Inspection on 20/02/08 for Rock Lea

This inspection was carried out on 20th February 2008.

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

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

Other inspections for this house

Rock Lea 22/11/06

Rock Lea 16/01/06

Rock Lea 05/07/05

Rock Lea 24/01/05

Rock Lea 26/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Rock Lea Abbey Road Barrow in Furness Cumbria LA13 9SJ Lead Inspector Ray Mowat Unannounced Inspection 20th February 2008 08:00 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 Rock Lea DS0000036579.V356557.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. Rock Lea DS0000036579.V356557.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rock Lea Address Abbey Road Barrow in Furness Cumbria LA13 9SJ 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) 01229 894546 01229 894543 www.cumbriacare.org.uk Cumbria Care Vacant Care Home 26 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (26) of places Rock Lea DS0000036579.V356557.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Standards. The home is registered for a maximum of 26 service users to include: up to 26 service users in the category of OP (Older people) up to 6 service users in the category of DE(E) (Dementia over 65years of age) 22nd November 2006 Date of last inspection Brief Description of the Service: Rock Lea is a care home providing personal care and accommodation for 26 older adults, of whom six may have dementia. The registered provider is Cumbria Care, an independent business unit of Cumbria County Council. The Home is located in a residential area on the outskirts of Barrow-in-Furness, close to bus routes into the town. The home was formerly a Victorian residence and has retained many original features. It has been extended and altered to provide accommodation on two floors, accessible by a passenger lift. The home has two good size lounge/dining rooms and a conservatory lounge/diner. The home has an EMI unit for six people with its own lounge/dining area with accessible toilet and bathroom facilities. All the twenty-six rooms are single occupancy, with eight having en-suite facilities. The home has extensive grounds to the front and rear, including well-kept gardens and parking facilities. Information about the home is made available to existing and prospective residents in the Service User guide and Statement of Purpose, which are displayed in the foyer along with the previous inspection report. The range of fees currently charged range from £363 to £422 per week. Rock Lea DS0000036579.V356557.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 1 star. This means the people who use this service experience adequate quality outcomes. This inspection visit took place over one day and involved two inspectors. One inspector completed a SOFI observation (Short Observational Framework for Inspection). This involves the inspector spending up to two hours observing a small number of people with dementia, who live in the home and assess what interaction they have with other people living in the home, staff and the environment. We also spent time talking to people who live in the home, their relatives and visitors, other professionals and the care staff. Surveys were also sent out as part of this inspection to the same groups of people described. We also examined records related to the running of the home and the care of the people living there. This involved ‘case tracking’ three peoples care plan files, which included meeting with them and examining the records kept by the home that guide staff in supporting them in their preferred manner. What the service does well: The home has a committed and experienced staff team who have developed good relationships with the people living in the home. The supervisory staff and care staff work well as a team. The majority of the people who we met or returned a survey said they felt “well looked after” and that the staff were “kind and helpful”. The home works closely with other agencies to make sure people’s individual personal and healthcare needs are monitored and responded to. Good practice was observed with the administration of medication and medication records were up to date. Staff receive appropriate training in the safe handling of medicines before they are involved in the administration of medication. Visitors, family and friends are always made welcome in the home and there was evidence of frequent visits. There is a four-week rolling menu that provides a good selection of nutritious meals with individual and special diets catered for. Clear policies and procedures are in place, which ensure concerns are listened to and people are kept safe. Rock Lea DS0000036579.V356557.R01.S.doc Version 5.2 Page 6 The home provides a safe and comfortable environment that is decorated and furnished to a good standard. The grounds and building are well maintained and provide suitable facilities for people to relax and enjoy their home. What has improved since the last inspection? What they could do better: A detailed assessment of a person’s needs must be completed prior to their admission so that the home can assess if they have the resources and facilities to meet their needs. This is particularly important for people on short term respite care or placements arranged at short notice. The home is required to ensure all people living in the home have a detailed care plan developed that is agreed with them and kept under review. There was evidence of care plans not being updated when changes have occurred, which puts both the person living in the home and staff at risk. The extractor fans in the kitchen are in need of cleaning as they are covered with a build up of grease and fluff. In addition there were areas of the floor behind some units that need to be more thoroughly cleaned. There must at all times be a suitable number of experienced and competent staff to meet the health and welfare needs of the people living in the home. The home has experienced staff shortages that have had a negative impact on the quality of the service provided. Staff training has also been affected by the management and staff absences. All staff must now be provided with suitable levels of training appropriate to the work they are to perform. Staff supervision is not taking place at regular intervals as required and should be at least six times a year and an annual appraisal in line with the requirements of the NMS. Rock Lea DS0000036579.V356557.R01.S.doc Version 5.2 Page 7 The information supplied to people living in or moving into the home needs to be updated to reflect the recent management changes. Daily records should include what activities people have taken part in and how they have spent their day. Relevant information should be recorded from CRB disclosures before they are destroyed in line with Data protection guidelines. Although the home have completed nutritional assessments and are recording people’s weight, when weight gain or loss is noted any actions taken should be recorded. 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. Rock Lea DS0000036579.V356557.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 Rock Lea DS0000036579.V356557.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, 3, 4, 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Needs assessments are inconsistent and must be more detailed to ensure people’s safety and comfort, particularly for people who will be on a short stay respite visit. EVIDENCE: The home’s statement of purpose and service user guide should be reviewed and updated to reflect the recent changes relating to the management of the home. Some people spoken to were not aware of the proposed changes relating to the manager vacancy and the interim arrangements in place. We examined the care plan and personal files of three people using the home on short-term respite care. The quality and the detail of the information recorded was inconsistent with only a minimal amount of information available for one person, including manual handling and general risk assessments not Rock Lea DS0000036579.V356557.R01.S.doc Version 5.2 Page 10 being completed. This leaves both the person and the home in a vulnerable position with staff not having adequate information to respond to their individual needs. Detailed needs assessments must be completed for all people entering the home, from which a person centred care plan can be developed. On the whole contracts have been issued to people in a timely manner giving them suitable information about the rules and terms and conditions about living in the home. These are signed and agreed with the person or their representative. People are encouraged to visit the home before moving in, however this is not always possible when people are being discharged from hospital at short notice or are in need of an emergency placement due to a deterioration in their health or wellbeing. By providing respite care this gives people an opportunity to ‘test drive’ the home before deciding to move in on a permanent basis. Rock Lea DS0000036579.V356557.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 adequate. This judgement has been made using available evidence including a visit to this service. The care plan records being kept by the home were not being kept up to date and changing needs were not being recorded consistently. EVIDENCE: As described previously assessments are not being completed consistently and therefore the quality of care plans is inconsistent. Based on our discussions with staff, feedback from surveys and by examining people’s care plan records there was evidence that some assessed needs were not recorded in the care plan. In addition there were examples in people’s daily care notes of changes being recorded by care staff but there was no evidence of care plans being updated and staff approaches being adjusted to respond to the new behaviour. Good dementia care is based on the principal that it is possible to communicate with people at all stages of their dementia. The current care plans are task orientated and do not reflect the individual and what makes them unique and what is important to them in their everyday lives. Stock phrases are routinely Rock Lea DS0000036579.V356557.R01.S.doc Version 5.2 Page 12 being used to describe people’s needs and their goals. The development of accurate person centred care plans that are kept under review and updated is central to providing a consistent and good quality service that meets people’s individual needs. We conducted a SOFI observation in the Dementia unit, which involved observing 5 people in the unit between 11.45 am and 13.45 pm in the lounge and dining area. For the majority of the observation there were 2 carers on duty. Staff on duty told us that it was unusual to have 2 carers there all the time, as generally it was only 1 person with help provided by staff from other parts of the home when needed. Care plans showed and we observed that 3 of the people needed moving and handling equipment and transfers to wheelchairs for their mobility. In this case staff told us they got someone from the front of the home to help. If that is the case the observation cannot be seen as observing normal practice as people may have to wait for help and on the day of the inspection the second carer was already there working throughout the observation. We observed that the state of being for the 5 people in the lounge was generally positive, they presented as comfortable and relaxed, relaxed body language and facial expressions were observed and they chatted to staff who responded to them. One staff member read to one from the paper and then they talked about the news, about how prices of things have changed and asking questions about what they recalled. Staff helped another person to look at a magazine, which had a story about Ravenglass and the lady was able to recall taking her children there when small and was smiling and laughing. This type of interaction is good practice and enhances people’s quality of life and their feeling of self worth. The concerns raised about the number of staff on duty have been addressed in the staffing section of this report. On the whole health care needs of permanent residents were well documented. The home is now completing nutritional assessments and weight is recorded on a regular basis, however on one file although there had been significant weight loss recorded, no actions in response to this had been recorded, so it was difficult to tell if and when appropriate action had been taken. It is recommended when weight gain or loss is noted any actions taken should be recorded. The staff team work closely with the District Nursing team to monitor and respond to individual healthcare needs. We met with a visiting District Nurse who confirmed that the staff make “appropriate referrals and seek out advice and guidance in a timely manner”. We examined medical records and observed a supervisory staff administering medication supported by what the organisation call a “quality checker”. Good practice guidelines were adhered to, with the two staff working closely to ensure the dose administered and the person it was being administered to Rock Lea DS0000036579.V356557.R01.S.doc Version 5.2 Page 13 were correct. The number of errors occurring has greatly reduced with policies and procedures now being robustly followed. Creams and PRN (when required medication) are recorded separately with protocols in place to guide staff in when and how to administer them. Rock Lea DS0000036579.V356557.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service. Staff shortages have affected the ability of the home to provide social and recreational activities on a consistent basis. EVIDENCE: The staff have worked hard to develop a two week schedule of social and recreational activities for people living in the home. These provide a range of different activities including armchair exercises, hand massage and manicures, bingo, board games and tabletop activities, a sing-a-long and a film evening. However based on our discussions with people living in the home, their relatives and care staff, when the home has experienced staff shortages activities have not taken place as planned. Several survey responses from relatives and people living in the home also commented on the shortages of staff impacting on the “quality of the service and the lack of physical or mental stimulation”. This has been equally frustrating for staff, as it is for the people living in the home, with staff feeling “they have let people down”. Rock Lea DS0000036579.V356557.R01.S.doc Version 5.2 Page 15 Some people we met talked about how they “looked forward to going out with their relatives each week”. Others talked about how much “enjoyment they got from the garden”. Others said, “They did not like group activities” and preferred to “sit quiet” or “socialise” with their friends. One person we met said “we are very lucky the staff are lovely and so kind”, which was confirmed by other people in the home and also from the comments written in “thank you cards” displayed in the home and comments in the surveys sent out as part of this inspection. Other comments included “I am happy living here” and “the home needs an activity coordinator to make sure activities take place on a regular basis”. It was difficult from the daily records in people’s files to judge what activities they had been participating in. The people we spoke to during the visit confirmed, “activities only happen when there are enough staff”. It is recommended daily records include what activities people have taken part in and how they have spent their day. The home has a four-week rolling menu that provides a good selection of food that is developed from feedback from people living in the home. We joined a group of people for lunch, this was served from hot trolleys in the dining area of one of the lounges. People were offered a choice of two hot meals and a pudding, which was freshly prepared and well presented. The mealtime was a relaxed social occasion and the people we spoke to were complimentary about the quality of the food. Rock Lea DS0000036579.V356557.R01.S.doc Version 5.2 Page 16 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. This judgement has been made using available evidence including a visit to this service. Suitable policies and procedures are in place and people feel safe and able to raise concerns. EVIDENCE: The home has a clear complaints policy and procedure that is made available to people in information provided when they move into the home. The policy and procedure is also displayed in the home. There have been no recorded complaints since the last inspection. People said they knew how to complain and would “Just tell staff if they have any worries”. The home has their own policy and procedure relating to the Mistreatment of vulnerable adults, which is in line with the Local Authority procedures. The home had a copy of the latest procedure displayed on the notice board. A whistle blowing policy has been developed, which is issued to all staff as part of the new ‘staff information handbook’. There has been one referral made since the last inspection. This was referred to the relevant agencies in a timely manner and procedures followed and a thorough investigation completed therefore safeguarding the individual concerned. The home has a commitment to providing appropriate training and reinforces to staff their responsibilities in identifying and reporting incidents through Rock Lea DS0000036579.V356557.R01.S.doc Version 5.2 Page 17 supervision and staff meetings. Staff we spoke to were aware of their responsibilities and the reporting procedures of the home. Criminal Record Bureau Disclosures (CRB) are held on file for all staff. It is recommended relevant information is recorded from them and they are then destroyed in line with data protection guidelines. Rock Lea DS0000036579.V356557.R01.S.doc Version 5.2 Page 18 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, 20, 23, 24, 25, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is decorated, furnished and maintained to a good standard. EVIDENCE: Rock Lea is furnished and decorated to a good standard. People living there feel safe and comfortable in their home. It is well maintained throughout with pleasant garden and patio areas. There is good access throughout the home with ramped access on all the ground floor and a passenger lift to the first floor. Not all the bedrooms were inspected on this occasion, however the rooms we did look at were personalised with their own furniture and belongings such as ornaments and photographs of family and friends. There was evidence of signs being used on bedroom doors and storage cupboards to help people identify their rooms and where to find equipment they may need. Rock Lea DS0000036579.V356557.R01.S.doc Version 5.2 Page 19 All the rooms are fitted with a call bell system that is accessible to people. All communal areas of the home were clean and hygienic and there were no malodours, however the extractor system in the kitchen is in need of cleaning as there is a build of dirt and grease in addition there was evidence of a build up of food debris behind some units. A new extraction system has been fitted in the designated smoking lounge, which has also been decorated and had a new carpet fitted. The home has an annual planned programme of repairs and maintenance, which is based on an annual condition survey. Rock Lea DS0000036579.V356557.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. Staff shortages have had a negative impact on the quality of the service provided and the staff morale. Staff training must be strengthened to ensure staff have the appropriate skills and knowledge. EVIDENCE: The home has experienced staff shortages due to high levels of sickness and insufficient relief staff to cover the absences. This has put the permanent staff under pressure not only to work extra hours but also working with reduced staff during a shift. A member of the care staff being “taken off the floor” as the second checker for the medication round has compounded these shortages. In addition to these staff shortages the absence of a permanent manager has put additional pressure on the supervisory team. Not only are they trying to cover care staff duties as well as their own duties, they are also trying to pick up management tasks. This has resulted in supervision not taking place with staff in the required timescale and records not being kept up to date. The shortages described above have had a direct impact on people’s lives, which was confirmed in people’s comments in the surveys returned such as, “There should be two staff on the dementia unit not one”, “there are staff shortages when medication is given out”, “sometimes staff levels are inadequate, there is a lack of physical and mental stimulation”. These staffing Rock Lea DS0000036579.V356557.R01.S.doc Version 5.2 Page 21 concerns must be addressed as a matter of priority and have resulted in a requirement being made. The organisation has sound recruitment procedures in place with all necessary checks and references completed. Each member of staff has a personal file in line with the requirements of the National Minimum Standards (NMS). A Continuous Professional Development (CPD) file is also in place to record all training and development activity undertaken by staff. Based on the contents of these many of the staff were not receiving the appropriate levels of training and refresher training in line with good practice guidelines. Once again this will in part be attributable to the absence of a regular manager and staff shortages restricting opportunities for people. Rock Lea DS0000036579.V356557.R01.S.doc Version 5.2 Page 22 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, 32, 33, 35, 36, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The effective management of the home has suffered due to the absence of a permanent full time manager. This has had a negative impact on the quality of the service provided and the morale of staff. EVIDENCE: Pearl Carter who is the registered manager for another Cumbria Care home is ‘acting manager’ whilst the recruitment of a new manager is ongoing. She is dividing her time between the two homes with the supervisory team taking a lead role in her absence. The appointment of a permanent new manager must now be a priority for the organisation. They should also seriously consider the temporary appointment of a full time acting manager to adequately support the home in the interim period before a new manager is appointed. Rock Lea DS0000036579.V356557.R01.S.doc Version 5.2 Page 23 Based on survey feedback and discussions with staff they do not feel they have been supported by senior management. They felt they have been “very committed during difficult times, with staff shortages”, but did not feel this has been acknowledged or valued by senior management. The home complete an annual quality assurance survey with the people living there and significant others. This provides valuable information for future developments, which are incorporated into the home’s Business Plan. In addition to the formal survey, informal consultation takes place with link workers working closely with a few individuals to ensure their ‘voice is heard’ and their needs and preferences are recorded. Only small amounts of personal finance are retained by the home when people request. These are securely stored in a safe with clear records maintained of all transactions. Based on feedback from all levels of staff and from examining records it was evident that the formal supervision sessions have not been taking place as required. Again this has been affected by the absence of a full time manager and the staff shortages the home has experienced. Supervision must be provided to all staff in line with the requirements of the National Minimum Standards (NMS) and Care Home Regulations. The home has appropriate policies and procedures in place to maintain the safety and welfare of the people living and working in the home. On the whole the records relating to the monitoring, maintenance and servicing of equipment were in place, although some checks had been missed occasionally. Rock Lea DS0000036579.V356557.R01.S.doc Version 5.2 Page 24 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 2 3 2 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 3 3 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 3 X 3 2 X 2 Rock Lea DS0000036579.V356557.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement A detailed assessment of a person’s needs must be completed prior to admission. The home must then confirm it is suitable and able to meet the person’s health and welfare needs. The home is required to ensure all people living in the home have a detailed care plan developed that is agreed with them and kept under review. (Original timescale of 01/01/07 was not met) All areas of the home must be kept clean and hygienic at all times. There must at all times be a suitable number of experienced and competent staff to meet the health and welfare needs of the people living in the home. All staff must be provided with suitable levels of training appropriate to the work they are to perform. Staff must receive formal supervision at least six times a year in line with the DS0000036579.V356557.R01.S.doc Timescale for action 01/04/08 2. OP7 15 01/05/08 3. 4. OP26 OP27 23 18 (1) a 14/03/08 01/04/08 5. OP30 18 (1) c 01/06/08 6. OP36 18(2) 01/05/08 Rock Lea Version 5.2 Page 26 requirements of the NMS. 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. 3. 4. Refer to Standard OP1 OP8 OP12 OP29 Good Practice Recommendations It is recommended information supplied to people living in or moving into the home is updated to reflect the recent management changes. When weight gain or loss is noted any actions taken should be recorded. Daily records should include what activities people have taken part in and how they have spent their day. Relevant information should be recorded from CRB disclosures before they are destroyed in line with Data protection guidelines. Rock Lea DS0000036579.V356557.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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 Rock Lea DS0000036579.V356557.R01.S.doc Version 5.2 Page 28 - 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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