Inspection on 04/09/06 for Rodley House

This inspection was carried out on 4th September 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Rodley House 28/08/07

Rodley House 01/02/06

Rodley House 02/08/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Rodley House Harrison Way Lydney Glos GL15 5BB Lead Inspector Mrs Ruth Wilcox Key Unannounced Inspection 4th September 2006 13:45p 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 Rodley House DS0000064588.V303781.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. Rodley House DS0000064588.V303781.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rodley House Address Harrison Way Lydney Glos GL15 5BB 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) 01594 842778 01594 845047 manager.rodley@osjctglos.co.uk The Orders of St John Care Trust Mrs Gaynor E Hughes Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Rodley House DS0000064588.V303781.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 2006 Brief Description of the Service: Rodley House is a purpose built Care Home, situated in a large housing estate close to Lydney town centre. It was totally refurbished in 1996. The Home, managed by The Orders of St. John Care Trust, provides nursing and personal care to residents over the age of 65 years. The accommodation, consisting of forty-one single rooms and one double room, is on two floors and has been fitted with a shaft lift to provide access to the first floor. Although none of the rooms has en-suite facilities, there are several assisted bathrooms and separate toilets throughout the property. There are four comfortable lounges within the Home, plus a large dining room and a number of smaller sitting areas where residents and their visitors may meet. The gardens are easily accessible and have attractive shaded areas where residents may enjoy good weather. The Home is part of the local community and links are maintained wherever possible. Information about the home is available in the Service User Guide, which is issued to prospective residents, and a copy of the most recent CSCI report is available in the home for anyone to read. The charges for Rodley House range from £460.00 to £637.00 per week. Hairdressing, Chiropody, Newspapers, Toiletries and Transport are charged at individual extra costs. Rodley House DS0000064588.V303781.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. One inspector carried out this inspection over two days in September 2006. A check was made against the requirements that were issued following the last inspection, in order to establish whether the home had ensured compliance in the relevant areas. Care records were inspected, with the care of four residents being closely looked at in particular. The management of residents’ medications was inspected. Eight residents and two relatives were spoken to directly in order to gauge their views and experiences of the services and care provided at Rodley House. Staff were also interviewed. Survey forms were also issued to a number of residents, visitors and staff to complete and return to CSCI if they wished. 100 of resident and 80 of relatives’ surveys, and 60 of staff surveys were returned. The quality and choice of meals was inspected, and the opportunities for residents to exercise choice and to maintain social contacts were considered. The systems for addressing complaints, monitoring the quality of the service and the policies for protecting the rights of vulnerable residents were inspected. The arrangements for the recruitment, provision, training and supervision of staff were inspected, as was the overall management of the home. A tour of the premises took place, with particular attention to health and safety issues, the maintenance and the cleanliness of the premises. Rodley House DS0000064588.V303781.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? A new and more up to date information brochure has been introduced, which is now being distributed to prospective residents; however, it remains that a copy was not sent to CSCI as required. A new washing machine, dishwasher, assisted bath and call bell have been installed. New curtains have been fitted in some areas, with more to follow. Redecoration is ongoing. Rodley House DS0000064588.V303781.R01.S.doc Version 5.2 Page 7 After a period of significant usage of agency staff some stability is now anticipated, as there has been some successful recruitment to the team of staff. A more structured staff supervision programme has been introduced, although it is unlikely that the home’s target of providing this at least six times in a twelve month period for each care worker will be reached this year. 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. Rodley House DS0000064588.V303781.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 Rodley House DS0000064588.V303781.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have access to information about the home to assist them in making their choice about moving there. They are admitted following a comprehensive assessment, so that they can be assured prior to admission that the home can meet their needs; however, until work to secure the garden is completed, the safety of certain residents wishing to use it could be compromised. EVIDENCE: Written survey responses from residents or their relatives confirmed that they had had access to information about the home prior to their admission. Revised information brochures (Service User Guides) have been produced since The Orders of St John Care Trust have taken over the management of the home, and these are now being issued to prospective residents. An updated copy of this, and the Statement of Purpose, has not been supplied to the CSCI as was required, within the agreed timescale. Rodley House DS0000064588.V303781.R01.S.doc Version 5.2 Page 10 Copies of pre-admission assessments carried out on four recently admitted residents were inspected. These had been conducted in hospital before their admission to the home was agreed. Each was fully detailed and recorded. Appropriate care and health information from other health care professionals was also on file, as were copies of the placing authority assessments and care plans where applicable. Actions to address a previously issued requirement to ensure the security of the rear garden have not been completed within the agreed timescale. Fencing and gates to make the garden secure for vulnerable residents are reported to be planned, with the work to erect them yet to be carried out. Rodley House does not provide intermediate care. Rodley House DS0000064588.V303781.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 at least once during a 12 month period. 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. Despite recording shortfalls in documented care plans, the health needs of residents appear to be met, although such shortfalls pose risks in this regard. The systems for the administration of medications are generally satisfactory, although shortfalls in recording will compromise any safeguards for residents. Care is offered in such a way as to meet residents’ needs in respect of their privacy and dignity. EVIDENCE: Each resident has their own personal plan of care, which is based on their assessed needs. Four care plans were selected as part of a case tracking exercise. A personal profile was recorded for each resident. Each had been regularly reviewed and updated as necessary. Generally plans were personalised, and were reflective of individuals’ choices, dignity and levels of independence. In two cases a risk of the person developing a pressure sore had been identified; there were no documented plans of care to address this. Rodley House DS0000064588.V303781.R01.S.doc Version 5.2 Page 12 In one case the person had a history of falling; there was no risk assessment for this, although an associated plan of care did record certain actions to take to provide some protection. In another case the person had some incontinence, and although there was no documented plan of care to address this, staff were helping to address it, and a medical review took place during this visit. A wound care plan contained only minimal detail and subsequent direction for staff to follow when carrying out the care. One person had rails fitted to their bed, although there was no history of falls. This person liked the security of the rails; there was no risk assessment or recording of any evidence that supported the decision to introduce the rails. One person had some particular mental health needs, and could present with challenging behaviour. The care plan to address this was not adequately robust to direct staff in the care necessary, and psychiatric interventions did not feature as part of the recorded care plan, although consultations had taken place. Case tracking showed that appropriate care was being carried out in these cases, with the appropriate support equipment and medical interventions provided where applicable. The shortfalls exist in the actual recording of some of the assessments and the care. Regular medical reviews take place, and residents have access to all community health care services as appropriate. Residents are supported to manage their own medications if they wish and are able to, and this is done on the basis of a recorded risk assessment, one of which was seen directly. Medications were stored safely and securely. The majority of medications are dispensed in a Monitored Dosage System, although some are boxed and bottled; such items are dated on opening so that they are not used beyond their expiry date. There were a small number of tablet sachets in the drug trolley that had been left out or fallen out of their containers. Items requiring cold storage were held securely in a designated refrigerator, and temperatures in here were regularly checked and recorded. Scheduled drugs are stored securely, and the associated register properly recorded; however, in one case where items had been disposed of by a denaturing technique, the register still showed a small stock balance, which was to be corrected. The supplying pharmacist prints the medication administration charts. Staff record the receipts of items on the charts, and a separate book of returned items is kept. The person responsible signs their hand written entries on medication administration charts, with a second signatory as witness. There were some omissions with this however, with no signature or date of commencement recorded in at least one case. Rodley House DS0000064588.V303781.R01.S.doc Version 5.2 Page 13 Directions for the use of certain items such as eye drops, external creams and analgesia are not clear on some of the medication administration charts, and are not linked to a relevant plan of care either. The route for administration of certain medicines in the case of a person who was nil by mouth was not clear on their chart. Some unlabelled external creams were seen in residents’ rooms, which were undated, making it difficult to know if they were being used within their expiry date. Care was being delivered in the privacy of residents’ own rooms or in bathrooms throughout this visit. Staff were observed being polite and respectful, though friendly, with the residents. When an aspect of care was being delivered in the ‘nurses’ room’, the nurse took care to close the door to ensure the person’s privacy. In another case, a carer was assisting a frail resident to mobilise as was part of his planned care; this was being carried out very sensitively, gently and supportively. Residents’ and relatives’ written survey responses all confirmed their satisfaction with the care being provided at Rodley House. One relative wrote that staff were particularly attentive. Residents spoken to during the visit were happy with the way in which staff cared for them. Many said that the staff were very kind, caring and helpful. All said that staff were respectful, and felt that their privacy and dignity was fully respected. Rodley House DS0000064588.V303781.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 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents are able to keep close contact with their families and friends, and in the main, have the opportunity to participate in a social activities programme. Their dietary needs are adequately catered for. However, despite efforts to respect individuals’ choices, there appear to be occasions when this is not entirely achieved in terms of activities and meals for some. EVIDENCE: 40 of written survey responses from residents indicated that they feel bored on occasions; some wrote that they would like to see more activity, with one saying they would like more trips out. Some staff surveys also confirm that they would like more time to offer more social opportunities for residents; the home is currently advertising for a Social Activities Coordinator, which will help with this. There is a social activities programme at Rodley House, and this is displayed in the reception area. Programmes show a range of group activities and entertainments, with a trip out planned during the week of this visit. One partially sighted resident enjoys regular trips out to a local club, where she is able to participate in appropriate social activities and pastimes with Rodley House DS0000064588.V303781.R01.S.doc Version 5.2 Page 15 other partially sighted people. This person is also enabled to walk freely in the grounds of the home, as is her choice, as she has the security of a ‘pendant call bell’ to wear around her neck. Another resident enjoyed a very free and independent lifestyle, going on holidays and dealing with his own affairs. Minutes of resident meetings demonstrate that staff have consulted with residents about their ideas for social activities. However, two residents said that they were not aware of certain activities, and had not been informed about events, which they would otherwise have liked to join in with. Visitors were observed coming and in and out of the home at various times. Relationships between staff and visitors appeared relaxed, welcoming and friendly. Residents confirmed that their relatives are made to feel welcome by the staff, and that they can visit at any time of their choosing. Written survey responses from relatives and friends of residents all confirmed that families are kept well informed by the home, and that they are appropriately consulted. Two visitors spoken to during this visit were both complimentary about the home, staff and care their relative was receiving. Those residents who were able, were seen moving around the home, spending time where, how and with whom they chose. Some were spending time quietly, some reading, watching television or doing crosswords; some were sitting in small groups, socialising independently. Others were sitting unattended for certain periods during the afternoons. There is at least one resident who has elected to manage their own affairs independently; there are others who have the necessary arrangements in place to assist them with their affairs, as they require more support in this regard; one person has the support of an advocate from Age Concern. Although evidence of residents’ freedom of choice was seen in these and other areas, such as the personal influences noted in individual bedrooms, a small number of residents felt that they did not have sufficient choice regarding their participation in social activities and with their meals. The service of an evening meal, a lunch and a breakfast was seen. Residents’ choices from the menu are obtained, and a list is submitted to the cook for their reference. Breakfast does not include a hot option, despite some residents asking about it previously; it was confirmed that this could be offered if requested. Lunch consisted of one hot option or a salad. One person’s lunch had been smothered in a savoury sauce that he had not requested and did not like; an alternative meal was eventually provided. Rodley House DS0000064588.V303781.R01.S.doc Version 5.2 Page 16 The evening meal was restricted on the first day of this visit, as there was no evening cook available, and only sandwiches and cakes were offered. Hot options were available for those with special needs, such as those needing a soft diet. Residents themselves spoke very positively about the food provided for them on the whole. Each said they had enjoyed the lunch, and two people said that the food ‘was absolutely lovely’. Three residents said that they would like to have more choice with their food, and felt that ‘there was not much choice as regards meals’. The food served certainly looked very appetising and nutritious, and was well presented. Staff were present throughout the meals, providing discreet assistance where needed. Eating aids were available for those who needed them. The kitchen was seen after the lunch service, and was in the process of being cleaned down. Records pertaining to residents’ dietary needs, temperature control monitoring with food storage and preparation, and a cleaning schedule were all in order. Rodley House DS0000064588.V303781.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. 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. The home has a good system for dealing with complaints, and there is evidence that residents feel that any concerns they may have are listened to and acted upon. The home’s Adult Protection policies help to provide a safe environment for the residents. EVIDENCE: The written Complaints Procedure is clearly displayed in the reception area. Resident and visitor written survey responses confirmed their awareness of how to make a complaint and of who to speak to if they had any concerns. When spoken to, many said that they had had no cause to make any complaints, but that they had complete confidence in the staff to help them with any concerns they might have. The home has a system for keeping records in relation to any complaints received, with appropriate auditing arrangements in place; records pertaining to two that were addressed many months ago were seen. The home has written policies and procedures for the protection of vulnerable residents, and staff have received training in adult protection issues, including recognition of abuse and whistle blowing procedures. Arrangements such as advocacy, a guardianship order and powers of attorney, are in place for more vulnerable residents where appropriate. Rodley House DS0000064588.V303781.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment within Rodley House is satisfactory, and provides residents with a comfortable, clean, and in the main, a safe place to live. EVIDENCE: One of the two maintenance persons was present in the home carrying out his duties during this visit, and there is regular attention to cyclical and small maintenance issues; external contractors address larger maintenance issues appropriately. A record is kept of all maintenance issues needing attention, and generally the environment is well maintained and decorated, with attention to safety; requirements to improve certain safety aspects are reported under standard 4 and 38. There is water damage in the ground floor bathroom, and also the sink in here is unsafe; both of these issues are scheduled for repair. Rodley House DS0000064588.V303781.R01.S.doc Version 5.2 Page 19 A carpet in one of the bedrooms was old, worn and stained; this too was scheduled for replacement. There are some areas of woodwork that have been damaged by every day wear and tear, and there are isolated pieces of furniture in rooms that appear fatigued by long usage. There have been a number of improvements in the home in recent months, which includes the provision of a new washing machine, dishwasher, assisted bath, curtains and call bell system. Further improvements are planned, with the provision of more new curtains and an ongoing redecoration programme. All areas of the home were clean, and apart from occasional and transient unpleasant odours, the environment was generally fresh. The laundry room was reasonably organised, though was clearly extremely busy and appeared slightly muddled. Laundry was being handled in accordance with good infection control practices. Gloves, aprons, liquid soap and paper towels are provided for staff. Clinical waste is handled appropriately, with a contract in place to ensure it is collected and disposed of safely. Sluice rooms are currently being fitted with a coded door entry security pad for improved safety. The metal storage cabinets in the sluice rooms are evidently old, worn and rusting. Rodley House DS0000064588.V303781.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 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 adequate. This judgement has been made using available evidence including a visit to this service. Staffing provision is just adequate to meet the needs of the residents currently living in the home. Robust recruitment procedures ensure that suitable staff are employed for the protection of residents. The arrangements for their induction and training are satisfactory, with staff able to learn the skills necessary for their role. EVIDENCE: A staff rota is maintained, which allows for one registered nurse to be on duty at all times, with seven care staff in the morning and an eighth helping residents in the dining room, six in the afternoon and evening, and two overnight. The staff team is divided into three groups and areas for working, so that there is an even distribution of staff at the busiest times. The manager works in a supernumerary capacity, and the deputy manager now has the advantage of having one day each fortnight on which she too can work supernumerary. The care and nursing team is ably supported by an ancillary team of cleaning, laundry, maintenance and administration staff; there have been some changes in the catering team, with a new head cook employed, and a new evening kitchen assistant about to commence work. Due to some vacancies and holiday times, the home has been using a significant amount of agency personnel recently. Although there remain some Rodley House DS0000064588.V303781.R01.S.doc Version 5.2 Page 21 care hours left to fill at this time, the home has made good progress with recruiting a more stable staff team for the future. Written staff survey responses indicate that there are some who feel they work short staffed. Isolated relative survey responses identify a concern about what is perceived as low staffing on occasions, and agency staff not ‘turning up’ for duty; this could not be validated by the manager. Staff seemed to be meeting the needs of the residents during this visit, with the home appearing calm and reasonably relaxed. There was just one occasion noted when a resident was kept waiting for attention, and as previously reported there were periods when some residents were unattended in the lounge. The home is making good progress with the National Vocational Qualification (NVQ) training programme. The home has not yet reached the standard of 50 of care staff being qualified to at least NVQ level 2, but there are currently thirteen care staff who are qualified to at least this level. Two other carers have started their award, and there are another four carers who have expressed an interest in starting the NVQ training. A selection of staff files was chosen for inspection, on the basis of their recruitment to the home since the last inspection. Each record contained application forms, including a full employment history. Records of interviews were seen. Full and complete evidence of the required pre-employment checks was seen in each of the files. In one case, there appeared to be a possible discrepancy between the declared employment history and the dates provided on a reference; the manager resolved to follow this up. New staff have a formal induction period, and receive structured induction training; they are allocated a supervisor during this period, which is one of the senior care personnel, the identity of whom can vary; although the identity of the supervisor could be ascertained from the rota, it is not actually recorded as such in the person’s records or on the rota. A training programme shows a range of training opportunities, which are either mandatory or optional, based on the developmental needs of the staff. However, the current programme is now out of date, and the home is awaiting the receipt of a more up to date programme from the Training Manager. With the exception of one written staff survey response, staff spoke positively about the training opportunities that are available to them. They are issued with the General Social Care Council Code of Conduct, and are issued with certificated evidence of their training and achievements. Rodley House DS0000064588.V303781.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 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 adequate. This judgement has been made using available evidence including a visit to this service. There are generally good management systems in place to ensure that the interests, health and safety of the residents are safeguarded. EVIDENCE: The manager has been in post at Rodley House for eight years. She is a first level nurse, has achieved the Registered Manager Award, and is registered with CSCI for her role. She demonstrates a commitment to her responsibilities and the welfare of the residents, and has a calm and professional approach. A range of quality monitoring is carried out in the home. This includes a range of internal audits in areas such as care planning, the environment and medications. Rodley House DS0000064588.V303781.R01.S.doc Version 5.2 Page 23 Residents and relatives opinions are sought, and recently an annual quality assurance survey has been distributed to them, so that they can provide feedback on their experience of the accommodation, facilities, catering, care, social activities and visiting arrangements. The manager has drawn up an action plan on the basis of results already collated, in order that strengths and weaknesses can be addressed. The home undertakes a six monthly review with each resident, with their relative in attendance if they wish, so that they can offer their views about care, services, facilities and any concerns they may have. Meal monitoring forms are also regularly issued to residents chosen on a random basis, so that they can give feedback on their experiences of the food and drink provided for them in the home. Some residents have placed personal money and valuables with the home for safekeeping. Clear and transparent records for each person, which include transaction details, running totals, and receipts, are kept. Residents or their representative sign to acknowledge some transactions, but where this is not possible in the majority of cases, two staff members sign the record to witness on behalf of the resident. The home now fulfils the requirement in relation to the formal supervision of staff, with a programme drawn up for twelve months at a time. The current programme incorporates all care and nursing staff, and the aim is to provide formal supervision at least six times in each year; progress to date does not confirm that this target will be reached during this year. There was evidence that health and safety issues are addressed satisfactorily in the main, with written policies, procedures and risk assessments and provision of necessary equipment; there is a designated Health and Safety Committee. All necessary safety checks and maintenance of equipment is undertaken in a timely fashion, and servicing and safety certificates were seen. A Legionella risk assessment has been carried out, and hot water temperatures are monitored for safety. There are two water outlets, which have recently been identified as a potential risk, and these have been isolated until maintenance work can be carried out in the immediate future. Staff have received training in fire safety, manual handling and first aid. A full fire safety risk assessment throughout the whole building has been undertaken by an external assessor, with due regard to revised fire safety regulations. Chemicals are generally safely stored, however there were isolated bottles of cleansing agents left in areas accessible to vulnerable residents; these were promptly removed. Rodley House DS0000064588.V303781.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 1 x 3 1 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x 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 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 3 x 2 Rodley House DS0000064588.V303781.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 OP1 Regulation 6(a & b) Requirement A copy of the revised Statement of Purpose and Service User Guide must be provided to the Commission. This requirement has been repeated from the last inspection. Secure arrangements must be introduced in the garden so that residents suffering from dementia related illnesses might have the benefit of this facility. This requirement has been repeated from the last inspection. The registered manager must ensure that staff record care plans which demonstrate how all needs are to be met in terms of all aspects of health and welfare. The registered manager must ensure that staff carry out and record assessments in relation to the risk of falling, and for the use of bed rails. The registered manager must ensure that all prescribed medications have a pharmacy label attached, with clear DS0000064588.V303781.R01.S.doc Timescale for action 31/12/06 2. OP4 2a 30/11/06 3. OP7 15(1) 31/10/06 4. OP7 13(4.c) 31/10/06 5. OP9 13(2) 31/10/06 Rodley House Version 5.2 Page 26 6. OP9 13(2) 7. OP14 12(3) 8. OP38 13(4.a) directions for usage. The registered manager must 31/10/06 ensure that staff sign consistently for any handwritten entries they make on medication administration charts, and record the date of commencement of a drug. The registered manager must 31/10/06 ensure that staff take into account the choices and feelings of each resident regarding access to social activities and choice of meals. The registered manager must 30/09/06 ensure that staff do not leave chemicals or other harmful agents in areas accessible to residents. 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. Refer to Standard OP9 Good Practice Recommendations Staff should ensure that: • The directions for the use of ‘as necessary’ and/or external medications should be recorded and linked in to a relevant plan of care • A second person signs as a witness to any handwritten entries on medication administration charts • All boxed and bottled medications, including tubs of cream are date labelled on opening. The registered manager should consider replacing the damaged metal storage cabinets in the sluice rooms. At least 50 of the care staff (excluding registered nurses) should be trained to NVQ, level 2 in care, or equivalent. The name of all new staff’s supervisors should be recorded on personal files or on rotas. 2. 3. 4. OP26 OP28 OP30 Rodley House DS0000064588.V303781.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Rodley House DS0000064588.V303781.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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