Inspection on 16/05/05 for Rosslyn

This inspection was carried out on 16th May 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Rosslyn 10/11/08

Rosslyn 27/11/07

Rosslyn 09/01/07

Rosslyn 28/06/06

Rosslyn 13/10/05

Rosslyn 18/10/04

Rosslyn 10/05/04

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 Rosslyn 29 Bagdale Whitby North Yorkshire YO21 1QL Lead Inspector Pam Dimishky Unannounced 16 May 2005 at 9:00 am 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. Rosslyn J53_s7728_Roslyn_v225594_16 May 2005_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Rosslyn Address 29 Bagdale Whitby North Yorkshire YO21 1QL 01947 820931 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) Mr Jeremy William Southgate Care Home 11 Category(ies) of OP Old Age (11) registration, with number of places Rosslyn J53_s7728_Roslyn_v225594_16 May 2005_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th October 2004 Brief Description of the Service: Rosslyn provides long-term accommodation and personal care for a maximum of eleven older people. The home does not provide any specialist services. A stair lift in lieu of a passenger lift gives access to the first floor for residents with limited mobility and consequently the residents placed in bedrooms on the first floor have to be reasonably ambulant. The home is located on a main route into Whitby and is conveniently situated for the shops and other community facilities including the main transport network. The home does not have its own parking facilities but there is on-road parking within close proximity. Rosslyn is a traditional house with modern extension built on two floors with the communal areas and two bedromms being located on the ground floor. One bedroom has an ensuite toilet facility. A patio with bench seats and small, sloping lawn are located at the front of the building and there is a ramp leading from the road to the main entrance for wheelchair users. The steps up to the main door have a hand rail fixed to the adjacent wall to aid mobility. Rosslyn J53_s7728_Roslyn_v225594_16 May 2005_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 12 hours (including preparation and travel). The inspection process included a review of documentation and a tour of the building. The inspector spoke to six of the seven residents, one relative and the acting manager. What the service does well: What has improved since the last inspection? What they could do better: A number of requirements made at previous inspections remain outstanding, therefore they have been brought forward and included in this report. All residents must have a needs assessment before entering the home, from which a care plan is developed to ensure health, personal and social care needs are met. The recruitment and selection of staff must improve to ensure the safety of residents. Routine maintenance of equipment and building must improve to ensure the health and safety of residents and staff. An application must be made to the Commission to register a manager. Rosslyn J53_s7728_Roslyn_v225594_16 May 2005_Stage 4.doc Version 1.30 Page 6 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. Rosslyn J53_s7728_Roslyn_v225594_16 May 2005_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 Rosslyn J53_s7728_Roslyn_v225594_16 May 2005_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 5 Improvements are needed the admission procedure to ensure no resident moves into the home without their needs being assessed. Without this there is no assurance that their care needs can be met by the home. EVIDENCE: Prospective residents are given the information they need to make an informed choice about where to live. This information has been updated to reflect the new management arrangements, but a copy has not been sent to the Commission. The grandson of one resident was able to confirm he was given a copy of the service users’ guide and visit the home prior to his grandmother coming into the care home. Each resident, apart from one, has a written contract and these have now been signed by the proprietor, which was not the case at the previous inspection. One resident who came into the home on 20.10.04, has not had an assessment of care needs either by the home or social services. This resident does not have a contract either with the home or social services, although fees are being paid by the local authority. The community psychiatric nurse did Rosslyn J53_s7728_Roslyn_v225594_16 May 2005_Stage 4.doc Version 1.30 Page 9 make a new patient assessment (dated 19.11.04) and advice included in the report regarding the use of sedatives is not being adhered to which could put the resident at risk. Rosslyn J53_s7728_Roslyn_v225594_16 May 2005_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 Without a care plan it is not possible to be sure that individual residents health, personal and social care needs are being fully met. Staff are not appropriately trained for the administration of medicines which may have the potential to place residents’ at risk. EVIDENCE: One resident who came into the home 20.10.04 is still without a care plan; the resident has special dietary needs which the manager is aware of but these are not recorded. The manager reviews care plans monthly and these have been signed by the resident or their relative, indicating their agreement to it. Three case files were examined and two were noted to have a comprehensive care plan. Care plans are kept in a separate file to the daily records which may be the cause of insufficient daily records being kept to evidence whether residents’ health care needs are fully met. However, all residents appeared happy, clean and nicely dressed. Care staffs’ interaction with residents was relaxed and appropriate and they were observed to be respecting their privacy and dignity. The home is supported by local health services and the continence nurse has visited the home and assessed two residents. Rosslyn J53_s7728_Roslyn_v225594_16 May 2005_Stage 4.doc Version 1.30 Page 11 A monitored dosage system (MDS) is used for medications which are suitably stored in a locked cupboard. Training for the administration of medicines has been provided by the previous manager and the manager stated she is to request updated training for staff with the supplying pharmacist and will also refer staff to the Royal Pharmaceutical Society’s guidelines for care homes. One member of staff was observed handling tablets when dispensing from the blister pack into a pot prior to being given to the resident and she was reminded by the acting manager this is not good practice. Rosslyn J53_s7728_Roslyn_v225594_16 May 2005_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 Residents are able to take advantage of activities provided by the home and are able to participate in community and family life. EVIDENCE: All residents have a profile of past medical history, their life and family, food likes and dislikes, social interests etc. Care plans indicate relatives visit regularly, some visiting daily. One resident related how staff had taken her into Whitby to buy some new clothing and shoes; and jigsaws and games are available in the lounge. Three residents said they preferred to spend time in their room quietly reading or watching television. The home’s telephone is available in the hall or outside the kitchen for residents’ to make and receive calls; the manager is looking into purchasing a cordless telephone for calls to be made in privacy. Residents expressed how they are able to exercise choices in their lives eg choose their own clothes, choice of food, and can eat when and where they wish. Two residents were observed having breakfast in the lounge, others ate in their room; lunch was also served in the dining room, lounge or bedroom according to choice. A menu book is kept of meals offered which is based on the known likes and dislikes of residents; alternatives are available on request and six choices were recorded at teatime. Fish features regularly as the manager has ready access to fresh fish which is brought into, and cooked, in Rosslyn J53_s7728_Roslyn_v225594_16 May 2005_Stage 4.doc Version 1.30 Page 13 the home. On the day of inspection residents were observed enjoying roast chicken, stuffing, carrots, turnip and potatoes (green vegetables are provided on alternate days), followed by jelly and fruit. One resident was happy to say that the food had improved significantly since the new manager was appointed. Rosslyn J53_s7728_Roslyn_v225594_16 May 2005_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 Staff have not had awareness training for the protection of vulnerable adults which leaves residents’ potentially at risk. EVIDENCE: Requirements made at the last inspection for staff to receive awareness training for the protection of vulnerable adults and amendment to the whistle blowing policy, in line with the Department of Health’s document “No Secrets”, in the home is outstanding. Residents’ and their relatives are given a copy of the complaints procedure and the manager gave assurance that there have been no complaints since the last inspection; the complaints book could not be found. Rosslyn J53_s7728_Roslyn_v225594_16 May 2005_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) 19,20,22 and 26 The standard of the environment within this home is generally good providing residents with an attractive, clean and homely place to live. Not all the chairs in the lounge and dining room provide for comfortable seating and the call alarm system does not maximise residents’ independence in communal areas. The lack of soap and towels in the laundry for washing hands are not conducive with maintaining satisfactory standards of hygiene. EVIDENCE: Since the appointment of the new manager the home has been made a no smoking building. The staff room is difficult for staff to use as the proprietor has now stored old chair lift parts and bits of carpet in the area; staff therefore now smoke outside. This is also the route to the laundry and therefore access must be kept free. A programme of routine maintenance and renewal of the fabric and decoration of the premises is outstanding from the previous inspection. However, there is evidence of improvements being made ie a new carpet has been fitted in two Rosslyn J53_s7728_Roslyn_v225594_16 May 2005_Stage 4.doc Version 1.30 Page 16 bedrooms, the porch and rooms 3 and 7 have been redecorated and a new refrigerator has been installed in the kitchen. Residents’ privacy and dignity is maintained in bathroom and toilet areas as doors have locks fitted; the locks may be opened on either side in an emergency. No bedrooms have locks fitted. A requirement for a call alarm facility in the dining room is outstanding from the previous inspection and one resident, who sits in her favourite area in the lounge, said she is unable to reach the call alarm when she needs toileting and has to rely on other residents to activate the alarm for her. The kitchen was clean and tidy; temperatures of the refrigerator, which should be recorded daily to ensure safe practice, had not been recorded since 10.4.05. A requirement for the provision of soap and towels for hand washing in the laundry is outstanding from the previous inspection. Staff working in the laundry have been using the kitchen to wash and dry hands which could lead to a risk of spreading infection. The bedroom door to room 5 was catching on the carpet and did not close into the rebate; the manager stated she would attend to this on the day of the inspection. Rosslyn J53_s7728_Roslyn_v225594_16 May 2005_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 The numbers of staff on duty are, at all times, sufficient to meet the needs of the current seven residents. However, the absence of vetting and recruitment practice and procedures for the employment of staff leaves residents’ potentially at risk. EVIDENCE: Seven residents currently live in the home and are being cared for by two members of staff on duty for the early and late shift (including the manager) and one at night with the manager on call. The manager lives on the premises and when she is absent, another member of staff lives in. Since the last inspection, a new member of staff has been appointed based on information from a telephone reference only; a Criminal Records Bureau (CRB) and POVA lst check have not yet been applied for. Recruitment procedures need to ensure only fit people are employed to care for vulnerable adults. Information about staff, required to be kept by the home, remains outstanding from previous inspections. The requirement made at the previous inspection to meet regulation for all staff to have contracts of employment, also remains outstanding. Induction training which meets Skills for Care requirements, has been booked for all staff and the manager is to explore whether foundation training can also be undertaken by the same company. Two members of staff are taking NVQ level II and the manager is hopeful that 50 of staff will have the qualification by the end of the year. A representative from Scarborough College has visited Rosslyn J53_s7728_Roslyn_v225594_16 May 2005_Stage 4.doc Version 1.30 Page 18 the home to discuss training with the manager. All staff have had moving and handling training, but not all have food hygiene or first aid. Rosslyn J53_s7728_Roslyn_v225594_16 May 2005_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) 31,34 and 38 The manager is working in an acting capacity only and until an application is made to the Commission to be the registered manager, does not meet the legal requirements for managing the home. Some areas of health and safety have the potential to put residents at risk. EVIDENCE: The acting manager has worked in the home for the last five years but no application to be registered with the Commission has been made. She is applying to take a qualification at level NVQ IV in care and management. The home is not responsible for any residents’ monies and arrangements for this are made by the family. A requirement made at the last inspection for a business and financial plan indicating the effective and efficient management of the business is outstanding. The proprietor is making monthly visits to the home and is signing a record of the visit, but is not making a report as required to indicate areas assessed and any action to be taken. Rosslyn J53_s7728_Roslyn_v225594_16 May 2005_Stage 4.doc Version 1.30 Page 20 Staff were given fire safety training on 6.4.05, the fire alarm is checked weekly and emergency lighting monthly; fire extinguishers were checked during September 2004. A fire risk assessment requested by the Fire Safety Officer in a letter dated 18.10.04 remains outstanding. Doors do not have intumescent strips and advice should be sought from the fire officer as to the protection afforded by them in case of fire. A Health and Safety poster is displayed in the kitchen and a record of accidents is being kept. However, there was no entry for one resident who fell the day before the inspection nor was there an entry in the daily records being kept for the care provided. The stair lift had a certificate dated 1.4.05 for a thorough examination but there was no evidence the bath hoist had been so examined or serviced. Windows in rooms 4,6 and 7 do not have restricted opening to 6” – 8” and room 6 also needs attention to the sash to stop the window dropping. Rosslyn J53_s7728_Roslyn_v225594_16 May 2005_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 2 2 1 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 1 1 x 1 x x x 1 STAFFING Standard No Score 27 3 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 1 1 x x 1 x x x 1 Rosslyn J53_s7728_Roslyn_v225594_16 May 2005_Stage 4.doc Version 1.30 Page 22 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. Standard 3 8 9 18 Regulation 14 15 13 13,19 Requirement Ensure no resident moves into the home without having had their needs assessed Ensure health, personal and social care needs are set out in an individual plan of care Ensure all staff responsible for administration of medicines receive appropriate training Ensure residents are protected from abuse by raising staff awareness through training and amending the whistle blowing policy in line with the department of health document No Secrets Replace or re-upholster dining room and lounge chairs as needed Ensure call alarm facilities are available to maximise residents independence. (Previous timescale of 31/12/04 not met) Ensure soap and towels are always available in the laundry. (Previously an immediate requirement not met). Staff working in the laundry must not enter the kitchen A Criminal Records Bureau and POVA 1st check must be Timescale for action Immediate Immediate 31/07/05 31/08/05 5. 6. 19 22 16 23 31/08/05 30/09/05 7. 26 16 Immediate 8. Rosslyn 29 19 Immediate Page 23 J53_s7728_Roslyn_v225594_16 May 2005_Stage 4.doc Version 1.30 9. 29 19 10. 11. 31 34 8, 9 17, 25 12. 38 13, 23 13. 14. 38 38 17 13 15. 38 13,23 requested for new staff employed to work at the home, before they start work Information about staff listed in Schedules 2 and 4 of the Care Homes Regulations must be kept in the home. A statement of terms and conditions (contract of employment) must be agreed and issued to all staff including the manager. (Previously an immediate requirement not met) The manager appointed to run the care home must be registered with the Commission There must be a business and financial plan for the establishment open to inspection. (Previously an immediate requirement not met) A fire risk assessment must be in place in accordance with North Yorkshire Fire Safety Officers letter of 18.10.04 Ensure accurate records are kept of any accident in the home (residents and staff) Ensure the bath hoist has regular servicing and a six monthly thorough examination by a competent person (Previously an immediate requirement not met) Ensure all windows on the first floor, in areas used by residents, have restricted opening to 6 8. Ensure the window sash in room 6 has repairs to stop the window from dropping On receipt of this report 31.8.05 On receipt of this report Immediate On receipt of this report Immediate Immediate RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Rosslyn Refer to Standard Good Practice Recommendations J53_s7728_Roslyn_v225594_16 May 2005_Stage 4.doc Version 1.30 Page 24 1. 2. 3. 4. 5. 6. 7. 1 2 9 26 30 31 38 8. 38 The Commission should be sent a copy of the amended statement of purpose and service user guide All residents should have a contract or statement of conditions with the home (Previous timescale of 31.8.04 not met) Medications must be hygienically dispensed at all times Surplus equipment and carpet must be removed from the staff room to enable staff to access the laundry The efforts made to imrpove staff training must continue The manager should have an NVQ IV qualification in care and management by the end of 2005 A report of monthly visits to the care home should be made by the provider to reflect interviews with residents and their representatives and persons working in the care home; also the inspection of the care home Obtain confirmation from Mr Rivers, Fire Safety Officer, Whitby, telephone 01947824080, that the doors in the home are satisfactory for the purposes of fire protection and forward a copy of his findings to the Commission Rosslyn J53_s7728_Roslyn_v225594_16 May 2005_Stage 4.doc Version 1.30 Page 25 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 Rosslyn J53_s7728_Roslyn_v225594_16 May 2005_Stage 4.doc Version 1.30 Page 26 - 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!