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Inspection on 21/03/07 for Rockley Dene Nursing Home

Also see our care home review for Rockley Dene Nursing Home for more information

This inspection was carried out on 21st March 2007.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provided a comfortable, clean, and pleasant environment. Staff were committed to maintaining resident`s health and well being, and were able to describe ways in which residents privacy and dignity was maintained. All of the residents spoken with and all of those who returned questionnaires said they were satisfied or very pleased with the care they received. Relatives also reported that the care was good and that they were made welcome at the home. They all said that the staff were very good, kind and caring. Resident`s reported that they were happy with their bedrooms, and with the standard of hygiene maintained at the home, including clean clothes and bathing facilities. There were "plenty of baths when they wanted". They also said that they enjoyed the meals provided.

What has improved since the last inspection?

A lot of work had taken place to address the requirements and recommendations from the previous inspections. These included working on the plans of care to include outcomes of actions taken, and updating the majority of risk assessments. A survey of all of the resident`s preferences of leisure activities, and cultural needs, had been undertaken by the activities coordinator, and the home was in the process of improving its activities programme to take account of these. The medication system had been overhauled to make it safer, and a programme of training for staff on Adult Protection had been put into place. Training on fire, health and safety and Moving and handling was also in the process of completion for all staff. CRB checks had been completed for all staff employed at the home. The manager confirmed that hot water problems at the home had been dealt with.

What the care home could do better:

The majority of the residents spoken with said that they were kept waiting to go to the toilet, and that there were insufficient staff on duty at times. Some residents also said that they did not know how to make a complaint although they had not needed to so far. Two recruitment files did not contain adequate references, or explanation for staff appointments in view of poor references. Staff did not maintain the privacy and dignity of one resident when they were hoisting them. Accidents were inadequately recorded with insufficient detail on action taken and the outcome. Staff were not sufficiently aware of what constituted a `notifiable incident`, and some incidents had not been reported to the CSCI, including a staff disciplinary action. Staff were concerned that they may be asked in future to undertake initial assessments of need for residents admitted to the home. Staffing rotas showed that there had been a shortfall in staffing during February, with the majority of afternoon shifts covered by only three staff. The manager stated that she had not been given authorisation to employ agency or bank staff to cover shortages of staff. The target of 50% of care staff achieving NVQ 2 qualifications had not been met. There were no residents or relatives meetings held at the home. A resident`s eye drops were missing on the day of the inspection. Residents would benefit by more trips and outings outside of the home. A resident said that the heating in their room was still too cold.

CARE HOMES FOR OLDER PEOPLE Rockley Dene Nursing Home Park Road Worsbrough Barnsley South Yorkshire S70 5AD Lead Inspector Claire McAuley Key Unannounced Inspection 09:00 21st March 2007 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 Rockley Dene Nursing Home DS0000006489.V325697.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. Rockley Dene Nursing Home DS0000006489.V325697.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rockley Dene Nursing Home Address Park Road Worsbrough Barnsley South Yorkshire S70 5AD 01226 207916 01226 280187 lpbennett@ntlworld.com 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) Angel Care Plc Mrs Jane Bennett Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Rockley Dene Nursing Home DS0000006489.V325697.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons accommodated shall be aged 60 years and above Of the 34 registered beds, 30 can be used as nursing care (N) or personal care and 4 can be used as personal care (PC) only. Can provide accommodation and care for one named service user aged under 60 years with terminal illness. 9th October 2006 Date of last inspection Brief Description of the Service: Rockley Dene is a purpose built home providing nursing and personal care. Accommodation is provided for 34 residents over the age of 60. There are 25 residents living at Rockley Dene at present. The home is owned by Angel Care Ltd and is situated at Worsborough Bridge. The home is on a main bus route into Barnsley town centre and there are local shops nearby. The accommodation is provided on two floors, a lift and stairs access the upper floor. Resident accommodation is provided in 9 double and 16 single bedrooms of which 10 have an en-suite facility. There is one large lounge area and another lounge area within the conservatory. One lounge area is non-smoking. The dining room opens onto a patio area and there is a pleasant garden area. It should be noted on the same site, but not attached, is Rockley Dene Personal Care Home. This is registered separately and not covered by this inspection report. The weekly fees are from £327.50 to £460.50. The home charges extra for hairdressing chiropody and toiletries. Rockley Dene Nursing Home DS0000006489.V325697.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 21st March 2007 from 9.00 am to 4.30 pm. The inspector spoke to nine residents, two relatives, three members of staff, and the registered manager. A sample of records including the manager’s pre inspection record, menus, medication records, staff rotas, care plans, recruitment records, supervision, staff training, and procedures and policies were inspected and a proportion of the environment was checked. Five questionnaires from residents were returned. The inspector also had the opportunity to observe care practice and the lunchtime meal being served. The registered manager Jane Bennett will be leaving the home shortly, and Gillian Robinson the Area Manager, and Debbie Taylor Smith RGN will be managing the home until a new manager is appointed. What the service does well: What has improved since the last inspection? A lot of work had taken place to address the requirements and recommendations from the previous inspections. These included working on the plans of care to include outcomes of actions taken, and updating the majority of risk assessments. A survey of all of the resident’s preferences of leisure activities, and cultural needs, had been undertaken by the activities coordinator, and the home was in the process of improving its activities programme to take account of these. The medication system had been overhauled to make it safer, and a programme of training for staff on Adult Protection had been put into place. Training on fire, health and safety and Moving and handling was also in the process of completion for all staff. CRB checks had been completed for all staff employed at the home. The manager confirmed that hot water problems at the home had been dealt with. Rockley Dene Nursing Home DS0000006489.V325697.R01.S.doc Version 5.2 Page 6 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. Rockley Dene Nursing Home DS0000006489.V325697.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 Rockley Dene Nursing Home DS0000006489.V325697.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Resident’s needs were assessed prior to them moving into the home. EVIDENCE: Records in relation to four service users were examined and all contained evidence that their needs had been assessed prior to them moving into the home. Issues in relation to appropriate assessment of a resident prior to their admission to the home had been discussed as part of a recent complaint and the manager stated that all pre-admission assessments would be carried out by the manager in future. Staff expressed concern that they may be asked to carry out initial assessments of need in future, and felt that this would not be appropriate. In comments to the report the director of care and development stated it will be the manager or herself that will carry out pre-admission assessments as it is an important decision whether or not to admit someone to the home. Senior care staff will then carry out the admission assessment for residential clients only. Knowing that this will be a new role to them, full Rockley Dene Nursing Home DS0000006489.V325697.R01.S.doc Version 5.2 Page 9 training will be given and several care plans written under supervision until they feel competent to write care plans independently. Rockley Dene Nursing Home DS0000006489.V325697.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Resident’s plans of care had been revised to contain the majority of required information to meet their needs. Service users’ health care needs were met. Medicine management had been revised and was sufficient to ensure the safety of all service users. Service users’ privacy and dignity was usually respected. EVIDENCE: Plans of care had been revised following the previous inspection. They were of a good standard and contained the full range of required information on resident’s needs and actions taken to meet those needs. Some risk assessments required updating. There was evidence of nutritional assessments, preferences of residents, and nursing needs. Rockley Dene Nursing Home DS0000006489.V325697.R01.S.doc Version 5.2 Page 11 There was evidence in the records that service users had access to medical input, and were appropriately referred for specialist services. These included GPs, chiropodist, dentist, optician, psychiatrist, and district nurses. A psychiatric nurse was visiting a resident at the time of the inspection. The medication system had been overhauled and revised following the last inspection, and there was a medication policy and procedure to ensure that staff adhered to safe practice. Three resident’s medication records were checked and were correct; their medication had been stored and administered appropriately, although one resident’s eye drops were missing and were later found to have been accidentally taken home by a nurse in her uniform pocket. Resident’s were consulted to see if they were able to take care of their own medication, and where possible, medication, creams, inhalers and other items were kept in resident’s rooms, under their control. Staff spoken to were aware of the need to treat residents with dignity and respect and were observed interacting in a friendly and pleasant way with them. Residents said that they were sometimes kept waiting to go to the toilet and said that there were not always sufficient staff to help them. The manager confirmed that residents had been offered keys to their rooms, but the majority chose not to use them. Staff were observed hoisting a resident, but did not maintain that persons dignity by covering them up properly while they were doing this. Rockley Dene Nursing Home DS0000006489.V325697.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Routines of daily living were flexible and suited residents individual choices and preferences. However, residents would benefit by the provision of more activities, and trips outside of the home. Residents were supported in maintaining contact with relatives and visitors at any reasonable time. Resident’s choice was promoted by the personalisation of their rooms. Good food was provided at this home. Service users were offered a choice of meals and said that they enjoyed the food. EVIDENCE: An activities coordinator was employed at the home from Monday to Friday. A weekly activities programme was displayed in the entrance to the home. Activities included cards, dominoes, films and nail care. The activities coordinator had conducted a survey of interests and preferred activities for all of the residents, and was currently in the process of developing a more comprehensive activities programme to reflect these interests. All activities Rockley Dene Nursing Home DS0000006489.V325697.R01.S.doc Version 5.2 Page 13 were now recorded. There had recently been a number of shows and entertainers at the home, and residents spoken to said they had really enjoyed these. Residents were also observed reading newspapers, and books. Residents went out to the local shops individually with staff members. However, there was a lack of trips, and visits for residents outside of the home. There were a number of visitors at the home on the day of the inspection. Residents were observed spending time with their relatives/friends in both communal areas and their bedrooms. Visitors spoken to said that staff were welcoming and friendly. Service users were supported to exercise choice and control over their lives where possible. The manager said that residents brought their own furniture and possessions with them when they moved into the home if they chose to do so. A small number of service users continued to handle their own financial affairs though the majority depended on family or legal representatives to do this on their behalf. Menus showed that meals offered to residents were varied and wholesome. A choice of meals was available and all residents spoken to were very satisfied with the meals provided. The lunchtime meal was attractively presented and soft and liquidised diets were also presented in an appetising way. A choice of drinks was offered. The cook had a good knowledge of resident’s preferences, portion sizes, and special diets. Staff were observed helping residents who needed it, in a gentle and unhurried manner, and the atmosphere in the dining room was very calm and pleasant. Rockley Dene Nursing Home DS0000006489.V325697.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. A complaints procedure was in place, but residents were not aware of how to make a complaint. Adult protection policies and procedures were in place and all staff will have received training by July 2007. However residents were not fully protected, as a staff disciplinary action had not been reported to the CSCI. EVIDENCE: A complaints procedure was in place at the home. Residents spoken to said they did not know who to complain to if the need arose. (Although they were quite happy with the service). Since the last inspection there had been three complaints. Issues included, inadequate care, including nursing care, moving and handling issues, and heating issues. The complaints records indicated that complaints had been appropriately dealt with. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. A programme of adult protection training including POVA had now been put in place, and the manager stated that all staff would complete this training by July 2007. There had been one adult protection investigation. This was an allegation that the resident’s needs had not been met; including inadequate nursing care and that staff had used inappropriate restraint. The conclusion of this investigation was not available, on the day of the inspection, although the manager stated that Rockley Dene Nursing Home DS0000006489.V325697.R01.S.doc Version 5.2 Page 15 no action was to be taken. A staff disciplinary action which had taken place in December 2006 had not been reported to the CSCI. Rockley Dene Nursing Home DS0000006489.V325697.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users live in a clean and comfortable home. Work needs to be completed to identify and resolve the heating issue in one room. Hygiene and infection control practices at the home were sufficient to protect residents. EVIDENCE: The home’s environment was of a good standard. It was clean, and all areas were fresh smelling. Resident’s spoken to all said they were happy with their rooms which were comfortable and well furnished. Dining areas, the kitchen and lounge areas were also clean and pleasant. Bathrooms and toilets were of a good standard. The manager indicated that problems with the heating and water temperatures had been resolved, and mixer valves had been fitted on hot water outlets. However one resident on their returned questionnaire Rockley Dene Nursing Home DS0000006489.V325697.R01.S.doc Version 5.2 Page 17 indicated that there was still a problem with the heating in their room, as it was too cold. There was also an area of subsidence in part of the hall, which had caused marks in the carpet. The manager indicated the home’s insurers were currently dealing with this issue. A suitable laundry room was provided and appropriate equipment was available. Sufficient laundry and cleaning staff were employed. There were policies and procedures in place for the control of infection and staff were aware of these. Staff indicated that there were plenty of items such as gloves, wipes and aprons, available to maintain the safety and hygiene of residents. Rockley Dene Nursing Home DS0000006489.V325697.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There were not always sufficient numbers of staff on duty to meet the needs of service users. NVQ level two training was in place, although the target of 50 qualified staff had not yet been achieved. Recruitment practices at the home had improved, and ensured the safety and well being of service users. However clarification of the relevance of some staff references was needed. Relevant training was now provided for staff which maintained the safety of residents. EVIDENCE: Staff rotas checked showed that in February there had been insufficient staff on duty in the afternoons. This was not the case in March when appropriate staffing was maintained. The manager said that this had been due to staff sickness and that she had not been permitted to employ agency staff to make up the shortages. Residents indicated that at times there were not enough staff to meet their needs, and this (as previously stated) meant that at times they were kept waiting to go to the toilet. Rockley Dene Nursing Home DS0000006489.V325697.R01.S.doc Version 5.2 Page 19 A NVQ level 2 training programme was in place. However the target of 50 of care staff achieving NVQ level 2 or above had not yet been met and a recommendation has been repeated regarding this matter. Following requirements made at the previous inspection, all staff had CRB checks completed. Four recruitment files were checked and application forms, references, CRB checks, identification, and health checks were in place. However, one staff file contained only one reference, which was unsatisfactory. There was no explanation as to why that staff member had been employed, and the manager was asked to record the reasons for the employment and any discussions, which had taken, place and send this to the CSCI. Another staff file contained one unsatisfactory reference from an employer, and a good one from a friend. Again there was no explanation or record of discussions as to why that staff member had been employed. Following requirements made at the previous inspection, staff training had been improved and updated. All staff had received fire training, adult protection training was in process, food hygiene, first aid moving and handling and health and safety training was being undertaken. New staff received a basic induction programme and the manager indicated that the Area Manager Gillian Robinson would be introducing an induction programme in the near future which met the Skills for Care standards. Rockley Dene Nursing Home DS0000006489.V325697.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The manager was qualified and competent to run the home. Residents were protected by the homes financial procedures. The quality assurance system did not adequately consult the residents or their relatives in order to measure the success in meeting the aims of the home. Supervision of staff was undertaken at the required level, enabling them to maintain the health and welfare of the residents. Health and safety procedures were in place, but the recording procedures for accidents and notifiable incidents were insufficient to protect and safeguard the residents. Rockley Dene Nursing Home DS0000006489.V325697.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager had completed the NVQ4 in Management qualification. She was however about to leave the home. Staff interviewed expressed their support for the manager and were sorry that she was leaving. The ISO9000 quality assurance system was in place. Regulation 26 visits took place and copies of these reports were sent to the CSCI. The manager said that questionnaires were sent out annually to relatives/friends of service users and service users. Head office analysed the results and a report with the findings was sent to the home. Residents and relatives meetings to ascertain their views and preferences were not held at the home. The manager confirmed that relatives dealt with the majority of resident’s finances. Two residents financial records were checked and they were correctly maintained with two signatures. Accounts and financial records were kept, and these were appropriately recorded and audited. The four staff records examined had evidence that staff received supervision at the required level. Staff members spoken to confirmed this. They received supervision, either from the manager or from the nurse in charge. Supervision included training needs, and care practice and philosophy. New staff were supervised by senior staff for a period of time, ensuring their competence. Servicing and maintenance of electrics and equipment was in place. There was a maintenance programme for the home, and health and safety monitoring was in place. Resident’s accidents were not all properly recorded, and did not have sufficient detail about action taken following accidents. One record did not indicate that a resident had received bruising injuries to her/his face some time after the initial fall. Another accident was not specific in describing minor injuries received as the result of a fall, and stated that no injuries were received. It was also apparent from talking to staff that they did not understand what a notifiable incident was, and how it should be recorded and notified to the CSCI. The manager stated that a list of what would be defined as notifiable incidents had been given to the nursing staff. Rockley Dene Nursing Home DS0000006489.V325697.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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Rockley Dene Nursing Home DS0000006489.V325697.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 Requirement A person who is appropriately trained and qualified must undertake Resident’s assessments of needs. All residents risk assessments in their plans of care must be updated. All medication, including eye drops must be securely stored within the home. Staff must maintain the privacy and dignity of residents at all times. Opportunities for residents to participate in trips outside the home must be developed. All residents must be informed of how to make a complaint if they wish to. Notifiable incidents, including staff disciplinary action must be notified to the CSCI. The faulty heating in a resident’s room must be repaired. Sufficient staff to fully meet the needs of residents must be employed at the home at all times. 50 0f all care staff must have DS0000006489.V325697.R01.S.doc Timescale for action 01/05/07 2. 3. 4. 5. 6. 7. 8. 9. OP7 OP9 OP11 OP12 OP16 OP18 OP19 OP27 13 13 12 16 22 37 23 18 01/06/07 21/03/07 21/03/07 01/06/07 01/06/07 01/05/07 01/05/07 01/05/07 10. OP28 18 01/06/07 Page 24 Rockley Dene Nursing Home Version 5.2 11. OP29 23 12. OP33 24 13. OP38 13 14. OP38 37 18 NVQ level 2 or above, qualification in care. Two references must be provided for all staff members. An explanation of the employment of two members of staff in spite of poor references must be added to the record and a copy sent to the CSCI. Meetings, or a forum for residents and their relatives/representatives in order to ascertain their opinions of the service must be put in place. Accidents must be recorded in sufficient detail. Staff must receive training on the recording of accidents Staff must be made aware of what is a notifiable incident. They must receive training to ensure that these incidents are properly recorded and notified to the CSCI. 01/05/07 01/05/07 01/06/07 01/05/07 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 Rockley Dene Nursing Home DS0000006489.V325697.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Rockley Dene Nursing Home DS0000006489.V325697.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!