Inspection on 30/05/07 for Rosalyn House

This inspection was carried out on 30th May 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Rosalyn House 26/05/09

Rosalyn House 15/06/06

Rosalyn House 18/10/05

Rosalyn House 13/02/05

Rosalyn House 19/08/04

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

CARE HOMES FOR OLDER PEOPLE Rosalyn House King Street Houghton Regis Dunstable Bedfordshire LU5 5TT Lead Inspector Pursotamraj Hirekar Unannounced Inspection 01:05 30th May 2007 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rosalyn House DS0000017690.V336980.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. Rosalyn House DS0000017690.V336980.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosalyn House Address King Street Houghton Regis Dunstable Bedfordshire LU5 5TT 01582 896600 01582 896601 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) SAH Nursing Homes Limited Vacant Care Home 46 Category(ies) of Dementia (16), Dementia - over 65 years of age registration, with number (46), Learning disability over 65 years of age of places (46), Mental Disorder, excluding learning disability or dementia - over 65 years of age (46), Physical disability over 65 years of age (46) Rosalyn House DS0000017690.V336980.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Mental nursing care for Elderly people (over 65 years) Up to 16 Adults (40-64 years) Date of last inspection 15th June 2006 Brief Description of the Service: Rosalyn House is a purpose built Care Home (with nursing) specialising in caring for both younger and older adults with mental health care needs. The home is in Houghton Regis very close to the town centre and in walking distance of local amenities and public transport routes. The home can accommodate up to 46 individuals in single rooms with en-suite facilities arranged over three floors. There is passenger lift access to all areas of the home. The home has a secure courtyard area at the rear and a designated parking area. The fees for this home vary from £786.38 per week, to £2000.00 per week, depending on the needs of the resident and funding source. If a higher staff ratio is required due to the assessed needs of the resident, fee levels will be above this figure based on the additional staffing costs. Rosalyn House DS0000017690.V336980.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection carried out on 30/05/07 over 6 hours by Pursotamraj Hirekar. The manager and the deputy manager coordinated the inspection through out. The method of inspection included study of care plans, risk assessments, personnel records, staff deployment duty rota, relevant care delivery documents, discussions with manager, deputy manager, staff, conversation with service users’ and partial tour of the building. This inspection report also includes information from the service users’ survey carried out by the commission and pre-inspection information provided by the home. What the service does well: The home had maintained good standards of care delivery and good working relations with the service users’ and their family members, staffs and relevant professionals which had been useful for appropriate care delivery and in meeting the service users’ assessed needs. It was observed during the interaction with the service users’ on this inspection that, the service users’ were neatly dressed and appeared clean. The commission had undertaken service users’ survey prior to this inspection, to get the feedback from the service users’ and their family members about the care and services they get from the home. Quotes from the survey in the words of service users’ and their family member’s: Service user – 1 said that ‘ this is the third nursing home my husband has been in. he has` been there 3 years. I feel very lucky that I have managed to get him into a nursing home where care is of the utmost, even the food. The cook goes out of her way to make sure service users get to eat what they enjoy. The nursing staff & carers, in my opinion, are the best. This also includes all the other staff’. Service user – 2 said that ‘very happy with the home. She (mother) is well cared’. Service user – 3 said that ‘Having been involved with senior establishment before personally (this is the 3rd home my father has been in looked at 7 others) and professionally in my work for over 15 years, I have to say that Rosalyn House is one of the best that I have come across. The welcoming, inclusive approach at all levels, including administration & management, the standard of care, events and effort taken in all areas are excellent and I would have no hesitation in recommending this care facility to anyone’. Rosalyn House DS0000017690.V336980.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. The summary of this inspection report can be made available in other formats on request. Rosalyn House DS0000017690.V336980.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rosalyn House DS0000017690.V336980.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home had made appropriate arrangements for the assessment of needs of the service users’ and the service users’ family members were aware of the care and services they would receive from the home prior to the admission. EVIDENCE: The home had made appropriate arrangements for pre-admission assessments of the potential service users’. The preadmission assessment tool used by the home covered: potential service user’s general profile, disease and diagnosis in the area of heart, musculoskeletal, mental health, sensory, memory, other, falls, accidents, nutritional status, mood & behaviour, emotions, mobility, continence, breathing, oral health, vision, hearing & communication, sleeping patterns, tissue viability, social, medication, and behavioural assessment. On this inspection a sample 5 service users’ pre-admission documents were seen and found that the home had carried out holistic assessment of needs and risk of the service users’ prior to their admission, which informed the preparation of comprehensive care plan. One service user who was admitted on 07/06/05 Rosalyn House DS0000017690.V336980.R01.S.doc Version 5.2 Page 9 with alcohol related dementia was discharged on 30/05/07, as his condition had improved. The inspector had the opportunity to interact with the service user; during the interaction it was observed that the service user was very excited, that he was going to lead a more independent life. Rosalyn House DS0000017690.V336980.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had made appropriate arrangements for the delivery and care of the personal and health care needs of the service users’. EVIDENCE: The home had prepared care plan of the service users’ on the basis of the needs and risk assessments. On a random sample, 5 care plans were seen on this inspection and found that they were comprehensive and were regularly reviewed and updated as and when required. The care plan covered details under various sections, such as: summary sheet, personal details, doctors notes, suggested drugs for use as household remedies, visiting professional notes, visiting professional log, medication profile, holistic risk assessment, waterlow assessment, nutritional risk assessment, manual handling assessment, fracture risk assessment, falls risk assessment, continence assessment, BASOLL – the behavioural assessment scale of later life, specific care plan with problem expected outcome and action plan, monthly care plan reviews, night care plan, medication with benefits side effects and precautions, life profile, property list, daily nursing notes, daily key worker notes, weight Rosalyn House DS0000017690.V336980.R01.S.doc Version 5.2 Page 11 chart, blood glucose monitoring chart, temperature chart, elimination record, personal hygiene chart, food intake chart, fluid intake chart, behavioural observation chart, meals taken schedule, daily care of resident in the bed, wound care assessment, wound care assessment body map, positional changes, incident report, warfarin chart and diabetic chart. The receipt, recording, current storage and handling of medication are appropriately carried out, and the home utilise a sealed dispensing system for the administration of medication. Controlled Drugs are administered by appropriately trained staff and recorded in a Controlled Drugs Register. Mar sheet of all the 5 service users’ was compared with medicine and found both correlated with out any gaps. As a routine, monthly reviews were carried out for each specific area of care of individual service user, and reviews were also held whenever the needs of service user change and then the care plan updated. The summary details of sampled 5-service users’ care plans specific to their needs, risks, and reviews, is as follows: Service user – 1, care plan records pertaining to doctor’s note, and suggested drugs for use as household remedies list agreed with GP, visiting professionals log of chiropodist, dietician, visiting professional notes of dietician, and speech language therapist were maintained. Medication information regarding name of medication, benefits, side effects and precautions that need to be taken by the staff members, nutritional risk assessment detailing build/ weight for height, ability to eat, medical condition, appetite/dietary intake, gut function, medical condition, waterlow assessment, build/weight for height, appetite, visual skin type, continence, mobility, and special risk factors were recorded. The home had used BASOLL – the behavioural assessment scale of later life - tool; that covered aspects of self-care, memory, & orientation, challenging behaviour, mood, sensory abilities, and mobility that was planned to be reviewed in a year’s time. Manual handling assessment, comprehensive full falls assessment and action planning that covered brief risk screen, care plan relating to falls & fractures, and falls prevention environmental risk assessment, falls risk assessment were carried out. Continence care pathway assessment, dietary assessment including weight and appetite, dietary information, eating environment, swallowing and mouth care, weight chart, personal hygiene, end of life care, continence, social isolation, nutrition and choking, night care plan, property list, daily activity plan using – clipper questionnaire, daily nursing notes, daily key worker notes, elimination record – for bowel movement, diarrhoea, and constipation, daily activity notes, weekly blood pressure chart, and daily intake and output fluid chart were maintained. Service user – 2, care plan records pertaining to doctor’s notes, suggested drugs for use as household remedies list agreed with GP, visiting professionals log, visiting professionals note of dietician, chiropodist, and social worker were Rosalyn House DS0000017690.V336980.R01.S.doc Version 5.2 Page 12 maintained. Medication information sheet that had name of medication, benefits, side effects and precautions need to be taken by the staff members. Nutritional risk assessment in relation to build/ weight for height, ability to eat, medical condition, appetite/dietary intake, gut function; waterlow assessment in relation to build/weight for height, appetite, visual skin type, continence, mobility, special risk factors were recorded regularly. Manual handling assessment, comprehensive full falls assessment and action planning tool covered brief risk screen, care plan relating to falls & fractures, and falls prevention environmental risk assessment. Continence, care pathway assessment, BASOLL – the behavioural assessment scale of later life tool; that covered aspects of self-care, memory & orientation, challenging behaviour, mood, sensory abilities, and mobility that was planned to be reviewed in a year’s time. Diet assessment covering weight, appetite, dietary information, eating environment, swallowing, and mouth care; personal hygiene – problem, expected outcome and action planned; continence, mobility issues slips trips and falls, lipoma, aggressive behaviour, social isolation, nutrition and choking, dementia self care deficits action plan with rationale, night care plan, property list, daily activity plan using – clipper questionnaire, daily nursing and key worker notes up to date, elimination record for bowel movement, diarrhoea, and constipation was maintained regularly. Daily activity notes, weekly blood pressure chart, regular intake and output fluid chart maintained. Service user – 3, doctor’s notes, suggested drugs for use as household remedies list agreed with GP, visiting professionals log, visiting professional notes of chiropodist and beautician were maintained. Medication information sheet had information about name of medication; benefits, side effects, and precautions need to be taken by the staff members. Nutritional risk assessment based on build / weight for height, ability to eat, medical condition, appetite/dietary intake, gut function, medical condition; waterlow assessment based on build/weight for height, appetite, visual skin type, continence, mobility, special risk factors were recorded regularly. Manual handling assessment, comprehensive full falls assessment and action planning covered brief risk screen, care plan relating to falls & fractures, and falls prevention environmental risk assessment. BASOLL – the behavioural assessment scale of later life covered aspects of self-care, memory & orientation, challenging behaviour, mood, sensory abilities, and mobility that were schedule for review in a year’s time. Dietary assessment based on weight and appetite, dietary information, eating environment, swallowing, and mouth care; personal hygiene problem expected outcome and action, social isolation, anxiety, and panic attacks, wandering due to mental status, dementia self care deficits action plan with rationale, night care plan, property list, daily activity plan using clipper questionnaire, daily nursing, key worker and activity notes, Elimination record for bowel movement, diarrhoea, and constipation, and weekly blood pressure chart were maintained on a regular basis. Service user –4, pertaining to doctor’s notes, suggested drugs for use as household remedies list agreed with GP were recorded. Medication information Rosalyn House DS0000017690.V336980.R01.S.doc Version 5.2 Page 13 sheet had information that included name of medication; benefits, side effects, and precautions need to be taken by the staff members. Nutritional risk assessment based on build/ weight for height, ability to eat, medical condition, appetite/dietary intake, gut function, medical condition; waterlow assessment was based on build/weight for height, appetite, visual skin type, continence, mobility, and special risk factors were recorded regularly. A comprehensive full falls assessment and action planning tool that covered brief risk screen, care plan relating to falls & fractures, and falls prevention environmental risk assessment; weight chart, personal hygiene covering details of problem, expected outcome and action planned; dementia, depressive disorder, continence, nutritional issues, falls, skin integrity, night care plan, daily activities like passive messaging, and daily nursing notes were regularly maintained. The service user was admitted on the 24/5/7 and the care plan was dated 24/5/7. Nutritional needs assessment and BASOLL assessment work was in progress and was scheduled for completion by end of this week. Service user – 5 care plan pertaining to doctor’s notes, suggested drugs for use as household remedies list agreed with GP. Visiting professionals log and notes that included chiropodist, beautician, social worker, and speech therapist was maintained. Medication information sheet covered information that included name of medication, benefits, side effects and precautions need to be taken by the staff members. Nutritional risk assessment was based on build/ weight for height, ability to eat, and medical condition, appetite/dietary intake, and gut function, medical condition. Waterlow assessment was based on build/weight for height, appetite, visual skin type, continence, mobility, and special risk factors were recorded regularly. A comprehensive full falls assessment and action-planning tool that covered brief risk screen, care plan relating to falls & fractures, falls prevention and environmental risk assessment; continence care pathway assessment, BASOLL – the behavioural assessment scale of later life covered aspects of self-care, memory & orientation, challenging behaviour, mood, sensory abilities, and mobility, which was scheduled for a review in a year’s time. Dietary assessment was based on weight and appetite, dietary information, eating environment, swallowing, and mouth care; weight chart, personal hygiene problem expected outcome and action planned; night care plan, property list, daily activity plan using clipper questionnaire, elimination record for bowel movement, diarrhoea, and constipation were maintained regularly. Weekly blood pressure chart, hypertension problem expected outcome and action planned, mobility issues slips trips and falls, social isolation, individual risk assessment for bed wedges, falling out of bed, dementia, daily activity, daily nursing, and daily key worker notes were regularly maintained. Rosalyn House DS0000017690.V336980.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service users’ dietary needs were assessed and choice of menu and timings were maintained. The service users were engaged in various activities and were encouraged to have appropriate relationships with their family and friends. EVIDENCE: The home had made appropriate arrangements for carrying out the activities in the best interest of the service users’ with the support of dedicated staff for activities. Service users’ interests are recorded in their personal files and the activities are advertised on a notice board in the home. The home had a variety of activities which included; news paper, shop, coffee bar, news and views, armchair aerobics in activity room, reminiscence, music and movement, cooking, music and coordination, bingo, beauty treatments, sensory, sing a long, church service, one to one head massage, arts & crafts, tea dance, story telling, and cinema. The service users’ had the choice of participating. Daily activity notes day wise record was maintained for individual service user for example chiropodist, dietician, beautician, and speech therapist. Service users’ said that the home had an open visiting policy and the service users’ are able to choose whom they see and do not see and are able to receive visitors in private. Service users’ are supported and encouraged to maintain and develop Rosalyn House DS0000017690.V336980.R01.S.doc Version 5.2 Page 15 appropriate control over their own lives. Their financial affairs are managed by them for as long as they are able and wish to do so. Many had personal possessions that they were encouraged to bring with them at the time of their admission to the home. The food menu was individualised to meet the nutritional risk assessment based on build/ weight for height, ability to eat, medical condition, appetite/dietary intake, gut function, medical condition. As well as dietary assessment based on weight and appetite, dietary information, eating environment, swallowing, and mouth care of service users’. Snacks and beverages are available at all times and offered regularly to residents. Special therapeutic, religious, or cultural diets are provided when required or requested. The food schedule was spread over early morning, breakfast, mid morning, lunch, afternoon tea, tea and supper. The kitchen is clean, tidy, and well organised and in place are robust monitoring procedures for hygiene and food preparation standards. Cleaning schedules, temperature checks and storage are carried out in the correct manner. Rosalyn House DS0000017690.V336980.R01.S.doc Version 5.2 Page 16 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. The home had a comprehensive complaints policy and procedures in place and the service users’ were aware of the complaints procedure and were confident to use the same when necessary. EVIDENCE: The home had a comprehensive complaints policy and procedures in place. All the service users’ and visitors had access to the displayed complaints procedure in the communal areas. A structured monthly complaints monitoring and audit form – was used for any complaints. The information provided in the pre-inspection questionnaire indicated that the home had 3 complaints in the last 12 months, of which 1 was substantiated and 1 was partially substantiated. All the complaints received were responded with in 28 days of which 2 POVA referrals were made. The homes complaints procedure gave sufficient guidance to staff on the action that they should take on receiving a complaint. The procedure described the rights of service users’ and that all complaints must be responded to. Service users’ confirmed that they knew how to complain and would not hesitate in doing so. The home also had in place a policy for the protection of vulnerable adults; the local policy in this subject area was also in place. Reporting procedures were clear if an alleged incident of abuse was to be made and staff records showed evidence that they had been trained in this area. Rosalyn House DS0000017690.V336980.R01.S.doc Version 5.2 Page 17 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 maintained clean and tidy without any offensive odours. The service users’ live in comfortable environment and were happy about it. EVIDENCE: Rosalyn House DS0000017690.V336980.R01.S.doc Version 5.2 Page 18 The partial tour of the home undertaken on this inspection found that, the home was maintained clean and tidy without any offensive odours. Individual rooms of residents contained items, which assisted in personalising of the rooms. The décor and furnishings and fittings were of a good standard, domestic, and well maintained. The home is purpose built. The grounds are attractive and well maintained and accessible to residents and their families. Documentary evidence was seen to show that at this time the home met all fire and environmental health requirements. The home had maintenance and decoration planner, which described what has been planned for year one, year two and year three for example, that all service users’ rooms would be re-decorated once every three years in accordance with the three year planner or sooner if required and practicable along with fittings as necessary. The home also had maintained records for refuse collection, domestic waste collection, clinical waste collection, heating system, leionella, pest control, wheel chairs, occupational therapy, alarm, automated gates, TV licence, insurance, car, mplc, kitchen, roof, emergency box, hair saloon, windows, fire doors. Since the previous inspection, the home had redecorated ground floor, had new carpets, new kitchenette, new furniture throughout, had 5 profiling electric beds, 5 electric reclining chairs, 10 airflow mattress, cuddly toy and new garden furniture. The home had take appropriate measure with regard to the recent problems of cylinder leakage on top floor and lift. Rosalyn House DS0000017690.V336980.R01.S.doc Version 5.2 Page 19 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. The home’s policy on staff recruitment was comprehensive. The home had staff with appropriate skill mix, to match with the current and changing needs of the service users’. EVIDENCE: The home had 3 shift staff arrangements; on all the shifts there was a nurse in charge supported by senior carer and care assistants. However, on day shifts there were 2 registered nurses on duty supported by care assistants and activity staff. The home also had dedicated staff for organising activities for the service users’. The home had a good recruitment policy, procedure, and practice was in place. Staff training need assessments were carried out and a training calendar prepared with details of training and time scale for them to take place. Both staff and training records confirmed that staff had access to a wide range of training opportunities. Registered nurses were supported in attending courses to maintain their continuing development including safe administration of medication, and professional practice. Staff when questioned was very clear in their own roles and responsibilities. The staffs’ appeared to have good working relations with the service users’, service users families, and external professionals. Rosalyn House DS0000017690.V336980.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, 33, 35, and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had maintained good standards of care delivery and good working relations with the service users’, their family members, staffs, and relevant professionals. The internal monitoring and quality assurance system and procedure had been useful for appropriate care delivery and in meeting the service users’ assessed needs. EVIDENCE: The home had appointed a new manager, who was in the process of making an application to the commission for registered manager. The home was managed with good professional standards to ensure quality and timely care was provided to the service users’. The manager had the responsibility to carry out monthly audit of the home that covered areas such as home presentation, exterior of the building, enquiry management, medication, medication audit, care documentation, review of pressure ulcers audits, review of accident audits, complaints management, statutory records, human resources, Rosalyn House DS0000017690.V336980.R01.S.doc Version 5.2 Page 21 personnel files, finance, maintenance and domestic services, training records, and social activity programme. A monthly manager’s report is prepared and sent to the managing director covering information about records, food, laundry, training records, personnel records, tissue viability, monthly care plan audit, monthly medication audit, medicine audit by pharmacist, complaints, internal environment, external environment, health & safety and activities. On the basis of the internal audit, action plan was drawn for implementation with details such as the subject, action required and time scale. For example for the month of April 2007 fire drills, staff recruitment & induction, infection control audit, COSHH training, room layout, care notes, meetings and sign post was planned for implementation. It was observed during the interaction with the service users’ on this inspection that, the service users’ were neatly dressed, clean, and have expressed satisfaction with the care and services they received at the home. The management of monies held on behalf of some residents showed that a good system was in place that provided a clear audit trail. The home had carried out a quality survey through a structured questionnaire, which was sent out to the service users’, service users’ relatives, visiting professionals, and staff. The questionnaire covered information about the home’s general environment, staff, laundry, catering, and management. On the basis of the survey information analysis, the home had developed an action plan with clear time scale. This has been a very useful exercise for achieving the overall quality of life goals for service users’. The home also had carried out ISO: 9001 quality management standard and was a recipient of ISO certification. The commission had undertaken service users’ survey prior to this inspection, to get the feedback from the service users’ and their family members about the care and services they get from the home. A pre-inspection questionnaire was also used for the responsible individual/manager to provide information to the commission with regard to various aspects of care provision and delivery they undertake. Quotes from the survey in the words of service users’ and their family member’s: Service user – 1 said that ‘ this is the third nursing home my husband has been in. he has` been there 3 years. I feel very lucky that I have managed to get him into a nursing home where care is of the utmost, even the food. The cook goes out of her way to make sure service users get to eat what they enjoy. The nursing staff & carers, in my opinion, are the best. This also includes all the other staff’. Rosalyn House DS0000017690.V336980.R01.S.doc Version 5.2 Page 22 Service user – 2 said that ‘very happy with the home. She (mother) is well cared’. Service user – 3 said that ‘Having been involved with senior establishment before personally (this is the 3rd home my father has been in looked at 7 others) and professionally in my work for over 15 years, I have to say that Rosalyn House is one of the best that I have come across. The welcoming, inclusive approach at all levels, including administration & management, the standard of care, events and effort taken in all areas are excellent and I would have no hesitation in recommending this care facility to anyone’. Rosalyn House DS0000017690.V336980.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 4 X X 4 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 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 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Rosalyn House DS0000017690.V336980.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. Standard Regulation Requirement Timescale for action 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 OP31 Good Practice Recommendations The home should make an application for registered manager to the commission as soon as possible. Rosalyn House DS0000017690.V336980.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Rosalyn House DS0000017690.V336980.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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