Inspection on 25/08/06 for Rockwell

This inspection was carried out on 25th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Rockwell 08/10/08

Rockwell 29/05/08

Rockwell 28/11/07

Rockwell 18/08/05

Rockwell 26/01/05

Rockwell 18/08/04

Rockwell 10/02/04

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

CARE HOMES FOR OLDER PEOPLE Rockwell Corbett Close Lawrence Weston Bristol BS11 0TA Lead Inspector Wendy Kirby Unannounced Inspection 09:30 25 August and 14 September 2006 th th 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 Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 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. Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Rockwell Address Corbett Close Lawrence Weston Bristol BS11 0TA 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) 0117 9825693 0117 3772448 Bristol City Council Mrs Elaine Stephens Care Home 30 Category(ies) of Dementia - over 65 years of age (30) registration, with number of places Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named individual under the age of 65 may be admitted for regular periods of respite care. 18th August 2005 Date of last inspection Brief Description of the Service: Rockwell is a purpose built home owned by Bristol City Council and registered with the Commission in March 2003. The home is registered to provide personal care only, to a group of up to thirty residents all of whom experience various types of Dementia. The home is located in the residential area of Lawrence Weston. It is arranged over two floors with lift access. It has one large dining room, three small lounges (one of which is for smokers) and includes a library and activities room. Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted as part of the annual inspection process. The inspection took 10 hours to complete over a two-day period. Prior to the visit the inspector spent some time examining documentation accumulated since the previous inspection, including the pre-inspection questionnaire, notified incidences in the home, (Regulation 37’s) and the unannounced reports conducted by the Registered Providers (Regulation 26’s). The inspector spent time throughout the course of the inspection in discussions with the registered manager and her senior staff team members. A number of records and files relating to the day-to-day running and management of the home were examined. Four residents were case tracked. Their care plans and care files were examined. The inspector had conversations with the residents and observed them indirectly going about their daily routines. The inspector toured the premises accompanied by the manager and conducted an environmental audit. Time was spent observing residents in the home throughout the course of the visits. Members of staff were observed on duty and were consulted individually. Relatives and visitors “Comment Cards” were sent and four of these were completed and returned. One comment card was returned by a health care professional that regularly visits the home. Information from these has been collated and is detailed throughout the report. Feedback was given to the manager on the outcome of the inspection. What the service does well: Staff provide a standard of care that, is individualised and person centred and are working hard to ensure that residents needs and wishes are met. There are safe systems of medication. Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 6 Staff were witnessed knocking on residents doors before entering confirming respect for the residents individual privacy and dignity and staff responded to residents in a sensitive and professional manner. The activities provide a regular, varied and stimulating programme to suit individual preferences. Meals were well presented and menus verify a healthy well balanced diet for all residents. Good accounting methods are adopted and policies and procedures are followed correctly when handling residents’ pocket money. The home was well organised and managed by an effective, stable management team that promoted the views and interests of the residents. The service was proactive in monitoring residents care needs and in ensuring health needs were being met. What has improved since the last inspection? What they could do better: Residents must be offered drinks at mealtimes. A planned programme of redecorating and refurbishment for the rooms identified must begin urgently, to ensure that residents are treated with dignity and live in a safe, comfortable, clean home. Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 7 The health and safety of residents, staff, and visitors will be further protected when relevant health and safety checks are carried out consistently at the required times. Residents, visitors and staff would be better protected if records can clearly identify those members of staff who have been present and those who have not been present during fire drills as recommended by the Avon Fire Brigade. All night staff should undertake this on a three-monthly basis, and day staff six-monthly. 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. Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 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 Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Prospective residents and their families are able to access clear information to enable them to decide whether the home is suited to their needs and are encouraged to visit the home. Pre admission procedures were able to demonstrate that resident’s needs were identified to ensure that the home would be a suitable place for them to live. Trial visits give prospective residents an opportunity to assess the nature of the home. EVIDENCE: An information pack on the home and the services offered was on display in the entrance to the home to take away. The content of the welcome pack should provide prospective residents with valuable information on the facilities and services available to them within the home. Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 10 Prospective residents are encouraged to visit the home either for the day or perhaps for lunch dependent on their wishes. On the first day of the inspection one prospective resident was visiting for the day. Staff were observed exchanging and sharing useful information with each other about the visit and how the visitor was settling in. The Inspector looked at four pre-admission assessments, which were completed fully and were informative. The prospective resident, family and carers are involved in the pre-assessment and all information is used to determine the suitability of the placement. Where possible the manager had also obtained comprehensive assessments and care plans from other professionals involved for example, social workers and hospital staff. Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Care planning has improved but will require further development. Residents’ healthcare needs are well managed, however care plans should be developed to evidence this. There are safe systems of practice in receiving, storing, administering, and disposing of drugs. Staff have a good awareness of individuals needs and treat the residents in a warm a respectful manner, which means that they can expect to receive care and support in a sensitive way. Plans are being developed with regards to resident’s wishes when dealing with acute illness and making plans for end of life. Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 12 EVIDENCE: The home continues to work hard in developing a simpler more organised care plan system of documentation for assessing, planning and evaluating care based on the activities of daily living. This is a relatively new format of documentation and in its early stages and overall completed to a satisfactory standard, some plans were more comprehensive than others and more detail is required. The manager and her staff have been working hard to develop their skills and confidence when devising care plans and writing the daily records. On admission to the home the resident is assessed over a four-week period and an action plan is developed whereby staff are able to identify residents needs and wishes to determine plans of care. All four care files showed consistency in assessing, planning, implementing and reviewing the resident’s care. The home operates a key worker system (named staff member who works closely with the resident). The key worker role includes the monthly updating and reviewing of care plans. The home conducts monthly and six monthly reviews, which were signed by the resident/relative, a delegated officer in charge and the key worker, wherever possible. Records of the General Practitioner (GP) visits/contact with residents and the outcomes were also available. Specialist referrals and visits from other professionals were evidenced in care files including Community Nurses, Chiropodists, Opticians and Dentists. District Nurses were visiting on the day of the inspection and good communication skills were noted between the staff in the home and the district nurses. Although there was evidence that the home was vigilant in identifying health care needs intermittent care plans were not available when short-term needs had been identified. The inspector had noted when reading the residents files that health needs had been identified for example a urinary tract infection. A care plan should have been developed to clearly identify how this was affecting the resident and how the staff would support the resident, for example, by monitoring and encouraging fluid intake, recording output and administering antibiotics as prescribed by the GP. It was pleasing to note on the second day of the inspection a format for intermittent care plans had been looked at and staff had devised information sheets on identified health needs and signs and symptoms for staff to be aware of. Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 13 Risk assessments were in place with detailed information to ensure safe procedures including, manual handling. In addition to this there were risk assessments written specifically tailored to individual needs. One resident had been recently experiencing “fainting episodes” potential risks were identified and actions recorded for preventative measures for example the provision of “hip protectors”. Opportunity was taken to inspect the medication system. The home operates a monitored dosage system for the administration of medication, which is supplied at regular intervals by the local pharmacist. Records held in relation to the storage and administration were accurately maintained and met with the requirements of the legislation. The home also keeps an accurate stock check of medicines given on an as required basis. Medication fridge temperatures are recorded daily which meets with current legislation. The statement of purpose, which is currently under review, documents various arrangements in place at the home to help ensure the privacy and dignity of residents. The home states that staff receive induction, supervision and training which involves considering the needs of individual residents and how they will promote dignity, privacy and that the rights of residents are upheld. All bedrooms in the home are for single use and all have locks for the doors and all residents can be issued with a key. Staff were witnessed knocking on residents doors before entering confirming respect for the residents individual privacy and dignity at all times. Systems in the home for record keeping, which includes all personal care records, financial records and medication, are kept in secure files in the office. The manager and her staff are continuing to make every effort to establish resident’s wishes concerning palliative care and any provision residents and their families would wish for by developing end of life care plans. Plans examined were very personalised and should enable staff to respect residents’ individual wishes. Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents’ benefit from a varied activities programme. Residents maintain family contact and staff encourage family and friends to join in with activities and any outings. Residents are not able to influence choice and control when being offered a drink at mealtimes. Residents receive a varied and wholesome diet. EVIDENCE: In consultation with the residents’ staff develop a monthly timetable of activities and forthcoming events. A copy of this is placed in communal areas throughout the home, to ensure that all residents and visitors are aware of the planned activities. Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 15 The rota this month includes gardening, makeovers and manicures, newspapers and discussion and massage for hands, arms, legs and feet. Regular sing-a-long evenings are arranged and an assortment of beverages is provided. Outings are arranged throughout the month and residents often visit Blaise Castle, Bristol Hippodrome, local shops, public houses, and enjoy trips to Weston. Staff recently organised a garden barbeque, which the residents said they enjoyed. The home is in the process of developing a new initiative to complete a personal history of each resident. It is a comprehensive document and should enable the staff in the home to relate to residents in a personalised way. It should also create topics of conversation, encouraging life review and reminiscence, which will have meaning to that resident. Some families have completed the forms and information was very useful including family history, previous education, occupations, special anniversaries and personal preferences for daily routines. The home operates an open door policy for visitors. Residents are able to see visitors in the privacy of their rooms and there are several semi-private seating areas around the home. Families and friends are also welcome to stay for lunch or tea to assist them with their visiting schedules. The size and layout of the dining room made it possible for all residents to enjoy the social advantages of dining together. Staff had used their expertise and knowledge of the residents, personalities, preferences and ability to eat independently, when seating them for lunch. The dining room was light, spacious and the tables were attractively laid with tablecloths. Residents that required assistance with eating their meals were supported by staff members, this was performed in a respectful, sensitive way, for example without rushing the residents and staff were sat at the same level as the resident. Staff were seen to be polite and helpful when serving the meals. Although jugs of squash were available it was noted on the second day of the inspection residents were served their meals without being offered a drink. The manager explained that in some instances residents, who were given drinks prior to their meal arriving, often meant that they felt too full too quickly and may therefore not take an adequate nutritional intake. For some residents it was said to be confusing as to the purpose of the drink and that it could be mistaken for sauce or gravy whereby a resident may poor this over their meal. Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 16 Although the inspector can understand this dilemma, issues around choice, preference and ability should be assessed individually to ensure that needs are met, for example staff were able to demonstrate throughout the two days a sound knowledge of individual residents and should use this expertise when offering them a drink with their meals. Residents who require assistance should also be offered a drink at mealtimes with supervision and support to ensure that they also receive an adequate fluid intake. The inspector spent time a short time with the cook and her assistant. The cook was able to demonstrate an awareness of individual requirements and needs of the residents, including special diets and personal preferences. The home demonstrates a proactive approach in diversity when accommodating individual preferences. A local Bristol company delivers ready prepared meals for one resident living in the home in order to meet their cultural dietary needs. The 4-week menu rota displayed traditional meals and choice was available daily. The menus are reviewed to reflect seasonal trends and availability of produce. Residents are able to influence the menus by discussing them at residents’ meetings. Extras are ordered on request for birthdays and special occasions. Documentation was provided to show the inspector that required temperature checks were being carried out on fridges and freezers and that food was also being probed after being cooked before serving. Risk assessments were in place and up to date. The kitchen was very clean and spacious. Stores exhibited a good range of foods. Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Complaints recording is satisfactory and residents and relatives are aware of the complaints process. There are good arrangements in place for staff training and awareness of protection of vulnerable adults. EVIDENCE: Prior to admission Prospective residents and families are given an information pack, which contains information on the complaints procedure in the home. The manager told the inspector that at the six monthly reviews residents and families are asked if they understand the information on how to complain. Complaints leaflets are also available in the entrance lobby for all visitors to access. There have been two complaints received by the home since the last inspection. Documentation about the complaint was examined and details confirmed that policies and procedures were followed correctly and that the complaints were dealt with and resolved effectively and efficiently. Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 18 Four relatives and visitors comment cards stated that they were aware of the complaints procedure. The manager explained that any concerns or requests are dealt with “on the spot” whenever possible and all information is logged in the daily record and cascaded down to staff through handover. There are policies and procedures as well as a range of guidance information on the topic of protection of vulnerable adults from abuse. The availability of this information should increase staff awareness and understanding of their role in protecting vulnerable adults who live at the home. Bristol City Council systematically trains its entire staff group on the protection of vulnerable adults and this training is organised as a running programme, staff training records evidenced that this was taking place for all staff members at Rockwell. A number of staff are undertaking the National Vocational Qualification in care award, and a component of the award addresses issues around the topic of the protection of vulnerable adults from abuse. Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Some areas of the environment require urgent attention; at present these areas are not well maintained, comfortable, pleasant or hygienic. EVIDENCE: Rockwell House is purpose built with accommodation on two levels with lift access. The home is accessible to residents who use a wheelchair. The courtyard garden was attractive and designed to the needs of the residents, which was well stocked with planters displaying colourful bedding plants. There was adequate seating provided for residents and sun screening. Some residents’ rooms had been redecorated and they were consulted and involved with choosing colours for their walls and carpets wherever possible. Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 20 The colours used were tasteful and gave warmth to the rooms; new bedroom furniture and curtains had also been supplied and residents had personalised their rooms with ornaments and pictures. However at least seven bedrooms have not been decorated for a long time and at best were shabby and cold in appearance. Walls were badly scuffed and wallpaper was peeling and hanging off walls in numerous places, bedroom furniture had drawers missing and were broken. In places curtains were not hung properly with hems hanging down. Several rooms smelt of urine, which was thought to be coming from the flooring and it was clear to see that the flooring was so old and split in places that the urine had permeated the grain of the flooring so that cleaning alone was no longer sufficient. Bedrooms are not en suite, however each resident has an individual commode and vanity unit with basin, some of these units encasing the sinks were old and the wood was warped and chipped. Communal bathing areas, showers and toilet facilities are located throughout the home. Room sizes are generally adequate for their stated purposes, particularly the lounges and dining room. The dining room has had dado rails removed to prevent potential accidents to residents who had knocked themselves in the past, however this had left the walls in need of redecoration, which has yet to be done. Corridors have been recently redecorated and residents chose the colours used. Residents were making full use of these areas and their bedrooms on the day of the inspection. The home was clean and apart from the previously mentioned bedrooms the home was free from unpleasant odours. Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The residents are cared for by skilled staff that are trained, supported and supervised by management. The relationships between staff and residents are good and create a warm positive environment to live in. EVIDENCE: The manager closely monitors the staffing levels to ensure they are able to meet the levels of care required by the residents. If levels of dependence were to increase, then staffing levels would need to be increased. The inspector examined staffing rotas at present there are staff vacancies. The manager uses her own staff group to cover any staff absences and makes good use of agency staff. This is good practice and provides a consistent care service to the residents. Following a requirement from the previous inspection photographs and proof of identity for each staff member is kept at the home for residents’ protection. This requirement has been partially met. Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 22 The manager and her staff are conscientious in attending training relevant to the care needs of the residents. During the past twelve months the team have attended training in various subjects including “Communication and Support for People with Dementia” and “Coping with Loss and Bereavement”. Future training is focusing on addressing issues in equality and diversity for example, “Sexuality and the Older Generation”, “Race Awareness” and “Culture Competence”. The home continues to support their staff with NVQ training and the enrolling programme continues. The inspector spent some time throughout the inspection observing staff carrying out their duties and assisting residents. Staff were respectful, warm in manner, good humoured and sensitive towards the residents within a relaxed homely environment. One visitors comment card stated, “I have been visiting at Rockwell for over five years. Rockwell is a lovely place and is always welcoming and calm. The staff all work extremely hard and are caring, kind, sympathetic and always willing to help. I think that they do an amazing job”. Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents’ needs and best interests are central to the management approach in the home. Good accounting methods are adopted and policies and procedures are followed correctly when handling residents’ personal money. Staff receive appropriate supervision. The health and safety of residents, staff, and visitors will be further protected when relevant health and safety checks are maintained regularly. Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 24 EVIDENCE: The inspector spent time in discussion with the manager and three senior members of her staff. It was evident in conversations that all were dynamic in their roles and enjoying the new challenges that faced them. They shared various initiatives they are putting in place with the inspector to further develop standards and procedures in the home. The overall outcome was that this fairly newly established management team and their staff are working together in order to provide a home with high standards for the benefit of all residents, visitors and staff. Staff comments about the manager and the atmosphere in the home were positive. Comments included “Staff meetings are useful and any problems are resolved quickly and efficiently” and “Continuity in the management has enabled us to work together as a team and make significant changes to the service we can provide”. The home has a three-monthly residents meeting, which are well attended by families. Minutes are taken and circulated to residents and their families and are displayed on the notice boards throughout the home. Evidence was provided to show topics discussed at the meetings including forthcoming events, any concerns or issues residents would like to discuss. Guest speakers are also invited to the meetings including health care professionals. The policy and procedure for holding residents personal money was examined and four individual accounts were looked at. It was evident that good accounting methods are adopted which account for all transactions documented and receipts for sundries were available to see. A plan has been developed to ensure staff receive supervision once every six to eight weeks. Arrangements in place confirm that individual supervision is based on an agreement between the manager and staff member. A plan is devised for discussion relating to key residents, work issues, staff issues, personal development and training. Some supervision records were detailed and reflected that sessions had been useful. Although this standard was not looked at in great depth it was apparent that the management team had not allocated time to enable consistency in supervisions and the team were looking at ways to address this. Some of the Health and safety records in the home were examined. Documentation showed that not all relevant checks were maintained consistently and at the required intervals including all fire safety equipment and emergency lighting. Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 25 Although Fire drills are undertaken records need to clearly identify that all members of staff have been present during fire drills as recommended by the Fire Prevention Officer and that all night staff undertake this on a threemonthly basis, and day staff six-monthly. Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 27 No Are there any outstanding requirements from the last inspection? 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. 2. Standard OP14 OP19 Regulation 12(2) 23(2)(b) (c) Requirement Enable residents to make decisions with respect to having a drink with all meals provided. An action plan must be sent to CSCI detailing the timescales and priority areas to: 1. Refurbish and redecorate all bedrooms identified during the environmental audit carried out during the inspection. 2. Replace flooring in all rooms identified. 3. Replacement of any unsuitable beds, headboards, chairs, and bedroom storage furniture. 4. Provide adequate storage facilities for residents’ personal belongings. 5. Replace identified curtains, and ensure that all curtains are hung properly. A photograph and proof of identity of each staff member must be kept at the home. (Previous requirement partially met) DS0000035302.V291815.R03.S.doc Timescale for action 14/09/06 31/10/06 3. OP29 19(1bi) Sch 2 31/10/09 Rockwell Version 5.1 Page 28 4. 5. OP38 OP38 13(4)(c) 23(4)(e) Health and safety checks must be carried out at the required intervals. Arrangements must be made for staff to attend a drill every three months for those on night duty and every six months for day staff. 12/10/06 31/10/06 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 Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 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 Rockwell DS0000035302.V291815.R03.S.doc Version 5.1 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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