Inspection on 02/12/05 for Rushley House

This inspection was carried out on 2nd December 2005.

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

Rushley House 19/11/08

Rushley House 19/10/06

Rushley House 26/05/05

Rushley House 08/02/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Rushley House 327 Lancaster Road Morecambe Lancashire LA4 6RH Lead Inspector Mrs Joy Howson-Booth Announced Inspection 2 December 2005 10:00 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 Rushley House DS0000062629.V256590.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. Rushley House DS0000062629.V256590.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Rushley House Address 327 Lancaster Road Morecambe Lancashire LA4 6RH 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) 01524 417405 01524 425900 Thackray Care Services Ltd Mrs Fay Lucille Thackray Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Rushley House DS0000062629.V256590.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 13 service in the category OP (Older Persons) The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 26th May 2005 Date of last inspection Brief Description of the Service: Rushley House is a small home situated in the residential area of Morecambe, accessible to local shops and amenities. The home is a large detached house built over two floors. The home is set within its own very plesant grounds which residents can access. There is one main lounge, a dining room and the hallway provides a pleasant and roomy thoroughfare. There is also a separate conservatory. All the rooms are single and six have ensuite facilities. There are toilets and bathrooms on both floors and a range of aids, including a stairlift and bathhoist. Rushley House DS0000062629.V256590.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and was carried out by the inspector for the home over one and a half days. The services provided by the home were inspected against the National Minimum Standards. There were 13 residents in the home and a number of these were spoken with. In addition, staff on duty, both during the day and night, were spoken with. A visiting relative was also spoken with. Four care files were examined, along with other documentation held by the home. Two comment cards were received, one from a relative and another from a GP surgery. More recently a change has taken place in that the home are now accommodating male residents. All the residents spoken with said they liked living at the home and felt they were well cared for and their needs met. The visiting relative spoke very highly of the care provided by the home. What the service does well: Rushley House continues to be a pleasant and homely environment which has a relaxed and friendly atmosphere. Staff commented that they feel the atmosphere in the home has improved. The owner manager works at the home on a daily basis and is on hand to deal with issues as they arise. Staff commented that they feel the registered provider is very approachable. Residents are free to maintain their own lifestyles, routines and support is provided as needed. The comment cards received from the relative confirmed that the home keeps them informed of important matters to do with their relative and they are made to feel welcome at any time. The comment card received from the GP confirmed that the home works in partnership with the surgery and the staff know about the needs of the residents. Rushley House DS0000062629.V256590.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Management hours and a night sleeper need to be addressed to ensure the home fulfils the requirements of the previous registration authority. Although staff appraisals are to begin, staff supervision should also be started. The registered provider confirmed staff supervision is to begin in January 2006. The policies and procedures for the home need to be organised and indexed so that staff can find what they are looking for. A review of the tea time arrangements should be carried out as staff spoken with felt this was now a very pressured time given the personal care needs of some residents and the need to serve food hot. The registered provider may wish to look at a procedure for the home in the event of an infectious outbreak taking place. Rushley House DS0000062629.V256590.R01.S.doc Version 5.0 Page 7 From discussion with staff, there needs to be some refresher training on fire safety ensure the safety of the home. In addition to this, the registered provider may wish to discuss with the fire safety officer strategies for the home. 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. Rushley House DS0000062629.V256590.R01.S.doc Version 5.0 Page 8 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 Rushley House DS0000062629.V256590.R01.S.doc Version 5.0 Page 9 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): 6 The home does not provide an intermediate care facility Standard 3 was assessed and met at the previous inspection EVIDENCE: Rushley House DS0000062629.V256590.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 and 9 The care plans provide information which enable staff to be aware of needs and how these are to be met. Systems have been put in place to ensure medication is safely administered to residents Standards 8 and 10 were assessed during the previous inspection EVIDENCE: A requirement highlighted at the previous inspection required the home to review and improve the care plans for residents. During this inspection four care plans were examined and found to be much improved and providing more information. The home has introduced separate sheets for individual specific needs which provide staff with clear information on how these are to be met. Staff spoken with confirmed they have access to the care plans and use these, Rushley House DS0000062629.V256590.R01.S.doc Version 5.0 Page 11 although most residents have lived at the home for a number of years and are well known to them. A comment card received from a relative confirmed that they are made to feel welcome in the home at any time and they are kept informed of important matters affecting their relative. A comment card received from a healthcare professional stated that the home communicates clearly and works in partnership with them, there is always a senior member of staff to confer with and they are able to se their patients in private. It was also confirmed that the staff demonstrate a clear understanding of the care needs of the residents and their medication is appropriately managed. A requirement highlighted by the Pharmacist Inspector at the previous inspection required the home to review the administration of medication and records maintained. The registered provider confirmed that the advice and guidance provided by the Pharmacist Inspector has been acted upon. In addition, all staff have just completed a safe handling of medicines course. Discussions with staff confirmed they found this course very helpful. Rushley House DS0000062629.V256590.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): 15 Arrangements and planning to provide good nutritional food are good. The residents are provided with good food to ensure healthy living. Standards 12, 13 and 14 were assessed during the previous inspection EVIDENCE: Residents spoken with were all very happy with meals. Menus seen on a four week rota and residents are informed by use of a menu board. This board was accurately maintained during the two visits to the home and residents confirmed they use this to request an alternative. Meals provided in a relaxed environment and served by staff in a dignified way. Second helpings were offered, if wanted. Observations of food provided confirmed good presentation, quality and quantity, with individual choices being respected. The Chef was spoken with who confirmed good stocks of food and of good quality are purchased. Different choices provided, including hot and cold dishes – staff ask residents what they would like to eat and menu board seen to reflect what is to be offered for lunchtime. Rushley House DS0000062629.V256590.R01.S.doc Version 5.0 Page 13 Nutrition is balanced in the menus – some changes have been put in place to ensure adequate nutrition – for example, skimmed milk has now been changed to full fat – a nutritional assessment is carried out and included as part of the care plan. Advice sought from dietician and GP if any concerns are raised. Staff raised an issue over tea time and the staffing levels at such a busy time. This was discussed with the registered provider who is to undertake an assessment and review of the current systems to see if any improvements are required. Rushley House DS0000062629.V256590.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 and 18 The arrangements for dealing with complaints are good. Residents can speak up and feel that they are listened to. There are systems in place, and training provided, to ensure that residents are protected from abuse. EVIDENCE: A requirement highlighted at the previous inspection required the home to implement a complaints/comments/compliments book to evidence that residents and others issues are being dealt with. A book has now been started with clear evidence that issues raised by residents are being dealt with. Discussions with residents also confirmed they feel their concerns are dealt with. A comment card received from one relative confirmed that they are aware of the home’s complaints procedure. A GP comment card indicated they have not received any complaints about the home. No complaints have been received by the Commission for Social Care Inspection regarding this home. Discussions with staff confirmed all are aware of abuse and what to be aware of. All know to contact either the registered provider or the senior on duty if any concerns are raised. Rushley House DS0000062629.V256590.R01.S.doc Version 5.0 Page 15 The registered provider confirmed that abuse training is to be provided to staff early in March 2006 No referrals to the POVA register (Protection of Vulnerable Adults) have been made to date. The Home’s abuse policy seen. The registered provider was advised to have clearer guidance over who to contact with telephone number, etc. Policies file generally needs an index as it is difficult to find specific policies, especially if these were needed in a hurry. Rushley House DS0000062629.V256590.R01.S.doc Version 5.0 Page 16 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): 19 and 26 Rushley House is a safe place for people to live in. Residents continue to feel safe and their accommodation continues to be homely, comfortable and well maintained. Procedures are in place to ensure the home remains clean and hygienic. EVIDENCE: The registered provider confirmed that all the home’s radiators have radiator guards in place. From general observations during this inspection, the home continues to be pleasant, well maintained and providing a pleasant and very homely environment for the residents to live in. All the residents spoken with were very satisfied with the accommodation at the home. Rushley House DS0000062629.V256590.R01.S.doc Version 5.0 Page 17 The home has a written Policy in place regarding Infection control – additional information regarding external websites linked to health protection were passed onto the registered provider at this inspection. The registered provider was advised that it may be expedient to have procedure in place for infectious outbreaks so that staff are clear what to do prior to such an event occurring. Discussions with staff confirmed they were all clear about what to do regarding infection control – personal protective clothing and things like laundry, soiled pads, etc. All staff are provided with their own personal hand-gel for infection control purposes. The registered provider has confirmed in the pre-inspection questionnaire that the home has a Contract for the removal of soiled waste/sharps. Rushley House DS0000062629.V256590.R01.S.doc Version 5.0 Page 18 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 Management hours and night staffing levels are not always maintained as previously agreed. EVIDENCE: The registered provider confirmed that there is a shortfall in the management cover of the home and is currently recruiting for an experienced senior member of staff to cover this. Additional management hours are being undertaken by the registered provider who was advised to reflect this in the home’s staffing rota. From discussions during this inspection, the night staffing arrangements are to be reviewed as there are times when there is no night sleeper on the premises. An official letter was sent to the registered provider regarding this and confirmation is awaited of the actions taken to address this shortfall. Comment received from both a relative and from a healthcare professional confirmed that they were happy with the staff at the home. Rushley House DS0000062629.V256590.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): 33, 35, 36 and 38 The arrangements to protect the residents’ money and property are good. Health and safety arrangements are generally good, with training now being provided for staff. The quality assurance systems currently in place should be reviewed to include external contacts. Standard 31 was assessed at the previous inspection EVIDENCE: A requirement highlighted at the previous inspection required the home to put in place formal supervision for all staff. Discussions with staff confirmed this is not yet in place. The registered provider advised that formal supervision with staff will commence in the New Year. A requirement highlighted at the previous inspection required the home to put in place quality assurance procedures, including staff meetings, residents Rushley House DS0000062629.V256590.R01.S.doc Version 5.0 Page 20 meetings and contact with outside professionals. The home has recently (November 2005) renewed its Investors in People Award Discussions with staff confirmed that, to date, only one staff meeting has been held and they would welcome regular staff meetings. Advice was provided to the registered provider over including outside professionals and relatives in the quality systems already in place in the home. The registered provider confirmed that no finances are managed by the home, these are managed either by the resident themselves or by their relatives. The registered provider also confirmed that the home does not keep any personal monies for residents, with residents managing this themselves. There are systems in place should this change. In respect of mandatory training for staff – the registered provider confirmed that mandatory training is now being provided to all staff and it hoped all will be completed by mid-2006. The Home’s fire risk assessment was seen. Discussions with staff did not evidence that all are clear as to what to do if a fire breaks out and the registered provider was advised to provide staff with update fire safety training/update training as a matter of priority. An official letter was sent regarding this issue. Advice was provided to the registered provider to discuss with the fire safety officer an strategy for the home should a fire occur and the home being unusable. Window restrictors are now in place on upper floors of the home. The registered provider confirmed that the health and safety of both residents and staff is maintained by regular maintenance checks and servicing of equipment and systems. The pre-inspection questionnaire also confirmed this. The home has pre-set temperature valves on all water outlets in the home. The registered provider also confirmed the home complies with all the relevant health and safety legislation. The registered provider complies with the requirement to notify the Commission for Social Care Inspection of any incident or serious accident in the home. The home has an accident book which is accurately maintained. Induction training for staff is ongoing via the local College of Further Education, including induction on the Skills for Care (formerly TOPSS) course. Rushley House DS0000062629.V256590.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 X X X X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 2 X 2 Rushley House DS0000062629.V256590.R01.S.doc Version 5.0 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 Standard OP27 Regulation 18(1)(a) Requirement There must not be any regression in the staffing levels agreed by the previous registration authority, including management hours for the home. Quality assurance systems must include staff meetings, residents meetings, contact and feedback from external professionals and relatives (Previous timescale of 30.6.05 not met) Formal supervision to be put in place for all staff (previous timescales of 30.4.05 and 30.6.05 not met) All staff in the home must receive training and be familiar with the fire safety procedures for the home Mandatory training for staff must continue Timescale for action 02/12/05 2 OP33 24(1) 31/03/06 3 OP36 18(2) 31/01/06 4 OP38 23(4)(d) 31/12/05 5 OP38 18(1(c)(i) 31/07/06 Rushley House DS0000062629.V256590.R01.S.doc Version 5.0 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 Refer to Standard OP12 Good Practice Recommendations The tea time meal arrangements should be reviewed to address the concerns raised by staff that this is a very pressured time with the personal care needs of the residents The abuse policy and procedures need to include clear instructions and contact names and telephone numbers of the relevant Social Services Department and relevant others. The policies and procedures file should be indexed so that individual documents can be found easily A procedure should be put in place in event of an outbreak of an infectious disease or similar The registered provider should discuss with the fire safety officer a strategy in case the home becomes unusable should a fire occur The employment of a dedicated domestic cleaner would be a clear asset to the staff at the home 2 OP18 3 4 5 6 OP38 OP26 OP38 OP26 Rushley House DS0000062629.V256590.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1 Tustin Court Port Way Preston PR2 2YQ 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 Rushley House DS0000062629.V256590.R01.S.doc Version 5.0 Page 25 - 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!