Inspection on 19/02/08 for Roann House

This inspection was carried out on 19th February 2008.

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 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

Roann House 28/07/08

Roann House 27/06/07

Roann House 30/05/06

Roann House 11/10/05

Roann House 10/05/05

Roann House 15/11/04

Roann House 05/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Roann House 91 Bouverie Road West Folkestone Kent CT20 2PP Lead Inspector Mark Hemmings and Kim Rogers Unannounced Inspection 19th February 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Roann House DS0000057418.V359919.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. Roann House DS0000057418.V359919.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Roann House Address 91 Bouverie Road West Folkestone Kent CT20 2PP 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) 01303 253705 01303 255057 Roann House Ltd Mrs Sursatie Sanicharie Pieries Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Roann House DS0000057418.V359919.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One (1) Service User with DE whose date of birth is 24/04/1951. Date of last inspection 27th June 2007 Brief Description of the Service: Roann House (the Service) is registered to provide accommodation and personal care for 17 older people and one younger adult who experiences difficulties with aspects of comprehension. The property is a detached three storey house. There is a passenger lift that gives step-free access to the parts of the accommodation occupied by the people in residence. When full, there is provision for one of the bedrooms to be shared by two people. In practice, all of the bedrooms are used for single occupancy. Each bedroom has a private wash hand basin. There is a call bell system that enables people to summon assistance should it be needed. There is various equipment such as a hoist to help those people who have difficulty getting about. There is a relatively small lounge and dining room. To the rear aspect, there is a large conservatory. At the back of the property there is an enclosed garden. The Service is located in a quiet residential street that is quite near to Folkestone town centre. This means that there is ready access to shops and public transport services. There is a limited amount of off-street car parking and there is also local on-street parking. People who might want to move in can get information from several sources. There is a Service Users’ Guide. This is a brochure that outlines the principal features of the facilities and services available in the Service. There is also a document called a Statement of Purpose. This gives a more detailed account of the provision in place than does the Guide. The Registered Provider ensures that a copy of the most recent Inspection Report from the Commission is available for reference. The range of fees charged currently for each person’s residence in Roann House, runs from £312.00 to £356.00 per week. Roann House DS0000057418.V359919.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 No (0) Star. This means that the people who use this Service experience poor quality outcomes. The Commission since 1 April 2006 has developed the way it undertakes its inspection of care services. This inspection of the Service was an unannounced “Key Inspection”. The Inspectors arrived at the Service at 09.30 and they were in the Service for about five and half hours. It was a thorough look at how well the Service is doing. It took into account information provided by Mrs Pieries who is the Registered Manager. The Inspectors also spoke with Mr Pieries. He is the Responsible Individual. This is a formal role that means he is accountable to the Commission for the performance of the Registered Provider. The Inspectors considered information that the Commission has received about the Service since the last inspection. The Inspectors also spoke with seven of the people in residence and with four members of staff. There are 15 Requirements at the end of this Report. What the service does well: What has improved since the last inspection? What they could do better: The information gathered about the needs of people who might want to move in needs to be more comprehensive. Parts of the system used to plan and to deliver personal and health care are not adequate. The calendar of social activities is not sufficient in its extent or in the way that it is organised. The catering service does not provide enough real choice. The system for enabling people to make a complaint needs to be strengthened. Roann House DS0000057418.V359919.R01.S.doc Version 5.2 Page 6 Parts of the accommodation are presented to a poor or to a very poor standard. Some of the security checks that should be completed for care workers have not been done. Parts of the training arrangements are not adequate. The quality assurance system is not sufficiently developed. There are significant omissions in the completion of some basic health and safety checks. 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. Roann House DS0000057418.V359919.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Roann House DS0000057418.V359919.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6. People who use the Service experience adequate outcomes. This judgement has been made using available evidence including a visit to the Service. Parts of the arrangements used to assess the needs of people who might want to move in need to be developed. EVIDENCE: The Registered Manager and the Responsible Individual complete an assessment of each prospective person’s needs for assistance. This is done before a decision is made about whether or not the Service is a suitable place for the person’s residence. The Inspectors looked at the assessment process completed for two of the people in residence. There was no written evidence to show what matters had been considered. The Responsible Individual said that he looks at, “general ability, things that they can do”. Also, there was no evidence to show clearly what had been done to actively involve the people concerned so that they could explain their wishes and preferences. Both of Roann House DS0000057418.V359919.R01.S.doc Version 5.2 Page 9 these parts of the introduction of someone to the Service are very important. Therefore, they need to be undertaken in an organised and sensitive manner. There is a Requirement in relation to this matter at the end of this Report. The Responsible Individual says that the Service is available for people who do not plan to make it their longer term home. This might be because they need somewhere to live while a carer attends to other commitments. Or, it might be because they have been in hospital and are not quite ready to go back to their own home. He says that suitable steps will be taken to help with the person’s return home so that their stay is not longer than is planned and is necessary. Roann House DS0000057418.V359919.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People who use the Service experience adequate outcomes. This judgement has been made using available evidence including a visit to the Service. Parts of the arrangements used to provide personal care and health care need to be strengthened to ensure that appropriate and reliable support is delivered. EVIDENCE: The people in residence say that the care workers offer them all the assistance they need. There is a written individual plan of care for each person. These are important documents. This is because they form one of the means by which people can be informed about and can agree to the assistance they will receive. Also, the plans are a source of information for staff. This then helps them to provide support in a consistent manner. The Inspectors examined two of the written plans. There were significant omissions in both. These gaps then related to uncertainty in the staff team about exactly what had to be done to best assist the people concerned. There is a Requirement in relation to this matter at the end of this Report. Roann House DS0000057418.V359919.R01.S.doc Version 5.2 Page 11 Sensible arrangements are in place to anticipate and manage potential risks to people’s personal health and safety. People are assisted to maintain their health. Care workers are alert to the need to identify occasions when someone is becoming unwell. This is so that medical assistance can be sought promptly. The Inspectors looked in detail at the arrangements in place to assist two of the people in residence to manage specific medical conditions. There were omissions in the written material used to plan the assistance. Again, this had contributed to uncertainty in the staff team about what should be done. There is a Requirement in relation to this matter at the end of this Report. Reliable arrangements are in place to enable people’s medication to be retained and to be dispensed in accordance with the doctors’ instructions. One person handles her own medicines. Special arrangements need to be made to ensure that suitable support is given to help with this practice. There are some omissions in these arrangements that could reduce the level of protection enjoyed by the person concerned. These include the system used to double check that medicines are being stored securely and that they are being taken in the correct manner. There is a Requirement in relation to this matter at the end of this Report. People told the Inspectors that members of staff are kind and attentive. Their relatives commented similarly. However, the Inspectors were concerned to observe an occasion when one person was told rather bluntly by a care worker that she would have to wait before being assisted to use the bathroom because she was busy doing something else. Also, the Inspectors noted that several of the people in residence had not been assisted to change items of clothing when necessary. Roann House DS0000057418.V359919.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People who use the Service experience adequate outcomes. This judgement has been made using available evidence including a visit to the Service. There is only a limited calendar of social activities. People are free to spend the day as they wish. An aspect of the catering arrangements is not adequate. EVIDENCE: There is a calendar of social events held in the Service. The events mainly involve indoor things such as musical movement and bingo. The calendar is not well developed. The events do not take place each day, the range of activities is rather narrow and there is no clear system to show who is taking part. There is a Requirement in relation to this matter at the end of this Report. The people in residence consider the pace of daily life in the Service to be relaxed and unhurried. They say that they are free to decide what to do each day. As appropriate, they can retire to the privacy of their bedroom. People are assisted to keep in touch with members of their families, if this is necessary and if it is their wish. Family members and friends are welcome to Roann House DS0000057418.V359919.R01.S.doc Version 5.2 Page 13 call to the Service at any reasonable time. People are free to spend time in private with their relatives and friends, should they choose to do so. People say that they receive good quality meals and that they have enough to eat. They consider meal times to be a relaxed and pleasant experience. The Responsible Individual said that there is a choice available for each mealtime. However, none of the people asked about this matter by the Inspectors knew what was on the menu for lunch on the day of the inspection visit. This was not helped by the fact that the meal served at lunchtime was not that listed on the written menu. There is a Requirement in relation to this matter at the end of this Report. The teatime meal is limited to a choice between different sorts of sandwiches. Roann House DS0000057418.V359919.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People who use the Service experience adequate outcomes. This judgement has been made using available evidence including a visit to the Service. Aspects of the arrangements used to deal with complaints and to promote people’s wellbeing need to be developed. EVIDENCE: There is a written complaints procedure. This explains how the people in residence and other interested parties can go about raising a concern. There is an omission in the document. This is because it does not explain that people are free to contact the Commission at any time if there is something that is concerning them. Another oversight is that a copy of the procedure has not been given to each of the people in residence. There is a Requirement in relation to these points at the end of this Report. Since the last inspection visit, the Commission has worked with a number of local agencies to look into allegations that have been made about the adequacy of the Service. These mainly concern aspects of the conduct of the Responsible Individual. The questions raised have yet to be resolved to the satisfaction of the Commission. There is a written statement of the Registered Provider’s commitment to promoting the wellbeing of the people in residence. There has not been much Roann House DS0000057418.V359919.R01.S.doc Version 5.2 Page 15 in the way of any organised training for members of staff in relation to this matter. This has contributed to a situation in which at least one of the care workers is not clear about some of the signs that might indicate to her that someone’s wellbeing may be in question. There is a Requirement in relation to this matter at the end of this Report. The people in residence with whom the Inspectors spoke during their visit to the Service say that they feel safe living in Roann House. Roann House DS0000057418.V359919.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 23, 24, 25 and 26. People who use the Service experience poor outcomes. This judgement has been made using available evidence including a visit to the Service. Parts of the accommodation are presented to a poor or to a very poor standard which means the people who use the service do not experience good outcomes in this area. EVIDENCE: Much of the furniture, fittings and décor are shabby and need improvement. For example, some light shades and light bulbs are missing, some curtains are hanging from rails, paintwork and walls are chipped and marked. Part of the dining room is cluttered. This reduces the space available for those people who have problems with mobility. Roann House DS0000057418.V359919.R01.S.doc Version 5.2 Page 17 The conservatory was cold, dirty and smells of stale cigarette smoke. It had a stained and worn carpet. Most of the bedrooms had dirty carpets and dusty surfaces. Most of the bedrooms had an unpleasant smell. Commodes were dirty, odorous and/or rusty. There is a Requirement in relation to this matter at the end of this report. Bedrooms are personalised with people’s own pictures and photographs of family and friends. Bathroom facilities are not adequately presented. The Registered Manager said that everyone uses one bathroom. This is because other bathrooms are not suitable to meet people’s needs. Some baths and toilets were dirty. The rooms were stark and unwelcoming. In one bathroom some of the wall tiles were cracked and others were missing. The laundry is adequate with two washing machines with sluice cycles and one dryer. One of the people who use the Service said that there are no problems with the laundry and that ‘you always get your clothes back’ Roann House DS0000057418.V359919.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People who use the Service experience poor outcomes. This judgement has been made using available evidence including a visit to the Service. There are not enough staff to meet service users needs. Staff are not trained or supervised appropriately. Service users do not take part in the recruitment process, which is not robust. EVIDENCE: In the morning and until the early afternoon there are three care workers on duty to provide assistance for the people in residence. This number reduces to two for the afternoon and evening. At night, there is one person on waking duty and one person who sleeps-in. There is a cook, but there are no domestic staff to help with the cleaning and the laundry. The care workers have to fit this is around their other duties. This reduces the amount of time that is available for the provision of personal care. There are no written records to show who has worked for what periods of time There is a Requirement in relation to this matter at the end of this Report. Given this omission, the staffing levels described above and the observations made in relation to Standards 10, 12, 19 and 26, the Inspectors cannot be confident that the Service is staffed adequately. Roann House DS0000057418.V359919.R01.S.doc Version 5.2 Page 19 None of the care workers have acquired a National Vocational Qualification (NVQ) in health and social care. None are in the process of studying for the qualification. This Award is useful because it provides care workers with a range of opportunities to confirm elements of good care practice and to extend their range of skills. There is a Requirement in relation to this matter at the end of this Report. People who use the Service are not involved in staff recruitment. The Registered Manager said that she and the Responsible Individual recruit and interview staff. Three staff files were sampled and they had no proof of identity or proof of qualifications. One of the three had no proof of a Criminal Records Bureau check. There is a Requirement in relation to this matter at the end of this Report. The arrangements for induction training are not adequate. In the three personnel files examined by the Inspectors, two of them had no record of their induction and one person had a basic tick list only. This did not show how who had carried out and the induction. Also, it did not show how the care worker’s competency and understanding had been assessed. In two of the three personnel files examined, there were no records to show that the care workers had received any organised training. One person said they had never been on a training course of any sort. There is a Requirement in relation to this matter at the end of this Report. The Responsible Individual has provided some training in-house. However, there were no records on site for the Registered Manager or for the Responsible Individual. This meant that their qualifications to deliver tuition could not be checked. Roann House DS0000057418.V359919.R01.S.doc Version 5.2 Page 20 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): Standards 31, 33, 35 and 38 People who use the Service experience poor outcomes This judgement has been made using available evidence including a visit to the Service. The management of the Service is adequate but it is not run in service users’ best interests. The quality assurance system does not give people sufficient voice in the running of the Service. The system used to administer people’s personal spending allowances is not rigorous. There are significant omissions in the completion of some basic health and safety checks. EVIDENCE: The Registered Manager and the Responsible Individual share the management of the Service, they also both work full time on shift. Both are registered Roann House DS0000057418.V359919.R01.S.doc Version 5.2 Page 21 nurses. However they do not seem to have completed any other recent training to update their qualifications. The views of the people who use the Service and their relatives have been sought by the Registered provider for the first time this year. The Responsible Individual said if people were unable to complete the written questionnaires they were given to relatives to complete. This means some people who do not have relatives did not take part and their views not sought. A summary of the results of the exercise has been written and is kept in the office. It has not been shared with the people who use the Service. This significantly reduces the value of the exercise. There are no other organised quality assurance systems in place. There is a Requirement in relation to this matter at the end of this Report. The Registered Manager and the Responsible Individual hold small amounts of money for three of the people in residence. This is done so that it does not get lost and so that everyday purchases can be made of things such as toiletries and consultations with the hairstylist. Parts of the arrangements are not well organised. The records of the transactions are not sufficiently detailed. Also, the system used to physically retain cash does not enable the balances to be tallied with what the records say should be there. There is a Requirement in relation to this matter at the end of this Report. A selection of records relating to health and safety were sampled. There were some serious omissions in some basic checks. For example, the gas safety check was last done on 26 August 2005. It should be carried out every year to make sure that the pipe-work is sound. The check of the electrical wiring installation had not been done. Its safe-worthiness should be checked at least once in every five years. This should be done to make sure that there are no faults that may cause someone to have an accident. One of the boilers did not have a service certificate and the other had not been serviced since 7 December 2002. There is a Requirement in relation to this matter at the end of this Report. There has been no recorded fire drill since 6 November 2006. There are no records of staff training or competency assessments relating to health and safety or fire awareness. There is a Requirement in relation to this matter at the end of this Report. The Service has the required public liability insurance. Roann House DS0000057418.V359919.R01.S.doc Version 5.2 Page 22 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 2 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 1 1 2 3 2 1 1 STAFFING Standard No Score 27 2 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 2 X X 1 Roann House DS0000057418.V359919.R01.S.doc Version 5.2 Page 23 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 OP3 Regulation 14 (1) (a) Requirement The Registered Provider shall not provide accommodation to a service user at the care home unless so far as it shall have been practicable to do so (the) needs of the service user have been assessed by a suitably qualified or suitably trained person - in that, the Registered Provider must ensure that a suitably organised and recorded system is used to consult with people who might want to move in about their needs for assistance and about their preferences. Unless it is impractical to carry out such consultation, the registered person shall after consultation with the service user or a representative of his, prepare a written plan (the service user’s plan) as to how the service user’s needs in respect of his health and welfare are to be met - in that, the Registered Provider must address the omissions in four of the service user plans. DS0000057418.V359919.R01.S.doc Timescale for action 01/05/08 2. OP7 15 (1) 01/05/08 Roann House Version 5.2 Page 24 3. OP9 13 (4) The Registered Provider shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated - in that, the Registered Provider must ensure that suitable arrangements are introduced to assist Service User C when she administers her own medicines. 01/05/08 4. OP12 16 (2) (n) The registered person shall 01/05/08 having regard to the size of the care home and the number and needs of service users consult service users about the programme of activities arranged by or on behalf of the care home and provide facilities for recreation including having regard to the need of service users, activities in relation to recreation, fitness and training in that, the Registered Provider must review and as necessary extend the calendar of social activities. When events are held, this should be recorded, as should be an account of who elected to take part. The registered person shall having regard to the size of the care home and the number and needs of service users provide in adequate quantities suitable, wholesome and nutritious food which is varied and properly prepared and available at such time as may reasonably be required by service users - in that, the Registered Provider must ensure that a real choice of main dish is provided at each lunchtime meal. The meals served to each person should be recorded. DS0000057418.V359919.R01.S.doc 5. OP15 16 (2) (i) 01/05/08 Roann House Version 5.2 Page 25 6. OP16 22 (1) The registered person shall 01/05/08 establish a procedure (the complaints procedure) for considering complaints made to the registered person by a service user or person acting on the service user’s behalf - in that, the Registered Provider must ensure that the complaints procedure is revised to ensure that people are informed about their right to approach the Commission at any time. A copy of the revised procedure must be given to each of the people in residence and/or to their representatives. The registered person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users - in that, the Registered Provider must ensure that all of the care workers have the knowledge and skills they need to enable them to operate its policy and procedure in relation to safeguarding the wellbeing of the people in residence. The registered person shall maintain in the care home the records specified in Schedule 4. A copy of the duty roster of persons working at the care home and a record of whether the roster was actually worked in that, the Registered Provider must ensure that there is a suitably detailed written account of how the Service is staffed. On a rolling basis, this should specify who is working what hours and in what capacity. 01/05/08 7. OP18 12 (1) (a) 8. OP27 17 (2) Schedule 4 (7) 01/05/08 Roann House DS0000057418.V359919.R01.S.doc Version 5.2 Page 26 9. OP28 OP30 18 (1) (a) 18 (1) (c) (i) The registered person shall having regard to the size of the home, the statement of purpose and the number and needs of service users ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users (and) ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform in that, the Registered Provider must enable care workers to begin a course of study that will lead to them acquiring the National Vocational Award in health and personal care. Also, the Registered Provider must ensure that suitable in-house arrangements are introduced to confirm the adequacy of the core competencies of all of the care workers. The registered person shall not employ a person to work at the care home unless ... he has obtained in respect of that person the information and documents specified in paragraphs 1 to 7 of Schedule 2, proof of the person’s identity, including a recent photograph, documentary evidence of any relevant qualifications of the person, either where the certificate is required for a purpose relating to section 115 (5) of the Police Act 1997 (registration under Part 2 of the Care Standards Act 2000, or the position falls within section 115 (3) or (4) of that Act, an DS0000057418.V359919.R01.S.doc 01/05/08 10. OP29 19 (1) Schedule 2 (1) (5) (7) 01/05/08 Roann House Version 5.2 Page 27 enhanced criminal record certificate issued under section 115 of that Act, or in any other case a criminal records certificate issued under section 113 of that Act - in that, the Registered Provider must ensure that the specified security checks are completed in relation to all members of staff. 11. OP33 24 (1) The registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the care home including the quality of nursing where nursing is provided at the care home - in that, the Registered Provider must ensure that there is suitable quality assurance system that adequately informs stakeholders about how suggested improvements are going to be addressed. The registered person shall maintain in the care home the records specified in Schedule 4, a record of all money or other valuables deposited by a service user for safekeeping or received on the service user’s behalf which shall state the date on which the money or valuables were deposited or received, the date on which any money or valuables were returned to a service user or used at the request of the service user or on his behalf and where applicable the purpose for which the money or valuables were used - in that, the Registered Provider must ensure that a suitable record is maintained of any personal spending monies managed on DS0000057418.V359919.R01.S.doc 01/09/08 12. OP35 17 (2) Schedule 4 (9) (a) 01/05/08 Roann House Version 5.2 Page 28 behalf of the people in residence. There must be a separate cash balance for each account. 13. OP19 23 (2) (d) The registered person shall 01/05/08 having regard to the number and needs of the service users ensure that all parts of the home are kept clean and reasonably decorated - in that, the Registered Provider must ensure that all parts of the Service are clean and free from offensive odours. The registered person shall 01/05/08 having regard to the number and needs of the service users ensure that the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally, equipment provided at the care home for use by service users or persons who work at the care home is maintained in good working order - in that, the Registered Provider must ensure that the required health and safety checks are carried out. This includes those relating to gas safety, the electrical wiring installation and the central heating boilers. The registered person shall after consultation with the fire authority make arrangements to ensure by means of fire drills and practices at suitable intervals that the persons working at the care home and so far as practicable service users are aware of the procedure to be followed in case of fire including the procedure for saving life - in that, the Registered Provider DS0000057418.V359919.R01.S.doc 14. OP38 23 (2) (b) (c) 15. OP38 23 (4) (e) 01/05/08 Roann House Version 5.2 Page 29 must ensure that regular fire drills are held and recorded and that all members of staff are competent to operate the Service’s fire safety procedure. 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 Roann House DS0000057418.V359919.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Roann House DS0000057418.V359919.R01.S.doc Version 5.2 Page 31 - 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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