Inspection on 07/04/09 for Rose Lodge Care Home

This is the latest available inspection report for this service, carried out on 7th April 2009.

CQC 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

Rose Lodge Care Home 26/06/07

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE Rose Lodge Care Home Walton Road Wisbech Cambridgeshire PE13 3EP Lead Inspector Elaine Boismier Key Unannounced Inspection 7th April 2009 9:45 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 Rose Lodge Care Home DS0000069320.V374719.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. Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rose Lodge Care Home Address Walton Road Wisbech Cambridgeshire PE13 3EP 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) 01945 474449 01945 474735 www.barchester.com Barchester Healthcare Homes Ltd Mrs Janet Olwyn Rippengill Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60), Physical disability over 65 years of age of places (60) Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of places not to exceed 60 at any one time Date of last inspection 1st April 2008 Brief Description of the Service: Rose Lodge, owned by Barchester Healthcare Homes Ltd, provides care for people over 65 years of age assessed to need both personal and nursing care. The home has 49 bedrooms that have ensuite facilities; 3 single bedrooms that have hand washing facilities and all the four shared bedrooms have ensuite facilities. There is a medium sized car park at the front of the home and large gardens that surround the building. The home is close to the centre of the market town of Wisbech that offers a range of leisure and shopping facilities. Current fees range from £347 to £725 per week. Additional costs include those for chiropody, hairdressing, confectionary and toiletries. Further information about fees can be obtained directly from the home. (Please note that although this inspection report is of the Commission for Social Care Inspection ((CSCI)) template the Care Quality Commission ((CQC)) has replaced the CSCI as of the 1st April 2009). A copy of the inspection report is available on request at the home or via the CQC website at www.cqc.org.uk Rose Lodge Care Home DS0000069320.V374719.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. This summary also includes information about our random unannounced inspection that we carried out on the 27th August 2008 and an Annual Service Review (ASR) that we carried out on the 10th March 2009. Random Unannounced Inspection-27th August 2008 The reason for this inspection was to assess the progress made with regards to care of any person with a pressure sore and to assess if the three requirements had been met, with regards to medication, following our key unannounced inspection of the home, on the 1st April 2008. Other findings, as a result of this inspection, were also reported on. As a result of our inspection we found that there had been little progress made with regards to the standard of the care plan records; we made an immediate requirement as we found a person, with a pressure sore, had not received the appropriate care and treatment that they needed for this condition; a requirement with regards to medication records was considered, on the whole, as met although two requirements were considered as not met with regards to making sure people were safe when receiving their medication when they were out of the home. Annual Service Review (ASR)-10th March 2009 An ASR was carried out on the 10th March 2009. An ASR looks at information that we have received about and from the home. The Annual Quality Assurance (AQAA) was sent to us but this was incomplete; we sent out surveys for the home to distribute to some of the residents and some of the staff although we received none of these. We also looked at our inspection reports for 2008. We concluded in our ASR that we would bring forward the next key unannounced inspection before the 31st March 2010 Key unannounced inspection-7th April 2009 We, The Care Quality Commission, carried out this key unannounced inspection by two Inspectors, between 9:45 and 14:45 taking five hours to complete. We looked around the premises, spoke with some of the residents and case tracked some of these people. Case tracking means comparing what we see and hear from the residents and the staff who are looking after them with the Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 6 person’s records. We also looked at other records kept by the home. We spoke with some of the staff, including the Deputy Manager and a visitor to the home. For the purpose of this report the people who live at the home are referred to as ‘people’, ‘person’ or ‘resident/s’. What the service does well: What has improved since the last inspection? Following our inspection of the 27th August 2008 an immediate requirement was made and two requirements with regards to medication were carried forward. All three of these requirements have been met. In our report for the inspection of the 27th August 2008 we noted that activities in the home could be better and we expected the home to take action about this, rather than we make a requirement. The standard of activities has since improved. Other areas that the home could have improved upon, and recorded in our report of the key inspection of the 1st April 2008 were as follows; ‘The home should provide means for people to call for assistance, when they are sitting in the lounge areas. We expect the home to manage this issue.’ This remains somewhat of an issue although we saw that the staff were in close range of these areas to hear if any of the residents needed help or attention. Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 7 ‘There should be a review of the needs of the residents to assess if the numbers of staff are sufficient to provide individual care and to offer choice.’We are unclear if such a review had taken place although there were sufficient number of staff. ‘Any risk of harm to people, must be identified and managed by the safe keeping of scissors. We expect the home to manage this, rather than we make a requirement on this occasion.’ This was actioned straightaway when we inspected this time. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Rose Lodge Care Home DS0000069320.V374719.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 Rose Lodge Care Home DS0000069320.V374719.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 & 3 Quality in this outcome area is good. There is good standard of information to help people in their decision where to live and there are systems in place to ensure that the home can meet the needs of any person moving in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA told us that the home has a pre-admission system in place to ensure that the home can meet the assessed needs of any person who moves into Rose Lodge, as there is a Total Care Assessment and that the ‘ Pre Admission Assessment (is) in great detail and person centered.’ Within the care records, including one of the people most recently admitted to the home, we saw that assessments about the person’s needs had been carried out before the person moved into the home and these assessments were made by the home and by a referring hospital. Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 10 A copy of the key unannounced inspection report, for April 2008, was available in the main foyer with the Statement of Purpose although we, with the Deputy Manager, were unable to find the last report of our random unannounced inspection we carried out in August 2008. Rose Lodge Care Home DS0000069320.V374719.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 & 10 Quality in this outcome area is good. People are safer from the risk of harm to their health and welfare. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Following our random unannounced inspection, of the 27th August 2008, we found evidence that indicated that there had been little improvement in the standard of care plan documentation; the wording of some of the objectives of the planned care were ambiguous, it was not person centred and was “clinically” orientated. For example we read for one person’s their long-term objective for breathing was recorded as “To maintain normal breathing pattern and adequate tissue oxygenation”. For the care plan, for a urinary catheter care, there was no description/assessment of what this meant to the person, who had such a catheter, rather the long term objective was described as “To maintain viability of catheter and prevent infection. To promote faecal continence.” Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 12 The AQAA told us ‘Care plans and risk assessments with monthly reviews take place’ and ‘All care plans are written in a more person centred way. Care is provided in a more person centred manner. Staff have a greater awareness of the changing needs of the residents and the importance of this being documented as such.’ During this key inspection, of April 2009, we looked at two people’s care records, spoke with the staff and spoke with the residents who the care plans were about. Evidence indicated that there has been an improvement in the standard of the care plans. The wording for long term objectives, such as for breathing, was more person centred and there were clear and less clinical aims for the care. For example the wording for the care plan for breathing stated that the person would be supported in ensuring that they do not encounter breathing difficulties. The assessments within the care plans were detailed and told the staff, in most areas, what the person needed. Some of the information in the preadmission assessments, such as food likes and dislikes, had been transferred into the care plan records. Risk assessments and care plans were reviewed each month and there were short-term care plans and new risk assessments developed due to the changed needs of the people. There were some deficiencies noted, however, where assessments had been carried out although no guidance was provided for how staff were to meet the person’s needs. For example a person was described, in their care plan for communication, to be confused and muddled although there was no further record as to how the staff were able to support the person with their communication during such episodes. We spoke with the staff and they told us what action they would take when the person became agitated. We noted the person had a medical history of depression and anxiety and from the medication administration records had been prescribed medication for these conditions. We found no record, in the care plan for mental health (care plan number 10) about the person’s anxiety and depression. We have made no requirement about care plans as there has been an improvement in this are although any deficiencies that we have noted and any of those noted by the home, we expect the home to take action to improve these deficient areas. We found evidence, during our random inspection of the 27th August 2008, that suggested a person had not received the appropriate care and treatment to prevent a pressure sore from developing and the care provided had not arrested the deterioration in the person’s skin integrity. We made an immediate requirement following this evidence and judgement. The AQAA told us that ‘Monthly Pressure ulcer reports, monthly nutrition reports – followed up by Clinical Development Nurse’. The Deputy Manager informed us that currently there are three people who have developed at least one pressure sore whilst living at the home. We looked at the pressure sore audit record (that was noted in the AQAA) and compared one of these records with the care records of one of these three people. We Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 13 found that the audit was correct and we found, from examining the person’s wound assessments chart, that the sore was healing. We looked at the person’s care plan for pressure area care and compared this with the person’s repositioning chart. On the whole the repositioning chart evidenced that the care plan was being carried out i.e. the person was having their position changed, when in bed, every 2-4 hours although there were some areas that the records provided insufficient evidence that the person had adequate pressure relieving care when sitting up in chair, albeit a pressure relieving cushion was provided. For example on the 6th April 2009 the repositioning chart indicated that at 11:30 the person was stood up with assistance, to relieve pressure on their bottom. The next recorded entry was at 12:20 that said the person was assisted with their dinner although there was no record to indicate the person had any pressure relief until the person was helped back to their bed, at 18:05. However, as there was evidence that the person’s pressure sore was healing, we consider this requirement has been met and action to be taken by the home to address any of the deficiencies in care practices and/or record keeping rather than we make a requirement about this, on this occasion. People’s care records indicated that they had received care from chiropodists and treatments from a physiotherapist. Visits had been made to an optician and contact had been made with a hospital audiology (hearing) clinic. There was evidence that people are weighed each month and a dietician had been contacted by the home for one of the people’s unintentional weight loss, with good effect. The Deputy Manager stated that a dentist has been contacted for some of the residents although one of the people we spoke with said that they had not received such treatment and they wanted to see a dentist for a checkup. We found no record, in their care notes, of any contact with the dentist. The Deputy Manger believed that the person had been seen by the dentist but would pursue this matter further. A pharmacist inspector examined the practices and procedures for the safe handling, use and recording of medicines. These have improved markedly over previous inspections. The home has good, up to date, policies and procedures for the safe handling and use of medicines to protect residents, including a procedure for the safe use of medicines when people are on shortterm absence from the home. Facilities provided for the storage of medicines are secure and temperature controlled. This ensures that people receive medicines of good quality and prevents unauthorised access. We found one medicine in the fridge used to store medicines on the ground floor which was clearly labelled “When in use, do not refrigerate”. We expect this to be managed by the home so that the person prescribed this medicine is not put at risk. We looked at records kept of the receipt and disposal of medicines and the records made when medicines are given to people. These were in good order with very few omissions. Most of the omissions we found had already been picked up by the home’s own audit procedures. This demonstrates that people receive the medicines provided for them. A medicine for one person Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 14 which should be given at least 30 minutes before food, drink or other medication was recorded as being administered at the same time. We expect this to be managed by the home without the need to make a requirement on this occasion to protect the person from harm. Medication is given to residents by suitably trained and qualified staff. We watched some medicines being given to people at lunchtime and this was done well with due regard to their privacy, dignity and personal choice. Requirements made on previous inspections have been met. The people we spoke with said that the staff were ‘Very good’ and we saw that the staff interacted with the people in a kind, caring and respectful manner. Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 15 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 & 15 Quality in this outcome area is good. People have opportunities to live a good quality of life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During our random unannounced inspection of the 27th August 2008 we found evidence that indicated that the more able people have the opportunities provided to go out on trips and to engage in in-house activities. We expected the home to manage this issue rather than we made a requirement. According to the AQAA there is a range of activities in and out of the home but areas that has been identified where the home could improve was noted, ‘Further choice of activity and inclusion of residents with high nursing needs’ and ‘Provide greater stimulation for those residents who wish to be more engaged’. We asked some of the people about activities provided, watched what was happening in the home and looked at the record of activities. On the day we Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 16 were at the home we saw some of the people being escorted, by staff, to visit the gardens. We also saw some of the people playing a game of dominoes in one of the communal rooms and we saw that there had been an improvement in 1:1 sessions for those people who were less able to take part in the other activities. We spoke also with a visitor who told us that their relative had been out on trips to a shopping centre, a wild life park and listened to a visiting singer. The person’s activities record also noted that they had taken part in the Red Nose Day entertainment. In the afternoon of our inspection a singer playing a guitar was entertaining some of the people. We saw that people’s rooms were personalised with their photographs, pictures and pieces of furniture. We saw from the visitors’ record book and people’s care records that people can receive their guest at any time and a visitor confirmed this was the case. People we spoke with said that the food was good and they were enjoying their lunch. For those people who needed to have pureed food we saw that portions were served separately rather than all mixed up together. We saw that the staff were helping those with their food whilst sitting down with the person. Dining tables were well presented with tablecloths and table decorations. Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 17 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 & 18 Quality in this outcome area is good. People are listened to and safe from the risk of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since our inspection in August 2008 we have received no complaints about the home and we have received no allegations of abuse against any of the residents. We looked at the record of complaints and we saw that, since January 2009, the home has received three complaints and all of these were responded to and resolved with the required 28-day timescale. None of these complaints had the same theme. The people and the visitor we spoke with knew who to speak to if they were unhappy about something and the staff also knew what to do. The staff told us that they felt the Deputy Manager actively listened to any concerns raised and took appropriate action to resolve these. The visitor said that any concerns they had, they felt satisfied with the way action had been taken to resolve their concerns. The staff we spoke with said that they had attended safeguarding training and we saw records to confirm their attendance. The staff were able to say what they would do if they witnessed abuse against any of the residents. Telephone Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 18 numbers for agencies involved in safeguarding alerts and investigations, such as social services and the police, are available for the staff although we considered that these numbers should be in a more prominent position to be made available in a more prominent way for any person living, visiting or working at the home. We expect the home to manage this should they need to contact such agencies. We spoke with a person who had a lap-strap on when they were in their wheelchair. They told us that they chose to have this piece of restraining/safety equipment on and showed us that they could easily release this strap without assistance from any other person. Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 19 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 & 26 Quality in this outcome area is good. People live in a safe and comfortable home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: According to the AQAA the home has improved because ‘Provided more seating in all garden areas’ and the ‘ Ground Floor activity room turned into quiet lounge area’ and during our tour of the premises we saw that this was the case. We spoke with a member of the staff who explained how some of the garden furniture (tables) had been adapted for those people in wheel chairs. The gardens were well presented and there is safe access around the home via clear pathways. Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 20 The décor and general furnishing of the home was of a satisfactory standard although it was clear that there is a shortage of storage space as hoists were kept in the main corridors. We found the place to be clean and there were no offensive odours. In November 2008 we received a notification from the home that told us that there had been an outbreak of diarrhoea and vomiting amongst some of the residents and some of the staff and appropriate action, to include restricted visiting, had been taken to reduce the spread of this infection. Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 21 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 & 30 Quality in this outcome area is good. People are in safe hands. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA was incomplete, as we were not provided with information about the staffing numbers or staff training. The staff told us that there is a sufficient number of staff on duty to meet the needs of the people although this is not always the case when there is unplanned staff sickness. We saw that the people were receiving indivualised care in an unhurried manner, for example at lunchtime. Call bells were responded to within 3 minutes or less. Currently the home employs 37 care staff and 13 of these have the National Vocational Qualification (NVQ) level 2 or equivalent in care i.e. 35 . This is a reduction in the numbers of staff with this desirable qualification since our inspection of the 1st April 2008. The Deputy Manager said that there is work in progress to increase the number of care staff with this NVQ. We checked two recruitment records of staff who were most recently employed to work at the home. We found that all the required information was available. Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 22 The staff we spoke with said that they were satisfied with their induction and ongoing training. We were told that their induction training covered topics such as helping people with their personal care and health and safety matters and we saw the induction-training programme covered such areas. The new recruit’s competencies were checked and signed off by a senior member of the staff. We looked at other training records and other information about the training of the staff. Evidence indicated that the staff have opportunities to attend training in how to care for a person with palliative care needs and there is planned training for staff to attend future training in learning how to care for some one who needs their food via a special feeding tube. Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 23 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 & 38 Quality in this outcome area is good. People benefit from a well-managed service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Deputy Manager, a registered general nurse, was in charge of the home and we were informed that a vacancy has arisen for a registered manager. The Deputy Manager has been in post since August 2008 and is supported by her line manager and a registered manager of another home that is owned by Barchester Healthcare Ltd. The staff told us that they appreciated the leadership style (‘firm but fair’) of the Deputy Manager and felt supported by her. The staff also felt that if they had any concerns, the Deputy Manager listened to them. Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 24 As we have not had any formal notification of the vacancy for the registered manager this inspection report retains the name of the registered manager. The AQAA, although not complete, was detailed in the areas where it was completed. It identified areas where the home has improved within the last 12 months and areas that could be better. The next AQAA that we request must be complete although we have made no requirement about this, on this occasion. We requested to see the last two visit reports (regulation 26) made by a representative of Barchester Healthcare Ltd and we saw that these were completed for visits made in July and September 2008. These contained some of the residents’ views about the home and audits of some of the records. According to the Deputy Manager the home has had, within the last two weeks, a regulation 26 visit although they were unable to access any report if sent to the registered manager’s email address. Evidence suggests that there is a satisfactory quality assurance system in place as demonstrated by an overall improvement in people’s standard of health and social care. According to the Deputy Manager the home does not keep any person’s personal monies for safekeeping and this was the case when we last assessed this Standard. We were unable to gain access to any records for people’s financial transactions such as invoices for hairdressing and chiropody. We have taken a reasonable view, based on our previous findings, that this Standard has been met. Service checks for fire alarms, fire fighting detection and fire fighting equipment were in date as were those for hoists and portable appliance tests. Records for hot water temperatures in baths and showers were also satisfactory. The staff told us that they had attended fire safety training and training in safe moving and handling techniques and we saw records that indicated 22 people, the majority of which were staff, were present at the last fire drill, that was carried out in October 2008. We noted, in our last key unannounced inspection of April 2008, that there were scissors left in an unlocked sluice room although there was no risk to any of the residents as, at that time, none of the residents were able to walk or move around unless with the help from the staff. As a result of this reduced risk we made no requirement. During this inspection we visited the first floor sluice room and found that the door was bolted from the outside. We unbolted the door and found two pairs of scissors hanging from hooks on the opposite wall. A member of the staff told us there were at least two of the current residents who were independent in Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 25 walking around. Due to some element of risk of harm to these people we noted that the scissors were removed from this sluice room and the Deputy Manager reported the scissors were removed to a safer place. Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 26 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 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 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 3 x 3 x x 3 Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action 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 Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 28 Quality Care Commission Eastern Region Quality Care Commission Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk © This report is copyright Care Quality Commission (CQC) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CQC. Rose Lodge Care Home DS0000069320.V374719.R01.S.doc Version 5.2 Page 29 - 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. 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