Inspection on 16/04/08 for Roman Court

This is the latest available inspection report for this service, carried out on 16th April 2008.

CSCI found this care home to be providing an Good service.

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

Roman Court 16/11/06

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Roman Court Old Farm Court Mexborough S64 9ES Lead Inspector Janet McBride Key Unannounced Inspection 16th and 17th April 2008 09:00 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 Roman Court DS0000067664.V362585.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. Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Roman Court Address Old Farm Court Mexborough S64 9ES 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) 01709 584986 F/P 01709 584986 romancourt@live.com.uk None Home and Care Limited Post vacant Care Home 35 Category(ies) of Dementia (35) registration, with number of places Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Dementia - Code DE. The maximum number of service users who can be accommodated is: 35. 15th October 2007 2. Date of last inspection Brief Description of the Service: Roman Court is a purpose built home catering for a maximum of 35 older people with dementia. It is situated in a residential district of Mexborough and is well served with public transport. There is limited car parking space at the home, however on street parking is readily available. People’s accommodation is all in single bedrooms these are located on both ground and first floor levels. There is level access throughout the home with the first floor being accessed by means of a passenger lift or choice of 2 staircases. The communal areas comprise two main lounges with an adjacent dining room. Additional smaller seating areas and lounges are located and available on both floors of the home. A communal area is set aside for people to have a cigarette with staff supervision as appropriate. An internal sheltered and secure garden with seating is readily accessed from the lounge area. People are able to exercise and benefit from an aromatic garden with flowers and plants whilst easily observing staff and fellow people. Fees are £ 397:00 to £427:55 per week, as at April 2008. Additional charges are made for hairdressing, magazines, chiropody and taxis. For further information contact the home. Information about the service was available for people and their families in the Statement of Purpose and the Service User Guide. This information was available in people’s bedrooms and in the reception area of the home. The last CSCI published inspection report, will be made available for people to read. Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Two inspectors carried out this Key Unannounced Inspection, which took place on the 16th and 17th of April 2008.Starting at 09:00 and finishing on the second day at 15:00 hours eleven hours in total was spent on this inspection. This service has been the subject of an adult safeguarding enquiry, therefore prior to this inspection a number of unannounced random inspection had taken place by previous inspectors. Pharmacist inspection on the 16/11/07. Random unannounced inspection on the 26/11/07 and 27/11/07. Summarised findings from these visits are within this report. Doncaster Metropolitan Borough Council (DMBC) contract and monitoring team have also visited the home and carried out various audits, because of these concerns restrictions were placed upon admissions until the home improves and provides a safe environment for people who live at the home. Pre-inspection work was carried out on the information received and other relevant documentation, for example analysis of statutory notifications and complaint records. During the inspection, documentation and records were examined, for example medication, complaints, accident records, staff rotas and staff training files. Four care plans were cross-referenced with other relevant documentation relating to those people who use the service, to evaluate how well their care needs were met. Information was gathered from as many different individuals as possible that had contact with people within the home, discussion with the manager and four members of staff. Six relatives were spoken to and one district nurse. They were asked to comment on the standard of care, staff skills, attitude, and how the needs of people using the service were met. Due to the nature of the people living at the home, it is difficult to obtain information directly from some people receiving services. Some judgements about quality of life and choices were taken from discussions with relatives, feedback on surveys, observations on the visits, followed by discussion with staff and examination of records held at the home. We would like to thank all the staff, relatives and people receiving services within the home for their co-operation in the inspection process. Verbal feedback was given at the end of the inspection to the homes manager and a telephone conversation was made to the owner of any issues or concerns that were raised on this visit. Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: • • • • • • A number of areas are in need of refurbishing and the registered provider must provide a refurbishment and renewal plan for the premises at the home with timescales. The badly stained floor in communal toilet should be replaced. Ensure bathrooms have homely features such as curtains or blinds. Ensure that baths have hoist facilities to meet the needs of people. Beds must be suitable for each person’s comfort and safety. Variable height chairs must be available to ensure individual peoples mobility is not restricted or impeded by difficulty getting into and out of chairs. Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 7 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. Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 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 Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. People who use the service experience Good outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People who use the service had information about the home and services provided. People were individually assessed prior to admission to ensure their needs could be met. EVIDENCE: Residential care is provided but not intermediate care. The homes statement of purpose had been updated and people who use the service were provided with sufficient information about the home and the services they provide. It was also confirmed that people in the home had been issued with contracts/statement of terms and conditions, which are being updated with appropriate information. The scale of charges was discussed with the manager, any extras that people pay for; this is documented on page 5 of this report. Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 10 There were clear evidence that each person’s mental capacity had been assessed with suitable persons identified who would ensure that people’s rights were considered and maintained. Records showed that pre-admission assessments had been updated since the last inspection. Care plans were more in depth with detailed care needs and personal preferences of people recorded. This ensures that people who use the service were fully assessed prior to moving into the home, with other professionals involved if required. Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 11 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. People who use the service experience Good outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Care plans provided staff with sufficient information to meet the needs of people who use the service. People were assisted and supported by staff to make decisions and choices about all daily living needs. Medication policies and procedures were well managed ensuring the safe administration of medication. EVIDENCE: A number of issues had been raised in the last inspection in regard to care plans and the daily recording of the care provided including some medication practices. DMBC contract and monitoring team had also echoed these concerns. There has been a great deal of time and effort spent on care plans to meet previous requirements. Five care plans were checked these set out in detail healthcare, personal and social care needs in an individual plan of care. All contained up to date information that reflected people’s needs as detailed in their assessments. People were nutritional assessed and a record of food they had consumed was recorded and people were weighed on a regular basis. Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 12 Daily records were found to be very comprehensive and informed staff on the care needs of people. Key workers had the responsibility to complete a weekly audit based on all sections of the care plan. All this information was then collated onto a monthly review. This ensured that staff monitor and review the care required and that peoples needs were identified and met. Risk assessments had been completed based on individual needs, these were incorporated into each persons care plans. Good health records were maintained and it was evident that people within the home were registered with a GP and had access to health care facilities. This included specialist health services such as mental health services. GP and health professional’s visits were recorded. The majority of people receiving services had a diagnosis of dementia, therefore a number of people could not make some decisions. Peoples mental capacity was assessed and it was documented in care plans when relatives, were involved in decision making. If people did not have any relatives then an advocates would be provided. Staff were able to describe the care needs of people within the home, they knew which people were able to make independent choices. However they said all were encouraged to make everyday choices, for example what to eat and what to wear. This promoted the choices and dignity of people living at the home. Medication policy and procedure were discussed with the manager and senior care staff on shift and records checked. All staff responsible for the administration of medication had completed the accredited medication training. Examination of records, storage and recording of medication was completed. All were found to be satisfactory with a big improvement of the handling of medicines and record keeping. All the issues raised on the last inspection had been addressed. Feedback from relatives, visitors and observation on the days of the visits showed that staff treat people with respect and dignity. Typical comments included: “We are kept informed of any concerns or issues about our relative”. “People are always dressed nicely and clothes match and hair done”. “I am very happy with the care provided and staff are always helpful and make you feel welcome”. Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 13 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. People who use the service experience Good outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People were provided with some stimulation and activities during the day. They were offered a wholesome and appealing balanced diet with a varied selection of food available reflecting people’s tastes and choices. EVIDENCE: Care plans recorded personal histories of each person. It is used to describe people, their lives and interests and include religious and cultural needs to inform basic lifestyle issues such as diet and dress, and how staff, sometimes in conjunction with families act to meet these needs. People were encouraged to choose their own clothes to wear each day, decide when to bathe, where to sit and select their own meals. There was a new activities co-ordinator in post, who was very enthusiastic and highly motivated, she confirmed what activities were available for people. Music and movement, reminiscence with books and making cards this was just a sample of activities she had planned, a programme of activities was advertised within the home. She talked about the plans to raise money to enable her to arrange outings and entertainment within the home. Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 14 Relatives said activities had been improved and spoke very highly of the new activities co ordinator, they were happy with what they saw being offered in the way of activities for their relative. Relatives said they could visit at any reasonably time and, that people had the opportunity to maintain some links with the local community by visiting local shops with either their family or members of staff. Daily routines were observed throughout the visit people were appropriately dressed and looked clean and tidy, this was confirmed when speaking to visitors who said they always find their relatives to be clean and tidy and dressed appropriately. Menus were discussed with the manager and menus seen. The manager confirmed the food budget was sufficient and that food and drinks were available at all times. The lunchtime meal was observed. The menu was displayed on the board in the dining room. Staff were observed to encourage and assist with meals as needed. Dining tables were set with tablecloths, cutlery and plate guards were being used and this assists people to eat their meal indepenendently. People were offered seasoning and a choice of drinks. Mealtimes were unhurried with extra portions available as required. People made very positive comments about the food and all relatives said they thought the home offered good food. Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 15 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. People who use the service experience Good outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The complaints procedure was accessible and displayed within the home. Policies and procedures were in place on adult protection, this promoted and protected people who use the service. EVIDENCE: Complaints policy and procedure had been updated and was on display in the reception area. Staff had received training to respond to any concerns raised; this should increase staff ability to report and respond to any complaints and concerns raised. Complaint records showed no complaints had been made since the last inspection. All relatives that were spoken to were aware of the complaint procedure and knew how to make a complaint. Relatives said they would be happy to raise any concerns with the manager who was very approachable. On past inspections there had been a number of situations when the home’s previous management and staff had failed to act in either a timely or effective manner, regarding incidents, accidents and complaints. These had not been properly recorded or notified. Therefore this service had been the subject of an adult safeguarding enquiry and DMBC continued to restrict admissions to the home until a number of ongoing Adult Protection investigations were concluded. However this has now been lifted and the home can offer places and care to people who need this service. Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 16 The manager has ensured that policies and procedures were in place regarding the protection of vulnerable adults. Staff had recently received training to enable them to recognise potential abuse and protect people who live at the home. Staff confirmed they were aware of abuse polices and procedures, they were able to describe the action they would take on receiving any allegations. Since the new manager has been in post she has kept the Commission for Social Care Inspection informed of any issues or concerns. Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 17 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, 21, 24 and 26. People who use the service experience Adequate outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The home was clean and tidy, but a number of areas are in need of refurbishing. However people who use the service felt they lived in a comfortable and accessible environment. EVIDENCE: On previous visits to the home there were a number of areas requiring attention identified included decoration, furnishings and soft furnishings were worn and there was a general lack of maintenance within the home. A tour of the premises on our visit of 16th April 2008 showed a considerably difference in the premises from previous visits. All communal areas were found to be clean and tidy with no unpleasant odours noticed and some decoration completed. However despite some improvement to the premises a number of furnishings and soft furnishings require upgrading. The home needs a Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 18 decoration and refurbishment plan with timescales to upgrade all areas within the home. Improvements to the central heating system had been made and room temperatures were maintained throughout the home this ensured people’s comfort. There was a lack of variable height chairs in lounge areas, this needs reviewing to ensure individual peoples mobility is not restricted or impeded by difficulty getting into and out of chairs. Large dining tables are not homely in appearance and do not aid staff assisting people with their meals. Bedrooms were found to be clean and tidy, however some furniture showed signs of wear and tear and needed refurbishing. People were able to bring their own personal possessions and memorabilia as some had been personalised by the person using the service or their families. All beds were noted to be of the same height with only one adjustable bed within the home. People should be assessed to ensure beds are suitable for each person’s comfort and safety. A call system was available in each bedroom, to ensure people could summon help when required. Door lock mechanism was not easily operated from inside the bedroom and consideration should be given for these to be replaced with a user friendly mechanism. There are assisted baths and one shower within the home. A tour of these areas confirmed most bathrooms were dated with basic amenities that lacked homely features such as curtains or blinds. Two baths were identified with no hoist facilities, therefore not used. Floor covering in most toilets was stained and worn. Arrangements were taking place to ensure a supply of hot water to bedrooms and bathrooms throughout the home was available. Laundry facilities at the home are satisfactory, it was found to be well organised and clean laundry available. Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 19 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. People who use the service experience Good outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Staff had the skills and knowledge to fulfil their roles within the home and recruitment policies were followed promoting the safety and protection of people who live at the home. EVIDENCE: Staffing was discussed with the manager and the duty rota examined, this clearly identified staff within the home and their role, gave a clear line of accountability of management and ancillary staff, including administrative support for the manager. There were both male and female care staff, this enabled a choice of carer for intimate tasks. Observation on the days of inspection and checking of duty rotas confirmed there were sufficient staff to meet the needs of people who use the service. The new manager has made changes and updates to the recruitment procedure and has implemented a thorough recruitment practice. This includes an equal opportunities policy. New staff recruitment files were examined, these confirmed that all the required employment checks had been undertaken prior to staff being employed, including Criminal Record Bureau (CRB) Protection Of Vulnerable Adults (POVA) checks. This ensured people who use the service were safe and protected. Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 20 Training and development of staff had improved, staff’s training records were available which were all up to date, and a record of planned training for the year was also available. The manager and staff confirmed what training had been completed; staff said that training had improved with ongoing development opportunities. Supervision and more staff meetings provided communication and support for the staff team to enable them to work more effectively. Training records indicated that a number of the staff team had accessed various courses since the last inspection, for example dementia, abuse, moving and handling, challenging behaviour and basic first aid training. Development of staff was evident by 50 of staff achieving National Vocational Qualification (NVQ) level 2 or 3 in care with other members of staff continuing to work towards attaining this qualification. Comments received from relatives said that the home had improved and were happy with the new manager and staff. “The staff always respond to any questions I have regarding my relative”. “Staff always seem to care for the residents and are very helpful from the manager to the care staff”. Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 21 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, 37 and 38. People who use the service experience Good outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People who use the service were protected by management practises. Plans were in place to continue to make improvements in the provision of services to ensure effective outcomes for people at the home. EVIDENCE: On previous random inspections the home was managed badly, with inadequate management systems in place. However on this inspection the management structure at the home consisted of a new manager (who has the skills and experienced for her role) and an administrator, a deputy manager will be appoint as soon as possible. In the short time the manager had been at the home she has provided leadership and direction to staff. She has implemented and number of systems to monitor that policies and procedures are followed. Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 22 She had also reviewed a number of polices and procedures, plans were in place to make improvements in the provision of services to ensure effective outcomes for people at the home. In past inspections the quality assurance system did not enable the company to monitor the quality of services or care provided. The manager has set up various audits to ensure they can measure and monitor the quality of care provided. She had recently sent out surveys to gain the views of relatives about the care and services provided, these are waiting to be collated for the results. However six of these surveys were returned and examined, these were found to be very positive, with most relatives being happy with the home and care provided. A number of meetings had been held since the last inspection, for example staff meetings, resident and relative meetings, these covered a variety of topics all had minutes taken to record peoples views. This gives an opportunity for people living at the home and their loved ones to influence the care provided. Notification of events affecting the wellbeing of people living at the home had been sent to the local office of the CSCI, this ensures care and safety of people is monitored. Staff supervision has been implemented; the manager had seen all members of staff and set up systems to ensure staff receives regular supervision sessions with documented records. This gives staff the opportunity to discuss care practices, training and development and ensures staff have the opportunity for feedback from the manager. DMBC financial monitoring team are in the process of completing audits, therefore finances and financial recording were discussed briefly with the homes administrator; records and balances were checked and found correct. They were stored separately with accurate recording of transactions and receipts kept. Health and safety was discussed with the manager and maintenance and service records were examined. These were up to date with current certificates. The required health and safety policies and procedures and the relevant notices were displayed throughout the home. Fire safety procedures were in place, records examined showed they were current and up to date. This keeps people living and working at the home safe. Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 23 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 24 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 OP19 Regulation 23(a)(b) Requirement The registered owners must ensure that all areas of the home are kept in a good state of repair both internally and externally and provide a refurbishment and renewal plan must be established for the home with timescales. This will ensure that people live in a well maintained environment. Variable height chairs must be available to ensure individual peoples mobility is not restricted or impeded by difficulty getting into and out of chairs. The registered owners must ensure that suitable equipment is provided in bathroom with regard to hoist facilities to meet the needs of people. Blinds or curtains must be fitted to bathroom windows to ensure privacy for people. The badly stained floor in communal toilet must be replaced to ensure that it is clean, pleasant and hygiene for people to use. Timescale for action 01/06/08 2 OP19 23(2)(c) 30/07/08 3 OP21 23(2)(j) (n) 30/07/08 4 5 OP21 OP21 23(2)(b) 23(2)(b) 01/06/08 30/06/08 Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 25 6 OP24 23(2)(c) Beds must be suitable for each person’s comfort and safety. 30/07/08 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 Refer to Standard OP12 OP21 Good Practice Recommendations Money should be made available to provide entertainment and outings for people within the home. Bathrooms should be made more homely. Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. Extracts may not be used or reproduced without the express permission of CSCI Roman Court DS0000067664.V362585.R01.S.doc Version 5.2 Page 27 - 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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