Inspection on 23/01/06 for Roxburgh House

This inspection was carried out on 23rd January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Roxburgh House 03/04/07

Roxburgh House 18/10/05

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 Unannounced Inspection 23rd January 2006 13:30 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.V275461.R01.S.doc Version 5.1 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.V275461.R01.S.doc Version 5.1 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.V275461.R01.S.doc Version 5.1 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. 18th October 2005 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.V275461.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by one Inspector. The inspection was undertaken between 13.30 and 16.00hrs. The inspection followed a visit to the home in late December to agree to register the new Dementia Care unit. This visit included a review of records, talking to staff and service users. Care records were reviewed as part of the “case tracking” of three service users. Roxburgh is owned by Southern Cross Health Care Ltd. Mrs Tracey Mancini is the registered manager. One of the previous three requirements has been addressed, one requirement was made as a result of this inspection. The home has a new dementia care unit has recently been completed and will open shortly. What the service does well: What has improved since the last inspection? The Manager has taken advice given to improve laundry systems to minimise the risk of infection. Twelve staff have enrolled to undertake their National Vocational Level 2 Qualification in care. Roxburgh House DS0000041335.V275461.R01.S.doc Version 5.1 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. Roxburgh House DS0000041335.V275461.R01.S.doc Version 5.1 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.V275461.R01.S.doc Version 5.1 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): No standards were assessed in this section during this inspection. EVIDENCE: Roxburgh House DS0000041335.V275461.R01.S.doc Version 5.1 Page 9 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 Service users needs are identified and met. EVIDENCE: Service user’s all have detailed person centred 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 monthly. Service users and their representatives are involved in the planning and review of their care should they wish to be. Roxburgh House DS0000041335.V275461.R01.S.doc Version 5.1 Page 10 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): 13,14 Services users are able to exercise choice and control over their lives and maintain contact with friends and family. EVIDENCE: Service users and visitors spoken to during the inspection and feedback from the previous inspection said that visitors are always made welcome by staff. Service users spoken to said that they are able to get up and go to bed when they wish, have a choice of meals and are able to choose whether they take part in the activities and social events. Roxburgh House DS0000041335.V275461.R01.S.doc Version 5.1 Page 11 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): 18 The home safeguards service users from abuse. EVIDENCE: The home has a Southern Cross adult protection policy. Local authority adult protection policies are available but the home needs ensure that local policies are referenced and incorporated into their adult protection policy. All staff spoken to had good awareness of what is abuse and appropriate actions to be undertaken in response to any abuse allegations. Staff training in abuse awareness is ongoing for all staff. Roxburgh House DS0000041335.V275461.R01.S.doc Version 5.1 Page 12 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 clean, hygienic and a pleasant place to live. EVIDENCE: Areas of the home seen during this inspection were found to be clean and homely with no offensive odour. The home has been completely refurbished within the last eighteen months and is decorated and furnished to a high standard. There is a large lounge and another lounge/ dining room, a separate smoking room is also available. A new and innovative dementia care unit has been created for ten older people with dementia. The dementia unit consists of a quiet lounge, a lounge and dining room. The unit also has a snoozelum that is used as a quiet and restful area. Snoozelums can calm distressed and agitated people with dementia with the use of soothing music, different lightening and aromatherapy and assorted items that can be touched. The home has appropriate procedures in place to minimise the risk of infection. Roxburgh House DS0000041335.V275461.R01.S.doc Version 5.1 Page 13 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): No standards were assessed in this section during this inspection. EVIDENCE: Roxburgh House DS0000041335.V275461.R01.S.doc Version 5.1 Page 14 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): 33,35 The home is run in the best interests of the service users. Service users financial interests are safeguarded. EVIDENCE: Southern Cross homes have an identified Quality plan for the home. Quality audits are undertaken six monthly with corrective actions identified, with a copy of the audit sent to both the Regional Manager and Regional Director. The home undertake monthly audits of pressure sores, service users weights, accident statistics, vacancies and recruitment, the kitchen and a review of all regulation 37 notifications that have been sent to the Commission for Social Care Inspection (CSCI). Weekly audits of care plans are also undertaken. A service user survey has been undertaken with results analysed and put into the service user guide and the homes newsletter. A new survey has recently been undertaken with plans in place to feedback the results to service users and all interested parties. Required visits on behalf of the registered company Roxburgh House DS0000041335.V275461.R01.S.doc Version 5.1 Page 15 are undertaken. The Manager and registered company proactively identify ways that requirements of Commission for Social Care Inspection will be met. The home displayed posters advertising the announced inspection which was undertaken in September. The majority of service users money is managed by their families, although service users can manage their own finances if they wish to. Secure facilities are available for the safe keeping of service users personal money and valuables. Written records are available for all transactions which detail the reason for the withdrawal and two signatures, receipts are available as proof of purchases. External audits of service users personal money are undertaken with an audit undertaken the week before the inspection. Roxburgh House DS0000041335.V275461.R01.S.doc Version 5.1 Page 16 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 x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 2 4 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 4 x 3 x x x Roxburgh House DS0000041335.V275461.R01.S.doc Version 5.1 Page 17 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 OP7 Regulation 14 Requirement Care plans must be reviewed at least monthly or as clinically indicated. The home’s Adult Protection is updated and refers to the local social services Adult protection policy. The home has 50 of its care staff with National Vocational Qualification level 2 or above. Timescale for action 30/10/05 2 OP18 13(6) 21/03/06 3 OP28 18 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. 1 Refer to Standard OP18 Good Practice Recommendations A flow chart is available of Adult Protection procedures. Roxburgh House DS0000041335.V275461.R01.S.doc Version 5.1 Page 18 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.V275461.R01.S.doc Version 5.1 Page 19 - 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. 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