Inspection on 15/11/06 for Rookwood Residential Care Home

This inspection was carried out on 15th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rookwood Residential Care Home 06/02/06

Rookwood Residential Care Home 31/10/05

Rookwood Residential Care Home 24/02/05

Rookwood Residential Care Home 08/06/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Rookwood Residential Care Home 219 Walmersley Road Bury Lancs BL9 5DF Lead Inspector Lucy Burgess Unannounced Inspection 15 November 2006 11:00 th Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 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 Rookwood Residential Care Home DS0000008425.V297671.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 Adults 18-65. 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. Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rookwood Residential Care Home Address 219 Walmersley Road Bury Lancs BL9 5DF 0161 761 7952 0161 761 7952 antric@tiscali.co.uk 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) Mrs Anna Geraldine Ellis Mr Colin Bruce Ellis Mrs Collette Mary Richmond Care Home 17 Category(ies) of Learning disability (17), Mental disorder, registration, with number excluding learning disability or dementia (17) of places Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Within the maximum registered numbers there can be up to 17 MD and up to 17 LD The service should at all times employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection 6th February 2006 Date of last inspection Brief Description of the Service: Rookwood provides residential care and support for up to seventeen people who are recovering from a mental illness. The home is owned by Mrs A Ellis and managed by Mrs C Richmond. Fees at the home are £400.00 per week. The property is a large converted house that is sited on a main road about a mile from Bury town centre. Accommodation is on three levels and comprises of three lounges, a dining room, eleven single bedrooms and 3 double rooms. There are also four bathrooms and eight separate toilets. The home is spacious, homely and well maintained. Service users have access to local shops, pubs and other amenities situated nearby and there is easy access to bus services. Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day for a period of 5½ hours. The inspector took the opportunity to look round the home, view records as well as talk with residents and staff. Discussion and feedback was also held with the Registered Manager. A pre-inspection questionnaire was completed and feedback surveys were received from a 1 CPN, 1 Social Worker, 3 GP’s, 5 relatives and 7 residents. Comments have been included within the report. The home is registered to provide accommodation for up to 17 people with mental health needs or a learning disability. At the time of the inspection there were no vacancies. All the key standards were inspected. What the service does well: Rookwood is a large house providing comfortable accommodation for the residents. The management of the home and staff team has been very stable with little change, as to have the resident with some having lived at the home for a number of years. Both the staff and manager have a good understanding of the needs of the residents and where needed will seek out the support and advise of health professionals making sure that residents health and well-being is maintained. Residents and staff made the inspector welcome and were happy to talk. One resident who had only recently moved into the home was very happy. She told the inspector that she ‘liked it’, ‘enjoyed having people to talk to’ and ‘it’s like one big happy family’. Other comments were made by visitors to the home. These included, ‘‘I believe the home to be one of the best homes in the area’, ‘staff are always helpful and professional’, ‘service users have always been happy with the care and support they receive’, ‘Rookwood seems to be a pleasant place with a homely atmosphere’, ‘we have good relations with staff’ and ‘the staff seem switched on and caring of the residents’. Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. As part of the resettlement programme information is gathered in relation to the assessed needs of prospective residents is generally provided. This enables the home to make an informed decision about the suitability of the placement. EVIDENCE: Rookwood will accept individuals requesting respite as well as permanent placement, where this can be accommodated. In the main information is provided to the home outlining the needs of individuals. Opportunities to meet also take place. Assessment information was looked at for one of the newest residents. This had been provided by the Funding Authority prior to the placement being made. Information was seen to provide a good overview in relation to the individuals emotional, physical and social care needs. Details included the person’s legal status, names of relevant professionals involved with the care management, brief social history and current medication. A summary care plan had also been provided and addressed areas such as communication, environment, physical health, mobility, mental health, medication, personal care, household Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 9 tasks and religious and spiritual needs. Areas of potential risk were also identified. A further resident had very recently moved into the home as an emergency placement made by the neighbouring authority. No information was provided by those arranging the placement nor was the home involved in the discharge arrangements. This is poor practice. The Manager had made several attempts by contacting the placing team and requesting that information be provided. The Manager is advised that any future placements are not agreed unless a general overview of the person’s needs and a discharge plan are provided. This will ensure that the placements is safe and that the home is clear whether they are able to meet the individuals needs. Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information details the support needs of residents and how this is to be provided. Residents expressed they were well cared for and were involved in making decisions about their lives. EVIDENCE: Information about residents is held securely within the office. These are separated into current and past information. Information includes; care plan, risk assessments, daily records, review notes, appointments, and weights, medication and correspondence. Risk assessments are also held within the care file. These are carried in areas where concerns have been identified, such as smoking in bedrooms, or behaviours etc. The Managers is aware that any intervention provided by staff to minimise risk should be recorded on file along with detailed information on how the resident is to be supported ensuring the risk is minimised and individuals are protected. Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 11 Information continues to be shared between the time using the daily diary notes and the communication diary. Information is also recorded with regards to appointments and any changes to medication etc. Residents are encouraged to be involved in the development of their plans. Of the files seen residents had signed the records to evidence their involvement and agreement. The home has a system of reviewing plans on a 6 monthly basis and any changes are noted. Where additional needs have been identified plans would be reviewed more frequently. The Community Psychiatric Nurses (CPN) and hospital Consultants continue to provide on-going support and advice to the team. Periodic reviews continue to take place with health and social care professionals. Minutes to meetings had been provided and copies held on file. Formal reviews are generally held on an annual basis however should an earlier meeting be required this would be arranged. This had been arranged for one resident whose mental health was deteriorating. The Manager had arranged for an early review with the Consultant so that further assessment and review and review of medication could be carried out. Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Daily routines promote residents’ independence and choice. Residents are actively supported to maintain contact with their family and friends. Suitable arrangements are in place with regards to meals and special diets are catered for. EVIDENCE: Daily routines reflect their the personal choices and preferences of residents. Each are encouraged to access the wider community enabling them to learn new skills and develop other friendships. Some of the residents access the local college, drop-ins and day centres. This provides a fairly structured week taking part in a variety of activities. Other residents however choose a more relaxed routine spending the majority of time at home. Each of the residents access local amenities and services such as the local shops, pubs and colleges which is seen as a positive step in involving the residents in becoming active members of their local community. Residents are Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 13 also encouraged to use public transport wherever possible and have a bus pass. Staff were observed interacting with the residents, relationships are relaxed and residents appear very much as ease. One resident said, ‘I like living here and I like the staff’. Another also said, ‘I enjoyed having people to talk to’ and ‘it’s like one big happy family’. Contact with family and friends are maintained with visits taking place both to and away from the home. This may include residents visiting relatives for the weekend or holidays. Residents also enjoy the company of each other and spend time relaxing and chatting together. Surveys returned by some of the relatives were also complimentary about the home. Relatives expressed, ‘I am quite happy with the care my relative receives at the home’ and ‘I know that any problems are dealt with by the owners and staff’. The residents are offered a variety of meals and encouraged to follow a healthy diet. One resident is vegetarian and this is also catered for. The main meal of the day is tea and there are menus planned on a four weekly basis. All meals are served in the dining room with residents dining together. One resident was to celebrate their 60th birthday the day after the visit and was looking forward to having a birthday cake. Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to maintain effective working relationships with mental health professionals who provide a positive support network for both staff and residents in ensuring their health and well-being is maintained. The medication system was found to be safe however minor improvements were needed to the records to evidence practice is safe. EVIDENCE: The staff fully support residents in maintaining their health and well-being. Action has been taken with regards to one individual who has recently become unwell. An early appointment has been made with the consultant to look at how this can be managed as well as having a medication review. Staff will support the resident in doing this. Some of the resident continue to have formal reviews in line with the discharge programme (CPA). The staff have good relationships with health professionals and will seek support and advise when necessary. Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 15 Residents also have access to all NHS entitlements such as dentist, optician and chiropody. Appointments are made as and when required. Where a resident would require support, staff would escort. Staff provide personal care support where agreed. This is very much dependent on individual needs however does not involve any physical lifting therefore specific aids and adaptations are not required. In the main residents are prompted in maintaining their own personal care and appearance. Support and encouragement is offered from staff in developing this area. Additional records are also held with regards to individual weights. These are completed for monitoring purposes, should any concerns be identified additional support and advice would be accessed. The medication system was examined this was found to be safe. The supplying pharmacist is Boots and deliveries are made on a monthly basis. Records are made of all items brought in to the home as well as those returned to the supplying pharmacist. At present the home does not hold any controlled drugs. With regards to the MAR sheets the Manager is advice that handwritten entries are checked then countered signed and dated to that the information recorded matches that on the prescription. Care must also be taken in ensuring that all records are completed in full and the relevant code is entered on to the form to prevent any unexplained gaps. The Manager has also developed a policy with regards to homely remedies. This identifies items, which can be purchased and administration details. Information also states that should items be used for a certain period then medical advice should be sought as a prescription may be required. Residents’ medication is also regularly reviewed with health professionals ensuring the stability of their mental health. At present residents are supported with their medication other than eye drops and hand creams. Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home holds clear procedures regarding complaints and adult protection, ensuring that residents were listened to and protected. Relevant training is being provided to members of the team. EVIDENCE: As previously identified Rookwood holds policies and procedures with regards to complaints and protection. A copy of the Inter Agency Procedure for the protection of Vulnerable Adults is also available. Through feedback and discussion with residents and staff no issues or concerns have been raised within the home or directly with CSCI. All but 2 members of the team have completed training in the area. The Manager is aware that formal training is required for some members of the team with regards to vulnerable adults. Arrangements for this are to be made. With regards to service user finances, the provider is appointee for 9 residents. All personal allowance are provided on a weekly basis and held by residents. Records are made of all transactions to show that money has been provided and signed by the resident. Other residents manage their own accounts. It was discussed with Manager about residents having a budget plan. This would be acceptable if this is requested by the resident or agreed with them due to an area of concern. Information would need to be entered within the care plan and signed by all relevant parties. Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Rookwood continues to provide comfortable, clean, homely accommodation, which meets the needs of those living there. EVIDENCE: Rookwood is a large converted house that is sited on a main road about a mile from Bury town centre. Accommodation is on three levels and comprises of three lounges and dining room on the ground floor with a laundry and staff office in the basement., eleven single bedrooms and 3 double rooms. There are also 11 single bedrooms and 3 double rooms. None of the bedrooms have en-suite. A number of bathrooms, shower rooms and toilet facilities are available throughout the home. The home is spacious, homely and well maintained and continues to provide a good standard of accommodation for the individuals living there. Regularly maintenance and redecoration is carried out as and when required. Consideration is currently being given to work being carried within the kitchen. Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 18 A number of rooms were looked at. These had been personalised with pictures, photographs and personal belongings. Residents spoken with were very happy and settled at the home. One resident who had recently moved into the home expressed that ‘I liked it here’. Other comments received from residents included, ‘it’s kept lovely and clean’ and ‘every nick, knack, nook and cranny is up to date!’. The room for one resident is in a poor condition. Whilst this has been addressed by the Manager more than once, issues continue to arise due the resident causing further damage and risks to themselves and others. The Manager is considering what further action needs to be taken to resolve the matter. The home continues to employs a domestic who carries out the majority of the domestic tasks. The support staff also carry out additional tasks. As already identified the home has a separate laundry, which also has hand-washing facilities to prevent any cross infection. The environment was seen to be clean, tidy and odour free. The home also has a gardener who ensures that the grounds are well maintained. Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient staffing is provided to meet the needs of residents. Recruitment checks need to be in place prior to staff commencing work so that residents are protected. On-going training is provided to equip staff with the knowledge and skills needed in meeting the needs of service users. EVIDENCE: The staff team at Rookwood comprises of the Manager, 10 carers and a domestic. As the team is small regular contact with the Manager is made on a daily basis. From observations made and through feedback received staff are clear about their role and responsibilities. Generally double cover is provided throughout the day with wake-in staff at night. The home also has an on-call facility should staff need any further assistance or advice. The Manager is aware of the training needs of staff and regularly liaises with training providers to arrange the relevant course. Recent training has included food hygiene and appointed first aid. The Manager and 2 staff also attended a course in relation to Mental Health, however felt this did not address the needs of the home. Further information and a video have been sought from mental health professionals and are accessible to staff as a training guide. Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 20 Further training courses are to be arranged for the newest members of the team and existing staff. These will include fire safety, medication and vulnerable adults. As an interim measure staff have completed some video training and a questionnaire until dates are provided for the formal courses. Staff have also undertaken training in NVQ level 2 and 3. Of the 12 carers 1 has completed level 2 and 3, 5 have completed 2 and 3 are currently receiving training in level 2 or 3. The Manager has previously attained her level 4 registered managers award. In relation to induction, the home has introduced the skills for care programme. At present the manager is working through the document with staff and is aware that the newest members of the team have yet to complete this. Arrangements are to be for this to be done. Recruitment files were examined for the 3 newest members of the team. Two have recently commenced and a third was due to start. Information gathered included a completed application form, written references, copies of identification, health declaration, POVA 1st checks, Criminal Record Check (CRB), signed contract and training information. Minor shortfalls were found. One file did not have a detailed employment history and gaps had not been explored. It also contained a CRB, which had been transferred from the previous employer. This cannot be accepted, the home must carry out the relevant checks on all new staff employed. Feedback received from the health and social care professionals was very complimentary about the service provided by staff at Rookwood. Comment included; ‘’I believe the home to be one of the best homes in the area’, ‘staff are always helpful and professional’, ‘service users have always been happy with the care and support they receive’, ‘Rookwood seems to be a pleasant place with a homely atmosphere’, ‘we have good relations with staff’ and ‘the staff seem switched on and caring of the residents’. Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The overall management of the home is consistent and reliable for the people living there. Systems could be developed with regards to the reviewing of the service provision. In the main satisfactory arrangements with regards to providing a safe environment are in place. EVIDENCE: Management arrangements within the home have remained unchanged for along time offering both residents and staff continuity. Both the Provider and Manager have a good awareness and understanding in relation to the needs of residents living at the home. Monthly monitoring visits by the provider are not undertaken as she spend time working at the home each week, therefore is actively involved or aware of the day-to-day running of the home. Discussion was held with the Manager with regards to developing the quality assurance system. Previously Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 22 questionnaires have been distributed to residents and relatives for feedback. This last took place in July 2006. One relative expressed that ‘they never tier of telling people how wonderful the home has been caring for their relative’. Further discussion was held in relation to additional feedback being sought from other stakeholders, such as health and social care professionals who are actively involved with the home. The Manager is to explore this area and develop a report in relation to her findings. A copy of the report is to be forwarded to CSCI. Residents have day-to-day contact with the manager and staff and feel able to discuss any matters or ideas they have. Residents choose not to have formal meetings preferring informal discussion. Feedback is sought from the staff during the supervisions and on a daily basis. Additional comments are also received during the residents formal review meetings, which involve health and social care professionals. Information was provided on the pre-inspection questionnaire with regards to health and safety checks. Details were confirmed during the visit and up to date certificates were in place. The inspector was unable to find an up to date certificate with regards to small appliance. Confirmation of the check is to be forwarded to CSCI. Further in-house checks are carried out by staff within the home with regards to fire safety and the general environment. Water temperatures are also recorded. The Manager was asked to identify within the records which area the check corresponded with. An accident book is also in place. No incident had occurred for sometime. Inspections have recently been carried out by the fire officer and food hygiene inspector. Action has been identified within both reports. The Manager is to ensure that all areas are addressed. Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement The registered Person must ensure that staff signed the MAR sheets following administration of medication or the relevant code is entered. The Registered Person must ensure that an up to date CRB/POVA 1st check is placed on file prior to any new staff commencing employment Timescale for action 30/12/06 2. YA34 19 schedule 2 30/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations The Registered person must ensure that hand-written entries on the MAR sheet are dated and countersigned to evidence that the information recorded reflects that on the prescription. The Registered person must ensure that a detailed employment history is recorded by new applicants, any gaps are discussed at the interview. 2. YA34 Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 25 3. 4. YA35 YA39 The Registered Person must ensure that all identified training is provided to all members of the team. The Registered Person must ensure that a system of reviewing the service is developed and feedback sought from other stakeholders involved within the home. Finding should be provided within a report and a copy forwarded to CSCI. The Registered person must ensure that records in relation to the water temperature specify which area has been checked. The Registered person must provide confirmation that up to date PAT testing has been carried out. 5. YA42 6. YA42 Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Rookwood Residential Care Home DS0000008425.V297671.R01.S.doc Version 5.2 Page 27 - 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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