Inspection on 18/10/05 for Roxburgh House

This inspection was carried out on 18th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Roxburgh House 03/04/07

Roxburgh House 23/01/06

Roxburgh House 10/01/05

Roxburgh House 24/08/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Roxburgh House Roxburgh House Reddall Hill Road Cradley Heath West Midlands B64 5JE Lead Inspector Mrs Amanda Hennessy & Mrs Mandy Beck Announced Inspection 4th October 2005 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 Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Roxburgh House Address Roxburgh House Reddall Hill Road Cradley Heath West Midlands B64 5JE 01384 411029 01384 565408 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) Southern Cross Care Homes No 2 Limited Tracy Mancini Care Home 47 Category(ies) of Old age, not falling within any other category registration, with number (47), Sensory impairment (1) of places Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 47 OP and up to 1 SI. Service user category SI remains until such time that the current service users placement is terminated. Date of last inspection Brief Description of the Service: Roxburgh is a large home providing accommodation for 47 residents who require personal care only. It is owned by Southern Cross Healthcare Limited who own a large number of homes throughout the UK. Situated on the border of Old Hill, it is easily accessible by public transport from Dudley, Halesowen and Birmingham. The local amenities include a library, community centre, post office, shops and public houses. The home has two large lounges situated to the left and right of the main hall with dining areas off each lounge. Throughout the home there are five double bedrooms and thirty-seven single rooms, one of the latter having en-suite facilities. Bedrooms are located on the ground and first floor and there is a lift available for residents to access all communal areas of the home. There are numerous toilets situated throughout the home and there are 6 assisted baths and 1 walk in shower room. A hairdressing room is also available. There is a small pleasant garden area that residents enjoy on fine sunny days. There is a car park situated to the front of the building that is quite reasonable in size. There are also smoking facilities for residents Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection undertaken by two Inspectors, Mrs Mandy Beck and Mrs Amanda Hennessy. The inspection was undertaken between 09.30 and 14.45. The inspection included talking to service users and staff, a review of records and information (pre-inspection questionnaire) forwarded prior to the inspection. Care records were reviewed as part of the “case tracking” of four residents. 18 comments cards were received from service users, visitors and relatives prior to the inspection. The home’s ownership changed in April 2005 and is now privately owned by Southern Cross Healthcare. The home’s manager is Mrs Tracey Mancini. All of the previous 4 requirements were found to have been addressed, three new requirements were made as a result of this inspection. What the service does well: What has improved since the last inspection? Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 Page 6 The home has taken steps to meet all of the previous requirements from the last inspection. 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. Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Prospective service users needs are assessed prior to their admission to the home, this gives assurance their needs will be met. There is a comprehensive service user guide which details what life is like living at Roxburgh EVIDENCE: Services users have a detailed assessment of their needs by either the Home Manager or a senior member of staff before coming to live at Roxburgh. Residents and their relatives are involved in this assessment of their needs. The Home Manager writes to the prospective service users confirming that the home is able to meet their needs should they wish to come and live at Roxburgh. There is a detailed service user guide for each service user, since the last inspection the home has changed ownership and has adopted a standard service user guide. Whilst this is comprehensive and covers all elements required by National Minimum Standards, it lacks the visual appeal and homely touch of the previous service user guide which was highly commended in previous inspections. Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 Page 9 Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9,10 The healthcare needs of service user’s are identified and met. Procedures in relation to medicines are satisfactory and safeguard service users. Service users are treated with respect and their right of privacy is upheld. EVIDENCE: All service user’s care records seen contained detailed care plans and care risk assessments. Risk assessments available include the risk of pressure sores, moving and lifting of residents, continence, nutrition and falls. Care plans and risk assessments are generally reviewed at least monthly, although one service user plan of care had not been reviewed since June. Records seen show that service users are able to access specialist medical and nursing services alongside dental, optical and chiropody services. Care records demonstrated, and relatives who returned comment cards confirmed, that they were informed that their relative had seen a Doctor or when there were changes to their health needs or treatment. Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 Page 11 The home has appropriate policies for the safe handling and administration of medicines. Medicines are administered to service users by qualified care staff that have received required training. The Staff now have appropriate records prescriptions have been ordered, when the prescription has been checked and medicines that have been received. The drugs fridge temperature is checked daily. The storage and administration of controlled drugs was checked and all was found to be appropriate. The medication administration records were checked and were appropriately completed. Service users said that staff treat them with respect and preserve their privacy. Staff were seen to knock on toilet and bedroom doors before going in. Service users may either receive their visitors in their own room or in one of the lounges if they wish. Staff address service users by their preferred name, with a record of their preferred name made in care records. Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 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 the following standard(s): Activities available meets service users social and recreational needs and expectations. Food provided appears nutritious and appealing and is served in pleasant surroundings. EVIDENCE: Service users spoken to during the inspection said that daily routines are flexible, they can choose where they spend their day, have their meals, get up and go to bed. Information about resident’s life history and preferred leisure interests is available in their plans of care. The home has an informative monthly newsletter informing them of any changes and forthcoming events. Families spoken to say that they are encouraged to attend and enjoy taking part in the various social events that the home holds. Comments from service users “there’s always something going on you can join in if you want there’s no pressure to take part” “we’re going to the pantomime at Christmas”. Service users we spoke to at the time of the inspection said that the food was always nice and they always had a choice of what to eat. One service user indicated that she didn’t like the summer menu preferring stew and dumplings all year round. Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 Page 13 Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 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 the following standard(s): 16 The home has appropriate and comprehensive policies and procedures to highlight concerns and complaints to safeguard and enhance the care that residents receive. EVIDENCE: The home has a detailed complaints procedure. The complaints procedure is displayed in the main reception area of the home and is also included in the service user guide. The home has received no complaints in the previous twelve months. Residents and relatives spoken to said if they had any concerns they would discuss them with the Home Manager. Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 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 the following standard(s): The home is decorated and furnished to a high standard and is safe, pleasant, homely with no offensive odours and has a well maintained garden for service users to enjoy. EVIDENCE: Areas of the home seen during this inspection were found to be clean and homely with no offensive odour. The home is decorated and furnished to a high standard. There are two large lounges with dining areas off with one lounge having a large conservatory. The home has a full call system and a variety of aids and adaptations such as grab rails assisted baths and a wheel in shower available for dependent service users. The home has a small well maintained garden with garden furniture, patio planters and a water feature. A requirement made at the previous inspection that the upstairs sluice is repaired, has been addressed. There is a need to have a commode pot rack in the upstairs sluice. Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 Page 16 Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Staffing at the home is appropriate to safeguard service users and all staff receive regular training to keep their skills updated and current. Recruitment procedures also ensure that service users are protected as vulnerable adults. EVIDENCE: Staffing numbers and the skills and expertise of staff meet the needs of residents. The home is staffed with the following staff: 08.00-14.00 5 care staff 14.00-20.00 5 care staff 20.00-08.00 3 care staff The home also has domestic, laundry and catering staff employed daily. The home currently has 2 of its care staff with National Vocation level qualification (level 2 or above) which is 10 . New staff are recruited in a safe manner that ensures that service users risk of harm is minimised. All staff are given a comprehensive induction which enables them to be able to meet service users needs and the aims of the home Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 Page 18 Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,38 A competent and enthusiastic manager who has the service users interests as a priority manages the home. As a result of this positive influence the health, safety and welfare of service users is protected EVIDENCE: The manager is competent and confident and fully understands the needs of the service users at Roxburgh House. The health and safety of service users is maintained by the safe working practices within the home, all staff have the opportunity to keep their knowledge and skills updated. The home is maintained and complies with all relevant legislation Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 Page 20 Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 4 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 x 4 X X X X X X X STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 3 Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? no 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 OP7 Regulation 14 Requirement Care plans must be reviewed at least monthly or as clinically indicated. A rack for commode pots must be available in the sluice. The home has 50 of its care staff with National Vocational Qualification level 2 or above. Timescale for action 30/10/05 2 3 OP26 OP28 13(3) 18 30/11/05 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Roxburgh House DS0000041335.V249560.R01.S.doc Version 5.0 Page 24 - 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!