Inspection on 18/12/06 for Rookery Cottage

This inspection was carried out on 18th December 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

Rookery Cottage 28/01/09

Rookery Cottage 24/02/06

Rookery Cottage 28/06/05

Rookery Cottage 04/11/04

Rookery Cottage 11/05/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Rookery Cottage 5 Church Way Thorpe Malsor Kettering Northants NN14 1JS Lead Inspector Mrs Kathy Jones Unannounced Inspection 18th December 2006 08:45 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 Rookery Cottage DS0000012898.V324202.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. Rookery Cottage DS0000012898.V324202.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rookery Cottage Address 5 Church Way Thorpe Malsor Kettering Northants NN14 1JS 01536 482776 01536 482570 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) Mr Derek Arthur James Bass Mrs Diane Bass Mrs Diane Bass Care Home 13 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (13) of places Rookery Cottage DS0000012898.V324202.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th February 2006 Brief Description of the Service: Rookery Cottage is care home registered to accommodate up to thirteen older people and up to four residents with dementia. Rookery Cottage is owned by Mr and Mrs Bass, who live in the grounds. Rookery Cottage is located in a small village of Thorpe Malsor, near Kettering, Northamptonshire. The home is in the style of other properties within the village. Thorpe Malsor is a small village with no local facilities and Kettering town centre is a short drive away. Rookery Cottage is furnished with comfortable furniture and decorated to create a homely atmosphere. Bedrooms are located on the ground and first floor, which are accessible by a passenger lift or the stairs. There is a large lounge with dining area. There is garden with a patio to the rear of the building. Car parking is also to the rear of the home. The Registered Managers office is located away from the home in a separate office. The following fees were provided in the pre-inspection questionnaire submitted by the registered manager: • Fees per week - £402.50 The fees include personal care, accommodation, meals and laundry. Chiropody and hairdressing services can be arranged and are charged separately. Other costs would include personal expenditure such as clothing and toiletries. Rookery Cottage DS0000012898.V324202.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Standards identified as ‘key’ standards and highlighted through the report were inspected. The key standards are those considered by the Commission to have a particular impact on outcomes for residents. Inspection of the standards was achieved through review of existing evidence, pre-inspection planning, an unannounced inspection visit to the home and drawing together all of the evidence gathered. The pre-inspection planning was carried out over the period of half a day and involved reviewing the service history, which details all contact with the home including notifications of events reported by the home, telephone calls and any complaints received. The report of the last inspection carried out on the 24th February 2006 was also reviewed. The information gathered assisted with planning the particular areas to be inspected during the visit. Information from a pre-inspection questionnaire submitted by the registered manager has also been used as part of the inspection process. At the time of writing the inspection report no comment cards had been received from residents, relatives or health professionals. The unannounced inspection visit covered the morning and afternoon of a weekday. The inspection was carried out by ‘case tracking’, which involves selecting samples of residents’ records and tracking their care and experiences. Observations of the homes routines and care provided were made and the inspector spoke with residents’, staff and visitors throughout the inspection. The management of residents’ medication was checked. A sample of staff files were also reviewed to check the adequacy of the recruitment procedures. Communal areas and a sample of residents’ bedrooms were viewed and observations were made of residents’ general well being, daily routines and interactions between staff and residents. Verbal feedback was given to senior staff throughout the inspection and a summary given to the registered manager of the inspection findings at the end of the inspection. What the service does well: The main strength of Rookery Cottage is the stable staff team and the apparent good relationships, which exist between the registered people, staff and residents, which assist in providing consistent, care to residents. Rookery Cottage DS0000012898.V324202.R01.S.doc Version 5.2 Page 6 Residents were full of praise for the staff and they were happy with the care and support that they receive which they felt was very good. Observations during the inspection confirmed that staff were aware of individual residents needs and had developed good relationships with them. Changes in residents’ health are monitored by staff, and residents said that the General Practitioner is contacted promptly if anyone is ill. Residents were happy that their lifestyle met with their expectations and that they could spend time where they wished in the home. They said the food was good and that visiting arrangements are flexible. Some organised activities take place such as a monthly music and movement session. I addition informal activities/discussion take place. The general appearance and décor of the home was good, it was clean and comfortably furnished. As Rookery cottage is a relatively small home it also had a relaxed and homely feel to it. What has improved since the last inspection? What they could do better: More clarity in the statement of purpose around the range of needs that Rookery Cottage aims to meet particularly in relation to people with mobility needs or dementia would assist prospective residents in deciding if it is the right home for them. A more detailed pre-admission assessment should be carried out to ensure as far as is possible that the full range of needs of prospective residents is identified in order to make an informed decision as to how their needs can be fully met. More detailed care plans need to be implemented, which are reflective of the full range of residents needs. This would ensure that if it was necessary for them to be cared for by staff who did not know them as well as current staff they could receive the same level of care. The management of residents’ medication needs to be reviewed to ensure that accurate records are kept of all medication received, administered to residents and returned to the pharmacist. A clear audit trail enables discrepancies to be Rookery Cottage DS0000012898.V324202.R01.S.doc Version 5.2 Page 7 identified and reduces the risk of to residents through error. Advice has also been given that staff must not sub dispense medication even occasionally. 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. Rookery Cottage DS0000012898.V324202.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 Rookery Cottage DS0000012898.V324202.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, standard 6 was not inspected as intermediate care is not provided. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are satisfied that they had sufficient information to make a decision about moving in to the home and that it met with their expectations. A more detailed assessment of residents needs would provide additional reassurances that their needs can be met. EVIDENCE: Prospective residents’ and their relatives are provided with a statement of purpose, which has relevant information to assist in deciding if the home will be suitable for them. The information includes the philosophy of care, accommodation, visiting arrangements and the services provided. The statement of purpose describes the care speciality of the home as “Long stay care of the elderly”. Discussions with the registered manager identified that although an individual assessment of needs would be carried out, there are certain needs which Rookery Cottage would be unable to meet such as anyone Rookery Cottage DS0000012898.V324202.R01.S.doc Version 5.2 Page 10 who required the assistance of a hoist for movement and handling. The inspector would suggest it might be helpful to include this information within the statement of purpose. Discussion with residents during the inspection confirmed that their expectations of the home were being met and that they had made an informed choice about moving in. Residents’ records showed that assessments of prospective residents’ needs are carried out prior to admission. Basic information about the prospective residents needs had been gathered; good information had been gathered about likes and dislikes, family relationships and information about previous work. Advice was given to review the process for gathering information to ensure that full information has been obtained. For example the enquiry record stated that the prospective resident had dementia and another record described her mental state as “very bad”. There was no information about the type or stage of dementia, whether a formal diagnosis had been made, or of particular needs relating to the dementia without which it would be difficult to ascertain if the residents’ needs could be met. Rookery Cottage DS0000012898.V324202.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The overall care provided appears to be very good however the lack of detailed care plans could put residents at risk of their needs and preferences not being met if the staff team changed. Practices in relation to the management of medication also have the potential to put residents at risk. EVIDENCE: Residents spoken with during the inspection were very satisfied with the care and support that they receive. Staff demonstrated a good understanding of residents’ needs and their individual preferences and personalities throughout the inspection. A sample of care plans were reviewed for three residents to check how their care needs were being supported. Advice was given of the need to increase the level of detail within the care plans about residents’ needs and the actions Rookery Cottage DS0000012898.V324202.R01.S.doc Version 5.2 Page 12 staff needed to take to meet the needs. At present there is a very stable staff team at the home who know residents very well however if staff were to change, particularly if a resident became less able to state their preferences the care planning information put together by staff would be invaluable in ensuring their needs and preferences were fully met. Some examples were given to the registered manager and staff during the inspection which included a plan for meeting the spiritual needs of a resident which stated “likes to have communion once a month”. While current staff were aware of the residents religion and how she accessed communion this would not be known to new staff. Similarly there was no indication if a resident required any assistance with a hearing aid and if so how much, without this information it is also difficult to assess and respond to changing needs. Advice was given that care plans should be reviewed at least monthly or as needs changed so that additional assistance can be planned if necessary. The inspector also noted that although some information had been gathered during the assessment this had not been transferred to the care plan which as the documents were kept separately meant that the information was not immediately available to staff. Records indicated that health care services, which include general practitioners and district nurses, are accessed appropriately for residents. Chiropody treatment is also arranged. Residents confirmed that if they are ill the general practitioner is contacted promptly and that they receive appropriate healthcare. Daily records are kept which demonstrate that staff are monitoring residents’ well being and records to demonstrate residents’ weight is being monitored have been introduced since the last inspection. A sample check of the management of medication was made. Medication was securely stored and the majority of the medication received from the pharmacist came with a month’s supply in a cassette system for staff to administer to residents. Medication for a resident who had been admitted during the month and had brought their medication in individual boxes and bottles identified that this had not all been recorded as received making it impossible to verify the safe management and administration. Some discrepancies were also identified with other medication for example 28 tablets were recorded as received for a resident, there were no signatures on the record to identify administration of the medication but only 27 tablets in the packet. During discussion with staff about the discrepancies the inspector was informed that in the past staff have dispensed medication into a spare cassette feeling that this was the safest way of managing it. The inspector re-enforced that this is not acceptable or safe practice and that the pharmacist is the only person qualified to do this. Residents were observed to be treated with dignity and respect throughout the inspection by staff and they confirmed that this is always the case. Rookery Cottage DS0000012898.V324202.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ are happy that their lifestyle meets with their expectations. Visitors are encouraged and welcomed into the home and residents’ are happy with the quality of food provided. EVIDENCE: The home is relatively small with at the time of the inspection just eleven residents. Residents said they are able to choose where they spend their time, one resident said that they preferred to read or watch television in their room rather than be in the communal lounge however another said that they prefer the lounge but if they want peace and quiet or to watch something different on television they can go to their rooms. Two residents told the inspector that they liked to do things to stimulate the brain and although no formal activities were arranged on the day of inspection discussion/debate involving a member of staff (folding laundry) and some residents was taking place as a result of a newspaper article found by a resident. Rookery Cottage DS0000012898.V324202.R01.S.doc Version 5.2 Page 14 Residents said that they had been out for a Christmas meal one day and that the hairdresser had been in that day to ensure they were looking their best. Staff advised that once a month a ‘music for health’ session is arranged which involves music and some movement. They also advised that sometimes residents’ enjoy jigsaws or videos. Residents said that the visiting arrangements are flexible and the inspector observed a visitor to be greeted warmly by the registered manager and staff. The lunch time meal on the day of the inspection looked appetising and residents confirmed that the standard of food is good. Rookery Cottage DS0000012898.V324202.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by staff who are aware of their responsibilities in safeguarding the people in their care. EVIDENCE: The commission for social care inspection have received no complaints about Rookery Cottage since the last inspection. There were no complaints recorded in the record of complaints and compliments held at Rookery Cottage and a staff member confirmed that none had been received. Residents spoken with during the inspection were aware of how to make a complaint and were satisfied that any concerns they raised would be taken seriously. Residents said they had no concerns about how they were treated by staff. Staff understood and accepted their responsibilities for protecting the vulnerable people in their care and the need to act on concerns. Discussion about the action senior staff would take in the event of an allegation of abuse being made, confirmed that they would act to protect residents’ however identified that staff would benefit from some staff training and clear policies and procedures in safeguarding adults’ procedures to ensure that they are clear about reporting procedures and the need to protect any evidence. Rookery Cottage DS0000012898.V324202.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): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean, comfortable and in good decorative order providing a pleasant environment for Residents. EVIDENCE: The premises are well decorated and maintained and comfortably furnished with a homely appearance. This inspection took place close to Christmas and the home looked very festive with the Christmas decorations. There are seven single bedrooms and three double rooms with en-suite facilities. A resident who prefers to spend time in her room confirmed that she found it comfortable and the same good standard of cleanliness seen on the day of inspection was maintained. A call bell was accessible if the resident required assistance and she confirmed that staff responded. Other residents Rookery Cottage DS0000012898.V324202.R01.S.doc Version 5.2 Page 17 also said they were happy with the accommodation and were able to choose whether to spend time in their rooms or in the shared lounge. There is a small dining table in the lounge, which would accommodate some residents’ for meals however they told the inspector that they preferred to eat from small tables next to their lounge chairs. All areas of the home were clean and there were no offensive odours. The toilet on the ground floor was well stocked with clean towels however advice was given to consider using paper towels to reduce the risk of infection. Rookery Cottage DS0000012898.V324202.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): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a stable staff team who demonstrate a commitment to increasing their knowledge and skills and working together to meet the needs of residents. EVIDENCE: Rookery cottage has a very stable staff team with most of the staff having worked in the home for several years, which provides residents with consistent care. Residents’ were keen to praise the staff and said that they felt there were enough staff to meet their needs. There are two staff on duty between 7am and 10pm and two ‘sleep in’ staff between 10pm and 7am. In addition to care duties staff are responsible for the cooking and cleaning in the home. Staff were very aware of the importance of good hygiene practices when carrying out multiple roles and the registered manager advice has been sought from the environmental health officer in relation to food preparation. Staff and residents appeared satisfied with the staffing arrangements. The staff rota shows that there is always a member of staff on call and another available if any additional duties are required. Staff advised that if a resident Rookery Cottage DS0000012898.V324202.R01.S.doc Version 5.2 Page 19 is ill or their needs change or if additional help is needed with extra tasks such as cleaning windows or putting away a food delivery an additional staff member would be called in. As the registered manager was not on duty on the day of inspection staff decided it would be beneficial to have another member of staff in to assist to allow a senior member of staff time to locate the necessary information and records for inspection, this was very quickly arranged and staff were seen to be supporting each other and working as a team to meet the needs of residents. The National Minimum Standards recommend, as part of good practice at least 50 of staff should hold a National Vocational Qualification (NVQ) at level 2 to provide them with a basic understanding of care practices and the needs of older people. Staff at Rookery Cottage have been supported in developing their skills and knowledge with all staff except one having achieved an NVQ at level 3. The member of staff who hasn’t achieved this is currently working towards it. In addition two staff are working towards an NVQ 4, which includes a management component. A sample check of staff training records and discussion with a staff member identified that some training updates are required. The required updates were mainly in relation to safe working practices, which are addressed in the management section of the report. There was no evidence on the staff files reviewed of any dementia care training. A senior staff member advised that they were aware of the need but training which had been booked last year was cancelled and was going to be re-booked. Induction training is flexible and the inspector was informed that new staff worked as an extra person for between two and four weeks dependent on previous experience and individual needs to ensure that they were able to fully meet residents needs. The adequacy of the recruitment process in protecting residents was checked through review of staff files. This demonstrated that references and criminal record bureau clearances were obtained prior to the staff member starting work in the home. Some advice was given regarding the need to ensure that the application form is fully completed, the source of the reference is clear and that there is a record made of any follow up queries to ensure that it is demonstrated that full information has been received and considered to determine suitability for working with vulnerable people. Rookery Cottage DS0000012898.V324202.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): 31, 32, 33, 35, 37, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run by an experienced and competent manager who promotes and safeguards the health, safety and welfare of the people living in the home. EVIDENCE: The registered manager is also a joint registered owner and has many years experience of owning and managing Rookery Cottage. The registered manager has achieved the registered managers award National Vocational Qualification at level 4, which relates to management of a care home. A copy of the certificate is displayed in the office. The registered manager is currently Rookery Cottage DS0000012898.V324202.R01.S.doc Version 5.2 Page 21 supporting two staff to achieve the same qualification, which in turn ensures that additional management support is available in the managers’ absence. The registered manager and staff were very co-operative with the inspection process and indicated a commitment to acting on the advice given. The management style is very open and inclusive with staff encouraged to take responsibility. For example the registered manager told the inspector that she did not change her plans when she heard there was an unannounced inspection as she felt it was important for staff to gain the experience and take responsibility. The joint registered owners live in a property within the grounds of Rookery Cottage and according to residents call into the home on a very regular basis. From observations during the inspection there is a very good relationship between them and residents and they appeared committed to the well being of residents. There is an informal quality assurance process in place, which involves listening to resident and relatives’ views on a daily basis. Staff advised that there is also a formal quality assurance programme in place which involves sending out and reviewing questionnaires however these documents were not available during the inspection to evidence this as a staff member had taken the information away to collate. The inspector was also informed that questionnaires have been sent to health professionals to gain their views on the standards of care provided to residents’. Review of residents’ records identified that a ‘communication book’ is currently being used to record information about individual residents’ and their needs. Advice was given that information on individuals must be kept separately to protect confidentiality and to comply with data protection legislation. Staff advised that residents’ manage their own money, or in most cases this is managed by relatives on their behalf. The pre-inspection questionnaire submitted by the registered manager confirms that equipment such as fire safety equipment; central heating system and electrical wiring and equipment are regularly checked and serviced helping to protect the health and safety of residents. Staff training records identified that training updates are due in safe working practices such as movement and handling. Although no residents currently require any assistance or support with movement and handling staff confirmed that this training was planned. Rookery Cottage DS0000012898.V324202.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 3 X 2 X 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 3 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 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X 2 3 Rookery Cottage DS0000012898.V324202.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 (1) (a), 12 (1) (a, b) 12 (1) (a, b), 15 (1) Requirement A full and detailed assessment of prospective residents needs must be carried out prior to admission to the home. The care plans must be detailed to accurately reflect the full range of, health, personal, social and emotional needs and be reviewed at least monthly. (A previous requirement with a timescale of 30/03/06 has not been fully met.) Records must demonstrate a clear audit trail of all prescribed medication. Regular reviews of staff training and competence must be carried out to ensure safe practices in relation to management of residents’ medication are consistently followed. Timescale for action 30/03/07 2. OP7 30/03/07 3. 4. OP9 OP9 13 (2) 12 (1) (a, b), 18 (1) (a, c) 31/01/07 31/01/07 Rookery Cottage DS0000012898.V324202.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP29 OP33 Good Practice Recommendations Staff records should include evidence that any gaps in information and sources of references have been checked. A review of record keeping should be carried out to ensure data protection legislation is fully complied with. Rookery Cottage DS0000012898.V324202.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Rookery Cottage DS0000012898.V324202.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. 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