked for a key to his bedroom since he moved to the home. His key worker confirmed this and said that some items of clothing had disappeared from his room, which caused him obvious distress. This had still not been addressed thirteen days after the first visit. As most residents are involved in activities during the day the main meal is in the evening. Menus provided a variety of dishes and catered for the likes and dislikes of residents. Rossendale Hall DS0000006617.V296550.R01.S.doc Version 5.2 Page 14 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): 18,19,20 Quality in this outcome is adequate. This judgement has been made using the available evidence including a visit to the service. The home maintains good links with community support services to ensure residents’ health needs are met; however, equipment must be provided so that residents’ assessed needs can be met safely. EVIDENCE: Staff support some residents with all aspects of their personal care. The level of assistance required is dependent on their assessed needs. A “key worker” system is in operation in the home. The low staff turn over and the fact most staff have worked in the home for a number of years ensures they know the residents well. One care plan inspected provided evidence that the residents receive advice and treatment from a number of health care professionals, eg: doctors, physiotherapists, continence advisors and community nurses. Three residents in the home are experiencing difficulties with mobility and confidence in relation to bathing. In 2005 advice had been asked from an occupational health therapist regarding bathing facilities in Riverside. An assisted bath has been recommended and although this has been identified in Rossendale Hall DS0000006617.V296550.R01.S.doc Version 5.2 Page 15 the maintenance and refurbishment programme, the manager was unable to confirm when funds would be available to undertake this work. One resident has recently slipped and fallen using the shower. Evidence was found that two residents pay for repairs and servicing of the technical equipment they need for their daily living, for example their beds and a hoist. The cost of maintenance and repairs/servicing of equipment needed by the service user should be met by the home. If these extra costs cannot be met this information should be clearly identified in the contract/statement of terms and conditions of living at the home. The home has good links with community nursing advisors and all residents have annual health checks relating to eyesight and dentistry. A specialist optician visits the home and while some residents with communication difficulties need this level of service others do not and should be registered with an optician of their choice. Medication records were inspected in Riverside. Medication is supplied by the pharmacy in a monitored dosage system. Administration of medication was recorded appropriately. Records for medication prescribed for short-term treatments or “as required” were not as clear. Accurate records should be maintained of all medicines received in the home to ensure a full audit trail can be achieved. Rossendale Hall DS0000006617.V296550.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome is poor. This judgement has been made using the available evidence including a visit to the service. The lack of training for staff on the protection of vulnerable adults may leave the residents at risk of harm. Although staff listen to the residents’ concerns/complaints, there are no records kept to show that the complaints process is effective for the residents. EVIDENCE: Information provided by the manager on the 22 June 2006 stated that no complaints had been received by the home. In discussion with one resident he said that he knew to whom he could complain to should he be unhappy with any aspect of his service. When asked if he had any worries or complaints he said “yes”, “I want a key to my room” “I still haven’t got a wardrobe” and “I’m fed up with someone going in my room taking things”. The resident’s key worker confirmed that he had raised these issues with the manager. A CD ROM training pack has been purchased by the home to develop staff awareness of Adult Protection issues and procedures. However due to technical difficulties with the equipment, the staff have not yet received training relating to protecting vulnerable adults. Rossendale Hall DS0000006617.V296550.R01.S.doc Version 5.2 Page 17 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, 26, 27, 29, 30 Quality in this outcome is poor. This judgement has been made using the available evidence including a visit to the service. Improvements have been made to the safety of the building following the completion of the rewiring of the Hall. However areas of risk relating to hygiene and safety have not been thoroughly assessed, leaving residents and staff exposed to unnecessary risk. EVIDENCE: A tour of the premises the Hall, Riverside and Hillside was undertaken as part of the inspection. The home has a number of double bedrooms and although the current residents have shared for a number of years, the manager should review this arrangement at the next opportunity. The home’s Statement of Purpose states that single rooms will be offered when available. Screens must be provided to provide privacy in rooms that are currently shared. A number of concerns about the building and provision of equipment were identified. There is a maintenance and development programme, dated May 2006, available for Riverside that showed most areas of concern will be addressed. This included providing the appropriate bathing facilities Rossendale Hall DS0000006617.V296550.R01.S.doc Version 5.2 Page 18 recommended by the occupational therapist. However, the manager was unable to confirm when funds will become available to undertake the work. There are a number of areas in Hillside that need to be addressed and the enamel of one of the baths is worn away in places and needs to be replaced. The rewiring in the Hall has now been completed and an electrical installation certificate issued on 22 March 2006. However, there are areas that require replacement and refurbishment, particularly worktops and tiles in the kitchen. One first floor bedroom window gives the occupant direct access to a flat roof but there was no risk assessment available to establish why a window restraint had not been fitted to protect the resident from potential falls. Rossendale Hall DS0000006617.V296550.R01.S.doc Version 5.2 Page 19 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, 33, 34, 35, 36 Quality in this outcome is poor. This judgement has been made using the available evidence including a visit to the service. Inadequate vetting of volunteer staff, insufficient staffing numbers and lack of staff training could lead to residents being at risk of harm or poor practice. EVIDENCE: Job descriptions are available for all staff working in the home and the training officer has completed individual training plans relating to each member of staff in the home. She confirmed that three staff have completed NVQ level 2, two staff have completed NVQ level 3 and seven under 25 year olds are registered with a local college. There was no evidence confirm that staff have achieved the minimum mandatory training in relation to health and safety, moving and handling, emergency aid, food hygiene and protection of vulnerable adults. On the day of the visit only two staff were on duty to provide support and cook the evening meal for the sixteen residents living in both The Hall and Hillside. This level of staffing was seen as insufficient to meet the needs of that number of residents effectively and safely. Three staff files were inspected and information contained in them had been improved to include application forms, references and Criminal Record Bureau checks. Rossendale Hall DS0000006617.V296550.R01.S.doc Version 5.2 Page 20 One resident said that she had just come back after being on holiday, which she enjoyed. The conversation with staff and the resident confirmed that two carers had gone to support two residents. However one of the carers was not employed by the Trust and was a family member of the staff. The manager confirmed that he had not carried out any checks regarding the volunteer. Support staff reported that they have regular contact with the house managers and monthly meetings take place between the manager of the home and the house managers. Senior staff have access to the registered manager on a daily basis, but no formal arrangements are in place for one to one supervision to monitor their performance and discuss their development needs. Rossendale Hall DS0000006617.V296550.R01.S.doc Version 5.2 Page 21 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, 38, 39, 42 Quality in this outcome is poor. This judgement has been made using the available evidence including a visit to the service. Health and safety training for staff has not been updated and internal monitoring processes are not in place to ensure continuing development of the service in the best interests of the service users. EVIDENCE: The manager has achieved the NVQ level 4 Registered Manager award and is currently working towards level 5. The responsibilities of the manager have been significantly increased from those he had when he was first registered with the Commission for Social Care Inspection. The extra work significantly reduces the time he has to monitor the quality and performance of the home. The manager he confirmed that these concerns are being addressed. The home has a complaints procedure. However this was found not to be effective (see standard 22). The resident who had made the complaint and the Rossendale Hall DS0000006617.V296550.R01.S.doc Version 5.2 Page 22 staff member who worked with him were not enabled to effect the way in which the service was offered as no action was taken. East Cheshire Advocacy service have recently concluded a survey to establish what the residents think of the service they are offered. The outcome was positive. A report is available in the home. There is no monitoring of the service being undertaken by a representative of the organisation that runs the home, in accordance with Regulation 26, to audit that the home is running in the best interests of the service users. The home does not have a continuous training programme to cover mandatory training in relation to health and safety, moving and handling, food hygiene, first aid. Information provided by the manager show that service contracts are up to date in relation to gas supply, electrical installation. The home’s records were inspected and are maintained appropriately in respect of the fire equipment, emergency lighting, alarms and fire extinguishers. Rossendale Hall DS0000006617.V296550.R01.S.doc Version 5.2 Page 23 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 Standard No Score 1 3 2 1 3 1 4 2 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 1 ENVIRONMENT Standard No Score 24 2 25 2 26 2 27 2 28 X 29 1 30 2 STAFFING Standard No Score 31 3 32 2 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 2 2 X X 2 X Rossendale Hall DS0000006617.V296550.R01.S.doc Version 5.2 Page 24 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 YA2 Regulation 14(1) Requirement Residents must not be admitted into the home unless the home can demonstrate that their assessed needs can be met. Residents must be given a 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, plus any extras that the resident must pay for. This requirement remains unmet from the previous inspection on 16/03/06 Care plans must be reviewed regularly and updated to reflect the residents’ current needs This requirement remains unmet from the previous inspection on 16/03/06 Risks to health and safety of residents must be identified and so far as possible eliminated Bathing facilities suitable for the needs of the residents must be provided in Riverside Technical equipment to meet the needs of the residents must be DS0000006617.V296550.R01.S.doc Timescale for action 31/10/06 2. YA5 5(3) 31/10/06 3. YA6 15(2) 31/10/06 4. 5. 6. YA9 YA18 YA18 13(4) 23(2) 23(1)(2) 31/10/06 30/11/06 31/10/06 Rossendale Hall Version 5.2 Page 25 7. YA23 18 8. YA22 22 9. YA24 23 10. 11. 12. YA25 YA26 YA33 16(2) 13(4) 18(1) 13. YA34 19(1)-(4) supplied and maintained by the home All staff must receive training on 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. This requirement remains unmet from the previous inspection on 16/03/06 The complaints procedure must be suitable for the residents’ needs and a record kept of all complaints made and action taken as a result. This requirement remains unmet from the previous inspection on 16/03/06 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 with appropriate timescales This requirement remains unmet from the previous inspection on 16/03/06 Privacy screens must be provided in double occupancy rooms Risk associated with potential falls from upstairs windows must be minimised. Staffing levels must be maintained to meet the individual and collective needs of the residents. Thorough vetting processes, Criminal Record Bureau checks and references must be in place for everyone who has regular contact with residents DS0000006617.V296550.R01.S.doc 31/10/06 31/10/06 31/10/06 30/11/06 31/10/06 30/09/06 30/09/06 Rossendale Hall Version 5.2 Page 26 14. YA37 10 15. YA39 26 Taking into consideration the size and the nature of the service, the registered manager must be given the time to manage the home effectively. This requirement remains unmet from the previous inspection on 16/03/06 Visits to the home must be undertaken by a nominated person for the trustees at least once a month and a report produced on the way the home is being run. This requirement remains unmet from the previous inspection on 16/03/06 30/09/06 30/09/06 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. 2. 3. Refer to Standard YA3 YA4 YA8 Good Practice Recommendations The home should not confirm residency in the home unless it can demonstrate that residents’ needs can be met. When emergency admissions are made the home should discuss the rules and routines of living in the home within 48 hours and assess their needs within 5 days. Residents of the home should be encouraged to participate in the running of the home by attending staff meetings, participating in staff recruitment and selection of new residents. Part of the basic contract price should include a minimum of a seven-day annual break, which they help chose and plan. Residents should be offered a key to their bedrooms. Residents when appropriate should be given the opportunity to registered with an optician of their choice The medication administration record should record all DS0000006617.V296550.R01.S.doc Version 5.2 Page 27 4. 5. 6. 7. YA14 YA16 YA19 YA20 Rossendale Hall 8. 9. 10. 11. YA25 YA32 YA36 YA37 medicines received into the home and include any stock already held, so an accurate audit trail of medications can be achieved. The manager should review the arrangements for providing shared bedrooms at the next opportunity 50 of staff should have achieved NVQ level 2 as a minimum by 2005 Regular recorded supervision meetings should take place as a minimum six times per year. 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.V296550.R01.S.doc Version 5.2 Page 28 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.V296550.R01.S.doc Version 5.2 Page 29 - 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!