Inspection on 09/01/07 for Rosslyn

This inspection was carried out on 9th January 2007.

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 but made no statutory requirements on the home.

Other inspections for this house

Rosslyn 10/11/08

Rosslyn 27/11/07

Rosslyn 28/06/06

Rosslyn 13/10/05

Rosslyn 16/05/05

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 Karen Ritson Key Unannounced Inspection 9th January 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rosslyn DS0000007728.V326203.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 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 DS0000007728.V326203.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosslyn Address 29 Bagdale Whitby North Yorkshire YO21 1QL 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) 01947 820931 Mr Jeremy William Southgate *** Post Vacant *** Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Rosslyn DS0000007728.V326203.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2006 Brief Description of the Service: Rosslyn provides long-term accommodation and personal care for a maximum of eleven older people. The home is located on a main route into Whitby and is conveniently situated for the shops and other community facilities including transport links. Rosslyn is a traditional house with modern extension built on two floors with the communal areas and two bedrooms being located on the ground floor. One bedroom has an ensuite toilet facility. 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 has its own parking facilities and there is onroad parking within close proximity. The front of the house has ramp access as well as steps. The home has a statement of purpose and service user guide, which provide information about the scope and nature of the care and facilities on offer. These, with CSCI reports, are available on request at the home. The fee charged is usually £375 per week; however, this may vary with the degree of assessed needs. Hairdressing and newspapers are not included in this fee and these are charged at cost. This information was provided to CSCI on 11/12/06. Rosslyn DS0000007728.V326203.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection for this service took 10 hours. This includes time spent gathering information and examining documentation before and after a site visit and in writing the report. The site visit took place on 9th January 2007 between 10am and 2pm. Information for this inspection was gathered from the following: • • • • • • • • A tour of the premises Observations of care throughout the day of the site visit. Speaking with service users. Case tracking three service users on the day of the site visit. Consulting health care professionals and relatives. Looking at information provided by the manager in a pre inspection questionnaire. Notifications sent to the commission from the home since the last inspection. Examining policies, procedures and records kept at the home. All key standards were looked at during this inspection. The acting manager, (referred to in the text as manager) was present throughout the day of the site visit. What the service does well: What has improved since the last inspection? The acting manager had just taken up post at the last inspection and has been influential in improving many areas of care since then. New residents have a thorough assessment of what they need and this is written down in a plan for staff to follow. Staff have now had safe medicine handling training. Rosslyn DS0000007728.V326203.R01.S.doc Version 5.2 Page 6 All service users are treated with respect and dignity and this has improved since the last visit. Staff take their time to explain what is happening when care is being given and to answer any queries kindly and patiently. A district nurse said the staff now all know how to use the hoists properly. The home now has an updated policy for dealing with comments and complaints. Residents said if there was a problem the staff did all in their power to put it right and took them seriously. The décor of the home has improved. Several rooms have been redecorated and all the requirements from the last inspection about repairs have been dealt with. All staff, residents, relatives and health care professionals remarked upon how much better the service has been since the appointment of the acting manager. Residents said they felt more secure and that: ’We know where we are with her.’ All said she had the welfare of residents at heart. The safety of residents has been improved through assessing the risks that are likely to happen in the home and putting plans in place to make sure these are kept to a minimum. The home also now has updated certificates regarding the safety of equipment and services. 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. The summary of this inspection report can be made available in other formats on request. Rosslyn DS0000007728.V326203.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rosslyn DS0000007728.V326203.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3. Standard 6 is not applicable. Quality in this outcome area is good. Prospective residents and their representatives have the information needed to choose a home. Service users needs are assessed and a care plan is drawn up from this. This ensures their needs will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users now receive a thorough assessment of needs. Files of recently admitted service users showed that all required areas had been considered. Risk assessments were included where necessary. A personal history is also compiled which proves very helpful when approaching service users for the first time. Staff said they found the assessments helpful. Some service users had lived locally prior to admission and they said this helped with settling in as they could talk about where they had lived and had friends in common. The contract is comprehensive and includes such details as which room will be occupied, what is included in the fees, the rights and obligations of service users and the registered provider and the period of notice required. This has all Rosslyn DS0000007728.V326203.R01.S.doc Version 5.2 Page 9 improved since the last inspection. Service users said they had received enough information to make an informed decision about admission and had been offered the opportunity to visit the home before moving in. Rosslyn DS0000007728.V326203.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. The health and personal care a resident receives is based on individual needs. The principles of respect, dignity and privacy are put into practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are drawn up based upon the assessment of needs. Each service user has their own plan and this, although not reviewed monthly in all cases, is nevertheless reviewed regularly. Risk assessments are included where this is necessary. The use of bed rails must be assessed for risk and the results of this recorded. Service users weight and pressure areas are well monitored. District nurses said that the home worked well with them and followed their advice closely. Notes regarding the care of each service user are made during each shift. These are detailed relevant and helpful to those members of staff coming on duty. This approach ensures that service user care needs are met. Each service user has a key worker who has special responsibility for welfare and details of day to day living. Service users knew they had a key worker but Rosslyn DS0000007728.V326203.R01.S.doc Version 5.2 Page 11 said that all the staff were very kind. The key worker system helps each service user to be treated as an individual and have a service tailored to their particular preferences. Medication is handled well according to policy and procedure. Staff who administer medication have all received safe handling of medicines training. This protects service users safety. The home does not at present care for any service users who require a hoist to move. However, the manager has taken note of the requirement to train staff in hoist use and a district nurse said the staff have been coached in how to use a hoist safely and had been observed by her doing this correctly. Throughout the day of the site visit service users were observed being treated with great respect and with regard to dignity by all staff. One service user said: ‘They’re so kind.’ Another said: ‘You only have to say and they’ll do anything for you.’ A visitor to the home agreed that the staff were kind and thoughtful. Rosslyn DS0000007728.V326203.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. Service users are able to choose their life style, social activity and keep in contact with family and friends. Social, cultural and recreational activities meet resident’s expectations. Service users receive a healthy, varied diet, which they enjoy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users said they lived their lives the way they wanted to. They were assisted to rise and retire to bed when they wished and visitors could call at any reasonable hour. All of the service users have visitors and all have the opportunity to go out on a regular basis should they so wish. The service users said that they sometimes went out shopping or they would go out with families. If they wished to attend church they would be assisted to do so. The home had a Christmas party and relatives were invited. Service users said they enjoyed this. All activities are recorded in the daily notes. Service users said they sat out in the summer months and sometimes went on outings by taxi. They commented that staff had time in the afternoons to sit and chat or watch television with them and that they enjoyed their company. All spoken to said the meals were first class. A visitor said: Rosslyn DS0000007728.V326203.R01.S.doc Version 5.2 Page 13 ‘They get good home cooked meals’ One service user said: ‘The food is wonderful’ Another said: ‘You get the sort of food you like here.’ A midday meal was observed and the food was of a high quality with a choice of dessert. Individual likes, dislikes and dietary requirements are taken into consideration. Staff who did the cooking had food hygiene certificates or had covered this in NVQ training. When asked if he had enjoyed his meal one service user replied. ‘I’ve had a good do altogether.’ One service user was having a rest at lunch- time and she was offered lunch later in the afternoon when convenient to her. Two of the service users enjoyed their dessert so much they were offered seconds to enjoy them with a cup of tea later. There is a choice at teatime and all fruit, vegetables and meat are bought locally. The manager said she had a weekly budget to cover all expenses and she had never needed to cut back on food quality because of financial restrictions. There was always sufficient for whatever meal was planned. This approach ensures that the meals meet service users expectations and preferences. Rosslyn DS0000007728.V326203.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Residents have access to an effective complaints procedure; their complaints are listened to and acted on. Service users are protected from abuse, though updated staff training and abuse procedures will improve this. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy and procedure. One visitor said she had raised an issue last year and it had been thoroughly dealt with. She said she was confident her relative was well cared for and that the service for her had improved. Service users said they could speak with staff if there was a problem and that they were always keen to put things right. This ensures that service users feel confident to make a complaint and that it is listened to and acted upon. The home now has a comprehensive abuse policy and procedure and also has a copy of the North Yorkshire County Council multi agency policy and procedure. Whilst staff were sure they would approach the manager if there was suspected abuse they were unsure of the procedure following this. The manager said that abuse training was planned for the coming week and that all staff would have the opportunity to attend. This will ensure that service users welfare is protected. Rosslyn DS0000007728.V326203.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. Service users live in a safe, well-maintained and comfortable environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users rooms were personalised and well decorated. All rooms are single occupancy at the moment although there are vacancies in doubles used as singles. The stair lift is operational; there are occupational therapy aids such as raised toilet seats, rails and a bathing seat. The shower has been mended and is now provides an option to the bath. Various improvements have taken place, in particular: • • Railings have been fitted to the external ramp. Room six has had an appropriate lock fitted. Rosslyn DS0000007728.V326203.R01.S.doc Version 5.2 Page 16 • • • • Room 5. The faulty floorboard has been replaced. This room has been redecorated with new carpet and curtains and a new bed. Room 4 has been redecorated and a new carpet fitted. Room 2a. The carpet has been cleaned and there are plans to replace this soon. Room 8 has been fully redecorated. The manager said the registered provider allowed her to manage the budget for the home as she saw fit. She had directed some of this towards upgrading the decoration and furnishing of the home. She has plans to upgrade the communal areas with new furniture and further redecoration. Rosslyn DS0000007728.V326203.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. Staff in the home are in sufficient numbers to fulfil the aims of the home and meet the changing needs of residents. Staff recruitment and training do not fully protect the interests of service users and require attention. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are sufficient staff on duty at any time to meet the needs of service users. There are always two members of care staff on duty during the day time, and although these staff also clean and cook, they said they were able to carry out their duties without needing to rush. Service users said the staff had time to sit and chat with them particularly in the afternoons and that they were unhurried when offering care. One member of staff is on waking duty and another sleeps in. Staffing levels ensure that service users receive the help they need in a way which is acceptable to them. Two members of staff has NVQ in care at level 2. The remaining staff are to commence NVQ Level 2 training this month. All staff have received induction training to ‘skills for care’ guidelines. Foundation training is offered on a rolling programme. The manager was aware Rosslyn DS0000007728.V326203.R01.S.doc Version 5.2 Page 18 that several staff needed this training updating. Service users will benefit from the plan to improve training. On the whole, staff are well recruited, although a standard set of interview questions would improve equal opportunities through ensuring that all candidates receive the same level of enquiry. The home does have an equal opportunities policy and the manager agreed to draw up interview questions for future use. All staff have a CRB and POVA check and two references taken out prior to employment. This ensures that service users welfare is protected. Rosslyn DS0000007728.V326203.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35, 36 and 38 Quality in this outcome area is adequate. Service users are protected by good health and safety systems. Although the manager is enthusiastic and has plans to improve the service regarding quality assurance and supervision of staff these improvements have yet to be put in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has NVQ in care level 3 and plans to do level 4 soon. She has been in post since summer 2006 and is preparing to submit an application to be registered with CSCI. Staff and service users were complimentary regarding her ability to manage the home well, although she has yet to establish a regular supervision programme with staff. Staff said they could go to the Rosslyn DS0000007728.V326203.R01.S.doc Version 5.2 Page 20 manager if there was a problem and that she was approachable. They said they felt well supported by her. A visitor said: ’Everything has improved since she came along’ A service user said: ‘We know where we are with her, she runs a very good home.’ The home has yet to implement a quality assurance system although the manager plans to survey service users, staff, visitors and any health care professionals involved with the care of those resident at the home. She is to collate the finding of such surveys and feed back the findings in a way which is accessible to prospective service users and any other interested people. Service users said they were often asked if everything was to their satisfaction and were confident they could make comments which would be taken seriously by staff. The home does not manage service user finances. Where a service user is unable to look after their own finances their financial welfare is protected through relatives, friends or a solicitor. Health and safety is protected and promoted through effective risk assessments, the checking and maintenance of electrical systems, gas supply, and servicing of all equipment. A fire risk assessment is in place. The fire alarm system and fire fighting equipment is regularly checked. Rosslyn DS0000007728.V326203.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X N/A 1 X 3 Rosslyn DS0000007728.V326203.R01.S.doc Version 5.2 Page 22 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 3. Standard OP18 OP31 Regulation 12,13 8, 9 Requirement Staff must have abuse awareness training as planned. The manager appointed to run the care home must be registered with the Commission. The registered person must establish and maintain a system for reviewing the quality of care provided at Rosslyn. Previous requirement of 13/10/05 not met. Timescale for action 31/01/07 30/04/07 4. OP33 24 28/02/07 Rosslyn DS0000007728.V326203.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP7 OP28 OP30 OP29 OP36 Good Practice Recommendations Care plans should be reviewed once a month. Staff should undertake NVQ level 2 in care training as planned. All staff should have foundation training as planned. A standard set of interview questions for new staff should be drawn up. Staff should receive regular supervision in line with standard 36. Rosslyn DS0000007728.V326203.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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