Inspection on 29/12/06 for Rose Cottage Nursing Home

This inspection was carried out on 29th December 2006.

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

The inspector 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

Rose Cottage Nursing Home 18/11/08

Rose Cottage Nursing Home 20/01/06

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Rose Cottage Nursing Home 47 High Street Haydon Wick Swindon Wiltshire SN25 1HU Lead Inspector Steve Cousins Unannounced Inspection 09:30 29 December 2006 and 2 January 2007 th nd 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 DS0000063107.V313095.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 DS0000063107.V313095.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rose Cottage Nursing Home Address 47 High Street Haydon Wick Swindon Wiltshire SN25 1HU 01793 706876 01793 706876 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) Hemingway Management Services Ltd Mrs Katharine Elizabeth Ann Pearson Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Rose Cottage Nursing Home DS0000063107.V313095.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th January 2006 Brief Description of the Service: Rose Cottage is a care home for older people that is registered to accommodate up to eighteen people requiring nursing care. It is located in Haydon Wick, Swindon, and situated about a quarter of a mile away from local amenities. The home is a two-storey building and has sixteen single bedrooms and one double. A passenger lift is provided to access rooms on the first floor. Although no bedrooms have en suite facilities, each room does have a wash hand basin. The home has a lounge near the front entrance and another lounge with an integrated dining area at the rear of the building. Patio doors from the rear lounge lead to a level garden area. Hemmingway Management Services Ltd owns the home and the manager is Mrs Kate Pearson. A registered nurse is on duty at all times supported by care assistants. Laundry, housekeeping and catering services are also provided. Rose Cottage Nursing Home DS0000063107.V313095.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 29th December 2006 and the 2nd January 2007 in order to inspect all of the key minimum standards relating to care homes for elderly people. The inspector visited the home between 9.30 a.m. and 4.30 p.m. on both days making a total of fourteen inspection hours. The inspector then met with Mrs Pearson, the registered manager, in order to discuss the outcome of the visit. The findings from this inspection are based on a tour of the premises, speaking to residents, relatives, the manager and staff, and visiting frail residents. A number of records were inspected, including care plans, medication records and staff records. Comment cards were received from four residents’ relatives and the home’s General Practitioner following the inspection and their views are incorporated in this report. The judgements contained in this report have been made from evidence gathered during the inspection and take into account the views and experiences of people using the service. What the service does well: What has improved since the last inspection? What they could do better: Although the care given to residents appeared good, care plans did not always reflect or record the support they require. Freeing up care staff from preparing breakfast may allow them to be more readily available to support residents in the morning and allocating more staff hours, and assessing residents’ social needs could further enhance social activity. The manager needs to ensure that Rose Cottage Nursing Home DS0000063107.V313095.R01.S.doc Version 5.2 Page 6 residents who have dementia do not effect on the quality of life of others in the home. Staff training needs to improve, particularly induction, abuse awareness and mandatory training. The complaints procedure could be made more accessible to residents and relatives and more regular meetings with them may give them more opportunity to have their say about the home. Fire safety checks need to be undertaken at the recommended frequencies. 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 DS0000063107.V313095.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 Rose Cottage Nursing Home DS0000063107.V313095.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply to this home. Prospective residents needs are assessed before moving into the home. The quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: Residents records reviewed by the inspector contained pre admission assessment forms that had been completed by the manager. Some contained other supporting documents such as assessments from care managers and hospital discharge summaries. The information is used to aid completion of individual care plans and information had been supplied by relatives where required. A new resident confirmed that somebody from the home “had come to visit me” prior to moving in. Rose Cottage Nursing Home DS0000063107.V313095.R01.S.doc Version 5.2 Page 9 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 Individual care plans are in place but some improvement is required to ensure they fully reflect residents’ needs. Residents’ health needs are addressed and they are treated with dignity and respect. The medication procedures protect the residents. The quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: The inspector reviewed the care of five residents, two males and three females between the ages of 77 and 88. They had varying physical, social and mental health needs. Some were new to the home and others had been at Rose Cottage for some time. Two were unable to comment on their care due to the level of their dementia. The residents care plans were reviewed. These appeared to be an accurate reflection of some, but not all, assessed needs and were being regularly reviewed. Assessments for tissue viability, manual handling and nutrition were in place. Rose Cottage Nursing Home DS0000063107.V313095.R01.S.doc Version 5.2 Page 10 There were areas where care planning and assessment procedures required improvement to reflect best practice. Plans were not always in place to record and direct care where a resident had been assessed as at risk from developing pressure damage. In one case where a resident was prescribed regular analgesia, a care plan was not in place in order to review efficacy and where it was recorded that a resident had developed a skin break, a wound assessment form had not been used to record subsequent reviews and treatment. A section of the resident assessment form refers to ‘special wishes in case of illness’, it was noted that this had not been completed in two cases. Not all of the residents reviewed had had an assessment of their social needs. The inspector visited the residents and found that interventions were in place, such as pressure relief equipment, continence aids, manual handling equipment and fluid intake charts. The residents’ appeared to be having their personal hygiene needs met and those who were able to communicate indicated satisfaction with the care given. Residents’ comments included “The staff are ok, they are good to me, I get all the help I want” and “The staff are a bit pushed at times, but I am able to get up with help. I don’t have to wait too long”. Those who were assessed as being nutritionally at risk were regularly weighed and records were kept. All residents are registered with the same General Practitioner (GP) who visits the home weekly. Records indicated that residents had access to their GP and that staff took prompt action when there was a health care need. Residents reported being able to see a GP when they needed to. Records also indicated that staff sought the advice of other health care professionals, such as the community mental health team, when required. The four comment cards received from relatives indicated that they were all satisfied with the overall care provided at the home and this was also the opinion of the home’s GP. Two relatives spoken to during the inspection stated that they were “very happy” with the care provided at Rose Cottage and another felt that the staff “do everything they can for her”. The arrangements regarding administration of medication were reviewed and found to be satisfactory. Registered nurses are responsible for the administration of medicines in the home. Medications were safely and securely stored and records of receipts, administration and disposals are maintained. Indirect observation confirmed that medication was being safely administered. Due to their needs, no residents currently self-administer their medication. There was evidence to suggest that residents’ privacy and dignity was respected. Residents’ comments included “They are very nice to me” and “ – they are very kind and help me quite a lot”. Personal care was given behind closed doors and staff knocked on doors before entering a room. Indirect observation indicated that staff spoke in a friendly and respectful way to residents. For those with dementia, efforts were made to ensure that they Rose Cottage Nursing Home DS0000063107.V313095.R01.S.doc Version 5.2 Page 11 were appropriately dressed and their personal hygiene needs were met. Some information recorded on care plans kept in residents rooms related to continence issues. Plans are currently kept in transparent envelopes and are pinned to bedroom walls. It is possible that visitors may see these and the resident’s privacy be compromised. Rose Cottage Nursing Home DS0000063107.V313095.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 Social activity is provided, however more staff hours being available for activities could further enhance this. Residents are able to maintain contact with family and friends and as far as possible, have some choice and control over their lives. The meals provided appear to be nutritious but further thought needs to be given regarding individual choice. The quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: Records indicated that residents are offered a varied mixture of external and in house activity. A church service is held once a month and a priest also visits the home. An activity coordinator works 25 hours per week from Monday to Friday, however this is during school term times only and means that there are long periods without an activity person. Residents who were able to voice an opinion indicated that they were happy with life in the home, however one felt they “would like a bit more to do”. The inspector observed that that the behaviour of some residents who had dementia could have an adverse effect on the quality of life of others due to noise and behavioural issues and this view was also reflected in the comments of some staff members. This was discussed with the manager who said that Rose Cottage Nursing Home DS0000063107.V313095.R01.S.doc Version 5.2 Page 13 arrangements had been made to move one resident with dementia to another home. It is recommended that a review of the other residents with dementia be held to ensure that the home is able to meet their needs and that their behaviour does not impact on the quality of life of other residents. The four relatives comment cards received all indicated that relatives were able to visit in private and were welcomed at any time. They also felt that they were kept informed of important matters concerning the resident. One comment was “Staff are very welcoming”. Residents confirmed that they received visitors and visitors were in the home over the two days of the inspection. Residents are able to receive visitors in their own room or one of the communal areas. It appeared that, as far as possible, residents were being supported to exercise choice and control. One said that they were “happy to stay in my room” and another stated that the staff “help get me up when I want”. Residents’ were seen using the homes sitting areas and some chose to eat in their rooms. Some had brought in personal items and furniture for their rooms and those who wish to can attend religious services held in the home. One resident continues to attend a local luncheon club and is supported in doing so. Comments about the meals available were varied. One resident remarked that the food was “good” and they “enjoy it”, but another felt that there was no choice of meal stating, “It just arrives and I don’t like some of it”. The manager stated that the menu’s had recently been reviewed and that residents are offered a choice if they do not like the ‘dish of the day’. The residents appeared to enjoy the lunchtime meals served over the two days of the inspection. The menu appeared to be a nutritious and varied however thought should also be given to providing a regular choice of food to those residents of different cultures. Some effort had been made but this had been sporadic. Rose Cottage Nursing Home DS0000063107.V313095.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 A complaint procedure is in place and the one received had been dealt with appropriately. The complaint procedure could be more accessible to residents and relatives. As far as possible, residents are protected from abuse, but further staff training in abuse awareness may further enhance protection. The quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: A copy of the complaint procedure is on display on a notice board and is also contained in the service users guide. Four comment cards received from relatives indicated that they were all aware of the complaint procedure and that none have had to make a complaint. Some residents were asked what they would do if they needed to complain, one replied “I would talk to the matron or one of the nurses’” and another “I just tell the staff”. Comments received in the annual questionnaire sent to residents and relatives indicated that not all were aware of the procedure and it is recommended that this is made more accessible. One complaint had been recorded in the complaint file since the previous inspection. The complaint appeared to be handled promptly by the manager. Copies of the local procedures for reporting allegations of abuse were available and staff spoken to during the inspection were aware of how to report alleged abuse. The manager demonstrated a good awareness of adult protection procedures and has experience of adult protection reviews and investigations. Rose Cottage Nursing Home DS0000063107.V313095.R01.S.doc Version 5.2 Page 15 Review of training records indicated that some, but not all staff had received training about abuse awareness and that others required training to be updated. A review of staff employment documentation indicated that procedures for the protection of residents had been carried out, including Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks. Rose Cottage Nursing Home DS0000063107.V313095.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22 and 26 The home is clean and well maintained and there have been improvements in the decoration and laundry facilities. Communal areas are pleasant and accessible. There are enough bathrooms and toilets for residents and specialist equipment is available to meet their needs. The quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: Rose Cottage is a small home with all the communal facilities on the ground floor that consist of two sitting rooms and a dining area. There is a lift and two staircases to enable access to the first floor. There is a garden area to the rear of the home that is accessible through the rear lounge. The front lounge has been decorated and some new dining room furniture purchased. There has been an overall improvement in the decoration of the home, including the corridors, which has enhanced the environment for the residents. Bedrooms 6 and 12 could benefit from redecoration. Rose Cottage Nursing Home DS0000063107.V313095.R01.S.doc Version 5.2 Page 17 A maintenance person is employed and the pre inspection questionnaire indicated that essential equipment and services are regularly maintained. There are five toilets and three bathrooms available. Although there are no ensuite facilities, all of the bedrooms have a wash hand basin. The bathroom on the first floor would benefit from refurbishment in order to enhance the facility for the residents. To help meet residents needs, the home has equipment such as portable hoists, seat raisers, handrails, wheelchairs, bed safety rails and pressure relief equipment and a call bell system is installed and working. The inspector toured the home, which was found to be clean and free from unpleasant odour. The laundry was clean and tidy and new equipment was in place and there were appropriate infection control measures to deal with soiled linen. The kitchen was clean and tidy and the manager stated that there were plans to refurbish the kitchen over the coming year. Rose Cottage Nursing Home DS0000063107.V313095.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 There appears to generally be enough staff on duty, however care staff preparing breakfast seems to impact on the ability to provide support to residents in the morning. Residents are protected by recruitment procedures. Staff training needs to improve, particularly induction and mandatory training. The quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: Staffing levels on both days of this unannounced inspection appeared to be enough to meet residents’ needs and call bells were answered without any undue delays. An extra member of the care staff was on duty to look after a resident with complex needs. Duty rotas indicated compliance with the homes minimum staffing notice. Residents spoken to who were able to offer an opinion felt staffing levels were “OK” and “Seem alright” although one stated: “The staff are a bit pushed at times (mornings)”. Three out of four people who sent in comment cards answered ‘yes’ to the question ‘In your opinion are there always sufficient numbers of staff on duty’, whilst one answered ‘no’. Two of the four care staff members spoken to felt that there were not always enough staff on duty and that the breakfast period was particularly busy due to the care staff having to prepare breakfast, which they felt compromised their ability to deliver prompt assistance to residents in the morning. It was also felt that sickness levels had recently had an impact and more staff needed to be recruited. The levels of laundry and domestic staff appeared to be satisfactory. Rose Cottage Nursing Home DS0000063107.V313095.R01.S.doc Version 5.2 Page 19 The recruitment records of four recently recruited staff members were reviewed. Criminal Record Bureau (CRB) checks had been obtained or applied for and references and Protection of Vulnerable Adults (POVA) checks had been obtained prior to the person starting employment in all cases. Other documentation required was in place. The records of staff induction indicated that two staff had undertaken training in a wide range of subjects in a short space of time. Induction training that it is recommended be completed over a six week period had been recorded as completed within three days of commencing employment, which brings into question the content and validity of the training received. The need for induction training to meet the standards introduced by the Skills For Care organisation was discussed with the manager. National Vocational Qualification (NVQ) training is available and the manager reported that there were currently seven out of fourteen care assistants with an NVQ level 2 (Care) with a further five undertaking NVQ level 3 and three doing NVQ level 3. Training records also indicated that not all staff had received regular updates in mandatory training subjects such as food hygiene, infection control and health and safety. Rose Cottage Nursing Home DS0000063107.V313095.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. The registered manager is fit to run the home and does so effectively and in the best interests of its residents. Quality assurance systems are in place, although these could be further enhanced by the introduction of more regular residents and relatives meetings. Fire safety checks need to be more robust to fully protect the health, safety and welfare of residents and staff. The quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: Mrs Pearson is a nurse who has obtained the Registered Managers Award. She is an NVQ assessor and has a degree in social sciences and a City and Guilds 7307 teaching qualification. She has been in post since November 2001. There were positive comments about the manager from residents and relatives. Rose Cottage Nursing Home DS0000063107.V313095.R01.S.doc Version 5.2 Page 21 Quality assurance measures include an annual questionnaire, which is sent to residents and relatives, the results of which were displayed on a notice board. Residents meetings are held, however the last recorded one was in May 2006. Clinical audits have taken place to look at nutrition, medication and tissue viability. Other audits undertaken have included quality improvement, and organisational fitness, which are a part of a quality assurance management plan. A representative of Hemmingway Management Services Ltd undertakes a monthly visit to the home and a report is produced. The inspector reviewed the arrangements for handling service users money. The manager reported that no member of staff was an appointee for resident’s finances, benefits or pensions. Money and valuables were kept securely in a safe however transactions were not clearly audited and in one case the home had possession of a bankcard and cheque book on behalf of a resident. Since this inspection the manager has reported that an audit system has been introduced in order to further safeguard residents money and property and a social services appointee has been requested for the resident in question. Environmental health and safety risks assessments are in place and the manager reviews residents’ rooms monthly. Accidents are recorded appropriately and reviewed monthly. Hot water temperatures are controlled and checked weekly. Radiators are covered. Manual handling aids are available. A review of the homes fire log indicated that there were times when the fire alarm test had not been carried out weekly and visual checks of fire equipment and escape routes had not been checked monthly. It was also noted that some fire doors fitted to bedrooms were not fitted with self-closing mechanisms. An environmental health officer undertook a food hygiene inspection in October 2006. No major problems were identified. Rose Cottage Nursing Home DS0000063107.V313095.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Rose Cottage Nursing Home DS0000063107.V313095.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15 (1) Timescale for action The registered person shall, after 01/03/07 consultation with the service user, or a representative, prepare a written plan as to how the service users needs in respect of their health and welfare are to be met. In relation to: • Pressure area care • Pain management • Wound care • Wishes relating to illness The registered person shall 01/03/07 ensure that at all times, suitably qualified, competent and experienced persons are working in such numbers as are appropriate for the health and welfare of the service users. In relation to: • The number of care staff over the breakfast period 01/03/07 The registered person shall ensure that persons employed to work at the care home receive training appropriate to the work they are to perform. In relation to: • Induction training to the standards specified in the DS0000063107.V313095.R01.S.doc Version 5.2 Page 24 Requirement 2. OP27 18 (1,a) 3. OP30 18(1,c,i) Rose Cottage Nursing Home 4 OP38 23 (4,c,v) Skills for Care, Common Induction Standards (2005). • Mandatory training. The registered person shall after consultation with the fire authority, make adequate arrangements for reviewing fire precautions, and testing fire equipment, at suitable intervals. In relation to: • Automatic fire door closures on the first floor. • Weekly fire alarm testing. • Monthly visual checks of fire equipment. • Monthly checks of fire escape routes. 01/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 4 Refer to Standard OP8 OP10 OP12 OP12 Good Practice Recommendations It is recommended that clearer information be recorded with regard to ‘end of life’ decisions. Recommendation from previous inspection held 20/01/06 It is recommended that thought be given to how care plans are kept in bedrooms, in order to maintain residents privacy. It is recommended that thought be given to increasing the staff hours available to support social activities. It is recommended that a review of residents with dementia be held to ensure that the home is able to meet their needs and that their behaviour does not impact on the quality of life of other residents. It is recommended that the menu be further reviewed to ensure individual and cultural dietary needs are catered for. It is recommended that further training in abuse awareness be provided for staff. It is recommended that rooms 6 and 12 be redecorated. DS0000063107.V313095.R01.S.doc Version 5.2 Page 25 5 6 7 OP15 OP18 OP19 Rose Cottage Nursing Home 8 9 OP21 OP33 It is recommended that the first floor bathroom be refurbished. It is recommended that residents and relatives meetings be held more frequently Rose Cottage Nursing Home DS0000063107.V313095.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 DS0000063107.V313095.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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