Inspection on 24/08/06 for Rose Cottage Nursing Home

This inspection was carried out on 24th August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Rose Cottage Nursing Home 20/12/05

Rose Cottage Nursing Home 21/09/05

Rose Cottage Nursing Home 16/03/05

Rose Cottage Nursing Home 23/06/04

Rose Cottage Nursing Home 09/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Rose Cottage Nursing Home Station Road Halfway Sheffield South Yorkshire S20 3GS Lead Inspector Stuart Hannay Key Unannounced Inspection 24th August 2006 09:30 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 Rose Cottage Nursing Home DS0000021802.V305824.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. Rose Cottage Nursing Home DS0000021802.V305824.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rose Cottage Nursing Home Address Station Road Halfway Sheffield South Yorkshire S20 3GS 0114 251 0595 0114 251 0595 none 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) RC Developments Limited Mrs Elizabeth Helena Hodson Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Rose Cottage Nursing Home DS0000021802.V305824.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 16 OP Old Age, not falling within any category, N (Nursing Care) beds 13 OP Old Age, not falling within any other category, PC (Personal Care) beds. 20th December 2005 Date of last inspection Brief Description of the Service: Rose Cottage is a care home providing personal and nursing care for twentynine older people, with sixteen nursing beds and thirteen personal care beds. The home is privately owned. Rose Cottage is situated at Halfway in a residential area with good access to public services and amenities (e.g. Supertram, bus services, shops, libraries etc). The accommodation is over three floors accessed by a lift. The home is well decorated, with a majority of single rooms and one double. The home has an appropriate number of lounges and dining rooms. The gardens are landscaped and there is a car park. The home said that the fees vary as they have people from a number of local authorities placed at the home. They said in their pre inspection questionnaire that the Local Authority ‘rate £5 is charged’. Extra charges are made for hairdressing, chiropody and newspapers and magazines. Rose Cottage Nursing Home DS0000021802.V305824.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection lasted for 7 hours. Ten service users were interviewed to obtain their opinions about the home. Interviews were also conducted with the manager, two care staff and two relatives. Information was also provided by a Registered Nurse on duty, who assisted the inspector to do a check of the medication system. The following records were checked: staff training, fire safety, accidents, complaints, service users’ care plans and staff recruitment records. A check was made of the environment. The inspector also observed some of the service users having lunch. What the service does well: What has improved since the last inspection? Rose Cottage Nursing Home DS0000021802.V305824.R01.S.doc Version 5.2 Page 6 The home had made good progress in addressing the previous requirements. Full needs assessments were in place for recently admitted service users and care plans now included all the information required. Improvements had been made to the building and the décor in identified areas. The manager had designed questionnaires for service users and relatives in order to obtain their views about the service and three staff meetings had been held in the eight months previous to the inspection. The manager had taken steps to ensure that confidential information about service users is kept secure but remains easily accessible for staff to consult. Mandatory training had been updated for staff. There was no evidence that toiletries or razors were being used for more than one service user. What they could do better: The main concern raised by service users, particularly those receiving ‘residential care’ was the lack of activities. They felt very well cared for physically but those who did not have relatives to take them said that they rarely got the chance to go out. They said that staff had little time to spend talking with them, except when they were providing care. The record of activities had not been kept up-to-date. There are activities in place for service users but these need to be incorporated into the service users’ day in a more structured way with dedicated hours on the rota. It would appear that the reduction in activities has been exacerbated by the increased dependency of two service users in the ‘residential’ part of the home, who are on permanent bed rest. The home needs to ensure that any temporary increase in dependency levels is met by increased staffing hours. The home had completed most checks on newly recruited staff but were still awaiting confirmation of clear CRB (Criminal Records Bureau) checks for 2 staff members. These had been applied for prior to the staff staring work at the home but had still not been received when they started at the home. The manager said that these people would not been working in an unsupervised way with service users until the checks were returned. The monthly reports by the owner need to include more information about the service users and their views on the service. Additions made to the Medication Administration Record sheets by nurses need to be signed and checked as accurate. There was a problem with the storage of wheelchairs in the lounge when service users were not using them. Rose Cottage Nursing Home DS0000021802.V305824.R01.S.doc Version 5.2 Page 7 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. Rose Cottage Nursing Home DS0000021802.V305824.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 Rose Cottage Nursing Home DS0000021802.V305824.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had received full assessments for service users prior to them coming into the home to ensure that the home could meet their needs. Service users spoken with said that they had been able to visit the home prior to moving in. EVIDENCE: The care plan was checked for a service user who had been recently admitted to the home. There was a copy of the full needs assessment completed by a social worker, which had been faxed to the home prior to the service user being admitted. Care plans for two other service users also included pre admission information. The service users who were able to express themselves clearly said that they had been able to visit the home prior to moving in. Two relatives, speaking on behalf of service users, said that they had been able to look round the home prior to assisting them to make the decision to move. Rose Cottage Nursing Home DS0000021802.V305824.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 at least once during a 12 month period. 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. There were plans in place to identify what help and support service users needed. They appeared well cared for and the plans identified that appropriate action had been taken to ensure these needs were met. Service users felt that the staff treated them in a friendly and dignified way. The medication system was generally well managed but the home needs to ensure that handwritten entries on the medication sheet are signed and witnessed to ensure that the correct medication is being given out to service users. EVIDENCE: Three service users’ plans were checked. These identified the personal, social and healthcare needs of the service users. They included guidance for the care staff on what action to take to meet the identified needs and daily recordings had been made to show what staff had done. The plans had been reviewed on a monthly basis to ensure that the information and guidance was still valid and there were written daily notes. These reviews included, wherever possible and whenever appropriate, the feelings and views of the relatives. Rose Cottage Nursing Home DS0000021802.V305824.R01.S.doc Version 5.2 Page 11 Contacts with opticians, dentists and chiropodists had been recorded and the people interviewed said that they could choose when to have a bath. The care plans contained risk assessments for manual handling, falling and pressure area care. The assessments had been regularly reviewed. Ten service users spoke with the inspector about the home. Most were able to clearly say how they felt about the service and all said that the staff treated them respectfully and in a friendly manner. Two visitors spoken with said that they were always welcomed into the home and generally found it to be friendly. Service users said the staff ensured that their dignity was maintained by the care staff, for example, staff ensured that bathroom, bedroom and toilet doors were closed if they were undertaking personal care. One service user said that she did not want to have personal care from male carers and the home made sure that she had female carers. Staff were observed knocking on service users’ doors and waiting for an answer before walking in. Medication was securely stored in trolleys in locked cupboards. There were systems in place for receiving the medication into the home and medication administration (MAR) sheets for each service user; these recorded the type of medication, the dosage and how it was to be administered. There were reasonable stock levels in the home. Records were kept of each time the medication was given. The system had been checked by the home’s pharmacist on a regular basis. Controlled drugs were safely stored and there were two signatories for the administration of controlled drugs. Printed Medication Administration Record sheets had been provided by the pharmacist. Prescription and administration information for medication received in-between the main deliveries, was sometimes written by hand onto the record sheets by nursing staff. However not all the handwritten entries had been signed by the person making the entry. The entries also need to be checked and countersigned by a witness to reduce the risk of errors. Rose Cottage Nursing Home DS0000021802.V305824.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The majority of service users did not feel that there were enough suitable activities provided at the home to keep them stimulated. Visits from relatives and friends were encouraged, ensuring that service users kept in touch with people who were important to them. Service users said that the food was good and they were offered plenty of choice; special dietary needs and preferences were recorded in the individual care plans to ensure people received appropriate nutrition and foods that they liked. Rose Cottage Nursing Home DS0000021802.V305824.R01.S.doc Version 5.2 Page 13 EVIDENCE: Of ten service users spoken with, seven said that they did not feel that there were enough activities at the home. People who were satisfied with the activities said that their relatives generally provided trips out. There was no dedicated activities co-ordinator and the service was mostly dependent on staff to provide games or events: staff interviewed said that the current dependency levels of the service users meant that they had little time to be involved in non-care tasks, such as talking to service users, going out on trips or providing activities. Staff interviewed felt that the service users did not always want to be involved in activities provided at the home, however two of the service users spoken with said they felt ‘lonely’ at times, despite of the friendliness of the staff. They said that it would be nice to have a chance to ‘have a chat’ with someone everyday. The home needs to tailor the activities to the wishes of the service users. Records of activities had not been kept up-to-date as required in the previous report. All the service users spoken with said that their relatives were welcomed into the home by the staff and were encouraged to stay for as long as they wanted. Two relatives spoken with confirmed that they were always made to feel welcome by the staff, who were very friendly. They said that they were fully involved with decisions about their relatives’ care. Both spoke highly of the dedication and commitment of the manager. Service users interviewed said that the food was generally of a good standard. They said they were offered a choice of meal each day and had a choice of puddings. The cook was aware of special dietary needs and some service users had a meal suitable for people with diabetes. There was information recorded in the service users’ care plans about their likes and dislikes and any special dietary needs. Rose Cottage Nursing Home DS0000021802.V305824.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints guidance was available in appropriate formats to allow service users to raise any concerns. Service users and relatives felt that the atmosphere at the home allowed them to raise issues without fear of intimidation. There was staff training on recognising and reporting abuse. EVIDENCE: The complaints procedures contained all the required information. The home had a record of complaints made by people living at the home. One complaint about damaged clothing had been received since the previous inspection and this had been resolved to the complainant’s satisfaction. Two relatives interviewed said that they would feel happy about raising concerns with the manager or staff and said that the manager was very approachable. Service users spoken with said that they would be able to raise any concerns or complaints with staff if they needed to. There was a system in place to record and report allegations of abuse and staff interviewed had undertaken training in this area as part of their NVQ work. There were regular training sessions for staff in recognising and reporting abuse. No allegations of abuse or complaints have been reported to the Commission For Social Care Inspection from this home in the previous 12 months. Rose Cottage Nursing Home DS0000021802.V305824.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 25 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, tidy and generally well maintained ensuring that the service users live in pleasant and comfortable surroundings. The number of wheelchairs in one part of the home was potentially hazardous and detracted from the otherwise homely atmosphere for service users. EVIDENCE: The communal areas of the home were clean and reasonably decorated. There were no unpleasant odours in the home. Five service users bedrooms were checked and these contained a range of furniture, including chairs for visitors, bedside tables, wardrobes and chests of drawers. Some of the bedrooms had en suite facilities. Service users had been able to personalise their rooms with pictures and ornaments. The bedrooms were decorated to a goods standard. Rose Cottage Nursing Home DS0000021802.V305824.R01.S.doc Version 5.2 Page 16 There were sufficient toilets and baths, which were in good condition and contained a range of hoists and other facilities, including a walk-in Jacuzzi/bath. The flooring in one of the bathrooms was in the process of being replaced due to the fitting of the new bathing facility. There were 5 wheelchairs in the downstairs lounge, which were not being used by service users all the time. These both detracted from the homely atmosphere and could also present a tripping hazard. The manager said that these chairs did belong to people who used the lounge but they need to be stored elsewhere when not in use. The service users who use these wheelchairs did not generally mobilise independently so they would not be restricted by them being stored elsewhere. There was also minor damage to the paintwork in this room. Rose Cottage Nursing Home DS0000021802.V305824.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were sufficient staff deployed to ensure that the service users’ physical and healthcare needs could be met, however the dependency levels meant that staff could not always provide stimulating activities for the service users. Staff had received training in understanding service users’ needs and how to provide a safe service. Checks had been made on staff to reduce the risks to vulnerable people, however not all staff had had a Criminal Records Bureau check prior to starting work. EVIDENCE: Staff interviewed said that there were usually 3 care staff and one qualified nurse on duty for the service users assessed as needing nursing care and 2 care staff for the service users assessed as needing residential care. This was confirmed on the rotas checked. At night there were 2 care staff and 1 qualified nurse for the whole building. Service users and said that they felt that they were well looked after by the staff and that there were always enough people on duty to meet their personal care needs and healthcare needs. Agency staff provided cover when necessary. Rose Cottage Nursing Home DS0000021802.V305824.R01.S.doc Version 5.2 Page 18 Staff interviewed felt that there were usually enough staff on duty and that the workload was manageable. The service users looked well cared for and it was clear that the staff had made the effort to ensure that people were clean and well dressed, that the women wore make-up if they wished and the men had been shaved, or assisted to shave. As noted in the “Daily Life and Social Activities” section of this report, there were no dedicated activities hours on the rota. This, combined with the fact that there were two people receiving residential care who were being cared for in bed, means that the staffing hours need to be reviewed again. The review needs to take into account how many care hours are provided to the 2 service users who are in bed for most of the day. The recruitment records of 2 recently recruited staff were checked. Both staff had completed application forms, provided evidence of identity and had POVA (Protection of Vulnerable Adults) checks. The home had applied for CRB (Criminal Records Bureau) checks for both of the staff members prior to them starting work, however these had not been returned by the time of their start date. The manager said that neither staff member would be working unsupervised until satisfactory CRB (Criminal Records Bureau) checks were returned. Staff interviewed felt that there was a strong emphasis on training at the home. Of the 2 staff spoken with, one had achieved NVQ II and one had completed NVQ III. They had received regular statutory training such as manual handling and fire training. They were able to clearly describe the fire procedures and had taken part in drills. Records were kept of staff training and training needs were discussed in supervision. Staff said that they had had regular supervision with senior staff and that there were regular team meetings. Rose Cottage Nursing Home DS0000021802.V305824.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32, 33 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is a qualified nurse and has a range of experience in care: staff and service users felt that she had their best interests in mind. Staff received regular professional supervision to monitor their practice and to ensure they were able to meet the needs of the service users. The home has started obtaining information to ensure that they are aware of service users’ opinions about the service and what they would like to do. Health and safety and fire records were well-maintained reducing the risk to service users. Rose Cottage Nursing Home DS0000021802.V305824.R01.S.doc Version 5.2 Page 20 EVIDENCE: The registered manager had an appropriate nursing qualification and was sufficiently qualified and experienced to run the home. She stated that there had been a problem in completing her NVQ 4 management qualification but this was now underway again. Staff members said that they had confidence in her abilities and said that she was supportive and helpful towards them. The manager had created and distributed a questionnaire for service users and their relatives, which asks questions about the service and asks for suggestions to improve the service. This process is still in the early stage and the information needs to be analysed and acted upon. The manager was of the opinion that this way of gathering information was more effective than full service users’ meetings. The manager confirmed in the pre inspection questionnaire that the home does not manage any of the service users’ finances. She also stated in the pre inspection questionnaire that the major systems at the home had been serviced by outside companies. These included the gas safety, electrical and fire systems. Certificates were seen on the day for the fire system – this confirmed the manager’s statement in the pre inspection questionnaire. There was regular staff supervision, which looked at working practice, the needs of the service users and staff training. This was also an opportunity for staff to discuss any issues that could be affecting their work. The registered owner had made regular visits to the home and provided a monthly report, however more detail needed to be included in this, especially information obtained from service users or relatives. The staff interviewed said that they had received fire instruction training in the last six months. Checks had been made of the fire alarm system and fire drills had been carried out and recorded. Accidents were appropriately recorded. Records were stored in lockable cupboards in the office; the office door was left unlocked to enable care staff to have access to the records throughout the day. No obvious hazards were noted, except for the wheelchairs in the downstairs lounge. Rose Cottage Nursing Home DS0000021802.V305824.R01.S.doc Version 5.2 Page 21 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 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 3 3 X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X X X X 3 Rose Cottage Nursing Home DS0000021802.V305824.R01.S.doc Version 5.2 Page 22 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 OP9 Regulation 13 (2) Requirement Handwritten entries on the MAR sheets must be signed by the person making the entry and by a witness to check the details are accurate. The home must provide more activities for service users in line with their wishes. If additional staffing hours are needed to facilitate this, they must be provided. The damaged wall area in the downstairs lounge must be repainted or redecorated. The home must find suitable storage for the service users’ wheelchairs when they are not in use. All activities undertaken by residents must be recorded. This requirement had been carried forward from March 2006. Dependency levels of residents living in the residential unit must be reassessed and sufficient staff employed to meet their needs. This requirement had been carried forward from March DS0000021802.V305824.R01.S.doc Timescale for action 30/10/06 2. OP12 12, 18 01/11/06 3. 4. OP19 OP19 23 (2) (b) 23 (2) (l) 01/12/06 31/12/06 5. OP12 16 31/10/06 6. OP27 18 30/10/06 Rose Cottage Nursing Home Version 5.2 Page 23 7. OP29 19 and Schedule 2 9 (2) 24 8. 9. OP31 OP33 10. OP37 26 and 17 2006. Staff must not start working at the home until the home has obtained a Criminal Records Bureau check for them. The registered manager must achieve a NVQ level 4 in management. The results of the service users and relatives questionnaires must be analysed and a plan identified to address any suggestions or issues raised. The Regulation 26 reports must include all of the required information. This requirement had been carried forward from March 2005. 01/11/06 30/03/07 30/11/06 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Rose Cottage Nursing Home DS0000021802.V305824.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Rose Cottage Nursing Home DS0000021802.V305824.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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