Inspection on 11/01/06 for Rose Court

This inspection was carried out on 11th January 2006.

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

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

Other inspections for this house

Rose Court 24/01/08

Rose Court 17/10/06

Rose Court 26/09/05

Rose Court 02/02/05

Rose Court 06/07/04

Rose Court 10/03/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Rose Court Rose Court 253 Lower Road Rotherhithe London SE8 5DN Lead Inspector Lisa Wilde Unannounced Inspection 10:00 11 January 2006 th 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 Court DS0000029619.V271675.R01.S.doc Version 5.0 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 Court DS0000029619.V271675.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Rose Court Address Rose Court 253 Lower Road Rotherhithe London SE8 5DN 0207 394 2190 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) Anchor Trust Ms Lucy Ross Care Home 64 Category(ies) of Dementia (0), Mental disorder, excluding registration, with number learning disability or dementia (0), Old age, not of places falling within any other category (0) Rose Court DS0000029619.V271675.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th September 2005 Brief Description of the Service: Rose Court is a residential care home registered for 64 older people. It is owned and run by Anchor Trust. The home is purpose built and was opened in March 2002 to replace two ex-local authority homes. Since December 2005 the home has taken over the borough’s respite care for service users with dementia. The accommodation is on four floors, each with a group living unit made up of 16 bedrooms all with en-suite facilities, a kitchen, a dining area and lounge. The kitchens on each floor are no longer used to prepare food and this is now done in a large central kitchen on the ground floor. There is a garden to the rear with garden furniture. Rose Court is situated on a bus route in Rotherhithe close to Surrey Quays shopping centre and a range of shopping and leisure facilities. Rose Court DS0000029619.V271675.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in January 2006. The inspector spoke with service users and their relatives, staff and the Registered Manager. All service users and relatives who spoke with the inspector said that they were very happy with the home. They said that staff are very good and they know what to do and who to talk to if they have an issue that they need help with. They said the building is well decorated and they like their rooms. Generally they had no worries at all. The home’s latest survey of service users and their families showed that 87 of people who returned the forms would recommend the home to others. The inspector found again a committed and caring staff team providing a generally high level of care to the service users but was particularly concerned on this inspection about finding recent medication errors occurring while the Registered Manager was away over the Christmas and New Year period, which had resulted in significant risk to some service users. Action was taken immediately by the Registered Manager to address the issues and take further action to make sure that it does not happen again. The inspector was satisfied that the Registered Manager had the ability to be able to manage this issue and keep the inspector informed as a matter of urgency but will be referring this case to the Commission’s Pharmacist Inspectors to see if they wish to have further input. What the service does well: The standards assessed at this inspection showed that the home makes sure that: • service users or their representatives sign a detailed terms and conditions on admission to the home. • prospective service users have their needs assessed before they move to the home. • prospective service users and their relatives can come and look around the home and meet staff before they decide to move there. • service users’ health and personal care needs are fully addressed in their Individual Lifestyle Agreements. • service users are treated with respect and their privacy is protected at all times. • as service users become ill they are supported to remain at the home as long as possible and die there if they choose. • service users are supported to access the local community and maintain contact with family and friends as they choose. Rose Court DS0000029619.V271675.R01.S.doc Version 5.0 Page 6 • • • • • • • service users are supported to retain control over their lives as long as possible. menus are varied and based on what service users have asked for. complaints are taken seriously, investigated fully and action is taken to address any issues. service users are protected from abuse. the home is clean, safe, well maintained and comfortable throughout. the manager is experienced, qualified and skilled and has the necessary awareness that ensures she is fit to be in charge and the home is well run. the home regularly gathers the views of service users and their relatives and takes action to improve things. 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. Rose Court DS0000029619.V271675.R01.S.doc Version 5.0 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 Court DS0000029619.V271675.R01.S.doc Version 5.0 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): 2, 3, 5 & 6 Service users or their representatives sign a detailed terms and conditions on admission to the home which means they have information about their legal rights, what they can expect from the home and what is expected of them. Long-term service users have their needs assessed by senior staff before they move to the home and know that staff have decided that the home can meet their needs before they move there. Service users who need respite care have their information sent to the home and their initial assessment takes place on the first day of their stay. Prospective service users and their relatives can come and look around the home and meet staff before they decide to move there. Standard 6 is not applicable as this home does not provide intermediate care. EVIDENCE: Service users have a signed and dated contract on file that outlines the terms and conditions of their stay at the home. Rose Court DS0000029619.V271675.R01.S.doc Version 5.0 Page 9 The Registered Manager described the process for assessing a potential service user. Senior staff will visit the service user and decide with the team if they can offer a service to that person. If someone is attending the home for respite care the home will receive the community care assessment and associated documents and decide if they can offer a service based on those documents. The assessment of specific need will be done on the first day of their attendance at the home and the initial care plan will be drawn up by the end of the day. Visitors to the home confirmed that they were able to visit the home with their relative as much as they wanted to have a look around and meet staff before they decided to move there. Standard 6 is not applicable as this home does not provide intermediate care. Rose Court DS0000029619.V271675.R01.S.doc Version 5.0 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, 9, 10 & 11 Service users’ health and personal care needs are fully addressed in their Lifestyle Agreements and care plans and action is in place to describe how staff will meet needs and manage or minimise risks. Service users’ social care needs are not fully addressed in all of these plans. These plans are not always usefully reviewed with the required frequency, which means that changing needs are not always addressed quickly. The home’s medication recording, administration and stock checking procedures are not effective which means that the home is not keeping an accurate record of all medication it holds on behalf of the service user and cannot be sure that medication is being given to service users as it is supposed to be. Service users are treated with respect and their privacy is protected at all times. As service users become ill they are supported to remain at the home as long as possible and die there if they choose. EVIDENCE: Rose Court DS0000029619.V271675.R01.S.doc Version 5.0 Page 11 There was a previous requirement that the Registered Manager must ensure that all service users’ Lifestyle Agreements and care plans are dated and signed by the service user or their representative (or include a note stating if there is no one available to sign). Of the files sampled during this inspection there was evidence that this area had improved but there were still some Individual Life Agreements and Care plans that had not been signed and dated. The Registered Manager said that they have worked on some service user’s files but have not had time to complete them all. The files generally showed this to be the case. The requirement is repeated until all files are consistent in this area. (See Requirement 1) Most of the Individual Lifestyle Agreements and care plans are reviewed but not all are reviewed annually and monthly as required. When they are reviewed monthly often there are no comments about any evaluation that has taken place or if there is they state ‘no change’ which could indicate that the review of the plan has not been meaningful. (See Requirement 2) There were previous requirements that the Registered Manager must ensure that a full and meaningful audit is undertaken of all individual service users’ preferences, needs and aims with regard to any social, religious and cultural activities and that the Registered Manager must ensure that all service users have in place care plans or activity programmes addressing social or leisure interests and activities (based on the audit). Again the Registered Manager said that this work had been started and evidence from the files showed that this area had improved but some files did not have any additional work in this area in them. These requirements are repeated until all files are work is consistent in this area. (See Requirements 3 & 4) There was a previous requirement that the Registered Manager must ensure that if a service user’s Lifestyle Agreement is not due to be completed until after the initial six-week trial stay, that there are in place initial care plans that describe the care to be provided in the interim. Any service user referred for respite must also have in place these care plans even if their initial stay is shorter than six weeks. There was evidence from the files that initial care plans are drawn up as soon as s service user arrives at the service pending the more detailed plans that are drawn up after six weeks. The inspector went through the medication stocks and records held on two of the four floors. There were previous requirements that the Registered Manager must ensure that all medication is signed for at the point of administration and that the staff member’s signature is clear and the same as the sample signature held on file and that the Registered Manager must ensure that the medication stock checking system is effective and accurate records are maintained at all times, of the medication held in the home. The inspector found that neither of these requirements was met as the same issues were present again. In addition the inspector found that lists of staff authorised to administer medication weren’t held in the files, amounts of medication brought Rose Court DS0000029619.V271675.R01.S.doc Version 5.0 Page 12 into the home were not recorded on the charts along with the day that the medication started and the keys on the charts weren’t being used consistently. One medication was a variable dose but it wasn‘t recorded don the chart whether one or two tablets were being given. Some photos were not on file for service users at the home on respite. On one floor the stock checks were significantly in error and it appeared that in many cases staff had been administering one tablet to service users when the dosage was two tablets and in one case they had been administering one tablet when the dosage was a half as the label on the box did not match the chart. If this was the case this has led to significant under and over dosing of several service users over the Christmas period. An immediate requirement was left in this area for the Registered Manager to address on the day of the inspection. (See Requirements 5-13) Systems in the home are geared towards protecting and respecting service users’ privacy and dignity. There are no shared rooms and all rooms are ensuite. Service users and their relatives talked about how staff are good and take care of them properly. Staff were seen to knock on service users doors before they entered on the day of the inspection. Staff addressed service users by their preferred names and talked to them respectfully. There was a previous recommendation that the Registered Manager should ensure that a note is made on service users’ file if they or their family do not wish to discuss issues of death or dieing. The Registered Manager said that this work has started to be addressed but as yet not all files hold the statement. The home evidenced throughout the inspection that the area of death and dieing is one that they pay a lot of attention to and visitors to the home sated that staff support them to allow their relative to die at the home and not in hospital if at all possible. Staff have attended End Of Life training recently and have links with the local Palliative Care Nurse. The Registered Manager talked about detailed plans they have to make the process of dieing more individual and meaningful at the home. The previous recommendation is repeated as not all files include the statements but this issue does not detract from the sensitive work that is done in this area. Rose Court DS0000029619.V271675.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 The home does not currently fully record service users’ social and cultural needs in their care plans so it was not possible to full assess if those needs are being met or goals being worked towards. Service users are supported to access the local community and maintain contact with family and friends as they choose. Service users are supported to retain control over their lives in areas such as finance as long as possible then independent advocates are brought in to support them if they have no family to assist them. Dining rooms are pleasant and there is one on each floor or service users can eat in their rooms if they choose. The menus are varied and based on what service users have asked for. Service users are regularly consulted about their views on the food they are given and action is taken to try to improve things. EVIDENCE: There is an ongoing requirement made under Standard 7 that requires more input around social activities. Comments from the home’s annual survey indicate that service users and their families would appreciate more activities in and outside of the home. Rose Court DS0000029619.V271675.R01.S.doc Version 5.0 Page 14 Visitors said that they are allowed to come and go as they wish and are always made welcome. They can use the kitchenettes on each floor to make drinks and small snacks as they choose. If service users are able to walk safely and independently they can go out into the local community as they choose. If they need staff support they can do this to an extent but on occasion local services such as Southwark Homecare may have to be used to provide them with additional community support where appropriate. Service users retain control of their finances as far as possible and when not possible relatives are used to manage their money. If there are no relatives then social service are used. The home is not appointee for any service user. The financial records of service users’ money are computerised receipts are given for all money issued and for all money received on behalf of service users from family or social services. The checking systems of these accounts are robust and open. There were previous requirements that the Registered Manager must ensure that handover time is used more usefully to give a full handover of issues and also include care or action planning issues for the forthcoming shifts and that the Registered Manager must ensure that service users confidentiality is respected by the staff handover being conducted in private with no service users present. The Registered Manager has spoken to staff about this and said that handovers are becoming more useful. She is drawing up guidelines for staff which will be sent to the Commission. The handover on the day of the inspection was short because there was staff training taking place in the afternoon. The menus showed that a variety of different food options are available to service users. They are consulted monthly about how they feel about the food. Some service users told the inspector that the food was good and some said it was ok. The latest food surveys on file seen by the inspector were all positive. Rose Court DS0000029619.V271675.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Service users and their families are given information on how to complain to the home and to independent bodies and their complaints are taken seriously and investigated fully. Action is taken to address any issues. Informal concerns are not recorded which means that day-to-day concerns and issues cannot be monitored effectively. Service users are protected from abuse by the home having policies and procedures in place, by staff being trained in them and by staff understanding what they have to do if they suspect any form of abuse. EVIDENCE: There is a complaints procedure that is displayed prominently in the entrance hall with leaflets for service user to complete if they wish. There is an additional system called Careline where service users can talk anonymously to a number within the Anchor Trust. The borough’s advocates are available for people who do not have family. The home keeps records of formal complaints that are made and records action taken and whether the complainant was satisfied with the outcome. Relatives told the inspector that they know who to complain to tin the home and when they do they are listened to and staff try to make sure that some thing is done about it. The home does not however keep records of the less formal complaints and concerns that may be made to staff by service users or their relatives on a day-to-day basis. (See Requirement 14) There was a previous requirement that the Registered Manager must ensure that the Complaints Procedure and leaflets include the contact details of the local Commission office along with a brief explanation of who the Commission is and why service users may want to complain to them. The home’s leaflets Rose Court DS0000029619.V271675.R01.S.doc Version 5.0 Page 16 and the care plans on file now give the correct details but the organisation’s policy on the wall has not been changed. The requirement is met as far as the Registered Manager is concerned but another is made with regard to the organisational policy. (See Requirement 15) There has been adult abuse training given to staff in December 2005. Staff described what they would do if they suspected abuse was taking place. The home has in place organisational policies around protection of vulnerable adults and associated policies such as managing of challenging behaviour, disciplinary and grievance and ‘whistle blowing’. Rose Court DS0000029619.V271675.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26 This home is safe, well maintained and comfortable. There are enough bathrooms that are decorated in a non-institutional manner. Bedrooms are large enough and all have en-suite bathrooms. Service users have personalised their rooms to their own tastes and can bring in some of their own furniture if they choose. The communal areas are bright and airy and the whole home is clean and free from unpleasant smells. EVIDENCE: The evidence found at the last inspection was found to be the same at this inspection. Rose Court is a purpose built building and was opened in 2002. The service user’s accommodation is on four floors and there are two shaft lifts of differing sizes to provide access to all levels. There is a reception and large sitting room on the ground floor. There are bedrooms, a lounge/dining area and a kitchen Rose Court DS0000029619.V271675.R01.S.doc Version 5.0 Page 18 for the group of people living on each of the floors. There is a large, central kitchen on the ground floor where all meals are prepared. There are kitchenettes on each floor, which have been recently refurbished. There is an accessible garden with garden tables and chairs. At the side of the building there was a car park for staff and visitors. There is a communal lounge the ground floor, which looks out onto the garden. Each floor is colour co-ordinated and the units on each floor had been given names that reflect in some way the homes from which service users had moved when Rose Court was built. The lounges and dining areas are pleasant, light and airy. There is a range of different types of seating available in the lounges. The dining areas provided tables and chairs for individuals to eat their meals in groups of four. The furnishings are of good quality and overall the communal areas are pleasant places to sit. Each service user’s room had an en suite toilet, level access shower and wash hand basin. In addition there was a bathroom with a toilet and two other toilets on each floor close to the lounge area. Each of the bathrooms had assisted baths with lifts for easy access. All service users’ rooms are wheelchair accessible. The bedroom doors have magnetic closures and close when the fire alarm is activated. There are handrails on all corridors. Toilets are fitted with grab rails. In service users’ rooms the showers are level access with plastic seats fitted. A call bell system is provided. All the bedrooms meet the minimum space requirements and had at least 12 sq m, which also ensured that there was adequate space for those using wheelchairs. There are no shared rooms. The inspector looked at a range of bedrooms. Each was furnished and carpeted to a good standard. Service users have personalised them and they contain photographs, pictures and ornaments. The standard items of furniture are provided. The home met health and safety requirements. The windows have and the radiators and pipe work are guarded and there are temperature control valves to allow service users to control the heat in their rooms. The water temperatures are appropriately controlled to prevent risks from legionella and regular checks are kept on water temperatures. On the day of this inspection the standard of cleanliness within the home was high. The inspector toured the building and it was clean and free from offensive odours. The laundry facilities are satisfactory. Rose Court DS0000029619.V271675.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 Senior staffing levels are due to increase in April 2006 which, along with other evidence from this inspection, would indicate that until then staffing levels may not be quite sufficient. This issue will be further assessed at the next inspection after the senior input has increased. EVIDENCE: Staffing levels are due to increase as of April 2006 with there then being one senior member of staff one each shift on each floor. Staff all felt that this would significantly improve practice as they would be able to focus attention on service user issues more consistently and currently this is not always possible. Evidence from this inspection could indicate that more senior input is necessary to make sure that areas such as care plan review and medication are monitored effectively. A review of this new staffing level would be necessary to establish if the new staffing levels are sufficient to meet the needs of the new levels of service user needs. (See Requirement 16) There was a previous requirement that the Registered Individuals must ensure that the POVAFirst check is only used for new staff in emergency situations. In normal circumstances staff must not commence employment at the home until a current enhanced Criminal Records Bureau check has been received by the organisation. The Registered Manager assured the inspector that practice has changed and this will not occur in the recruitment drive occurring currently. Rose Court DS0000029619.V271675.R01.S.doc Version 5.0 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, 32 & 33 The Registered Manager is experienced, qualified and skilled and has the necessary awareness that ensures she is fit to be in charge and the home is well run. She is clear about the expectations of staff and ethos and approach the staff at the home should take. Staff say that she is very good and supportive and service users survey results rate her as excellent. The home has systems in place to regularly gather the views of service users and their relatives. Action is taken in response to these views to make sure that the home improves in ways that will benefit service users. EVIDENCE: The Registered Manager has ten years experience as a manager of residential care homes for older people and a further two years as a deputy manager. She is a trained nurse and also has a Diploma in Health Care. She has almost completed the Registered Manager’s Award. On the home’s annual survey the comments received back about the Registered Manager rated her as excellent. Rose Court DS0000029619.V271675.R01.S.doc Version 5.0 Page 21 Staff stated that the Registered Manager is good, supportive and clear about what is expected of them at the home. On the day of the inspection she talked about strategies she has in place and that she is hoping to develop that would improve practice and the standards of service provided to service users. The organisation send out annual surveys to service users and relatives and the home has their own survey as well. There is a suggestion box in the entrance to the home to further gather views of the home. There is an audit of the building and practical issues that is conducted by staff and the Registered Manager said that next time they will be asking a relative to do it with them as well. The organisation completes the monthly monitoring required by the National Minimum Standards and sends copies of these reports to the Commission. The results of the annual survey clearly indicate the areas for improvement required in the home and the Registered Manager is planning to write an action plan in response to the survey (the results had only just been published and there hasn’t yet been time to publish the action plan). This action plan must be sent to the Commission. Relatives spoken to on the day of the inspection said that they were not aware of the Commission’s reports. These reports are in a folder in the entrance hall to the home but more work is needed to make service users and relatives aware of them. (See Requirement 17) Rose Court DS0000029619.V271675.R01.S.doc Version 5.0 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 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X X X X Rose Court DS0000029619.V271675.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (1) Requirement Timescale for action 31/03/06 2. OP7 15 3. OP7 16(2)(m) & (n) 4. OP7OP12 16(2)(m) & (n) The Registered Manager must ensure that all service users’ Lifestyle Agreements and care plans are dated and signed by the service user or their representative (or include a note stating if there is no one available to sign). Previous requirement: Unmet timescale 14/12/05 The Registered Manager must 31/03/06 ensure that all Individual Lifestyle Agreements are reviewed annually and changed as necessary and all individual care plans are reviewed monthly. Reviews must be meaningful and comments of evaluations recorded. The Registered Manager must 31/03/06 ensure that all service users have in place care plans or activity programmes addressing social or leisure interests and activities. Previous requirement: Unmet timescale 31/12/05 The Registered Manager must 31/03/06 ensure that a full and meaningful audit is undertaken of all DS0000029619.V271675.R01.S.doc Version 5.0 Rose Court Page 24 5. OP9 13 (2) 6. OP9 13 (2) 7. OP9 13 (2) 8. OP9 13 (2) 9. OP9 13 (2) 10. OP9 13 (2) 11. OP9 13 (2) individual service users’ preferences, needs and aims with regard to any social, religious and cultural activities. (This audit must form the basis of the individual care plans identified in Requirement 2 of this report) Previous requirement: Unmet timescale 30/11/05 The Registered Manager must ensure that all medication is signed for at the point of administration and that the staff member’s signature is clear and the same as the sample signature held on file. Previous requirement: Unmet timescale 22/10/05 The Registered Manager must ensure that the medication stock checking system is effective and accurate records are maintained at all times, of the medication held in the home. Previous requirement: Unmet timescale 22/10/05 The Registered Manager must ensure that lists of staff assessed as competent and authorised to administer medication are held in the medication files. The Registered Manager must ensure that photos of service users are held on the medication files. The Registered Manager must ensure that records of medication brought into the home and the date it starts are recorded on the medication administration charts. The Registered Manager must ensure that the keys on the medication administration charts are used effectively and consistently. The Registered Manager must DS0000029619.V271675.R01.S.doc 18/01/06 18/01/06 18/01/06 18/01/06 18/01/06 18/01/06 18/01/06 Page 25 Rose Court Version 5.0 12. OP9 13 (2) 13. OP9 13 (2) 14. OP16 22 ensure that variable doses of medications are clearly recorded on the medication administration charts so that it is clear how many tablets were given in each dose. The Registered Manager must 18/01/06 ensure that when a medication dose is variable e.g. give one or two tablets, that the G.P. issues staff with clear, signed guidelines as to in what circumstances to administer one or two tablets. Senior staff must be trained in the specific issues around these guidelines. The Registered Manager must 11/01/06 ensure that she conducts a full audit of all medication on the day of this inspection and contacts the G.P. for advise as to the potential effects of any under/over dosing. The Registered Manager must send a report to the Commission that outlines the results of this audit and any action taken to address any problems caused by under/overdosing plus any longer-term action taken to ensure that all staff understand their responsibilities, how to administer medication correctly and action taken to prevent this happening again. Service users and their families must be made aware of any medication errors found as a result of this audit. The Registered Manager must 31/03/06 ensure that day-to-day complaints and concerns from service users or relatives/friends must be recorded along with any action taken in order for trends of concern to be audited effectively and to ensure action taken is effective and responsive. DS0000029619.V271675.R01.S.doc Version 5.0 Page 26 Rose Court 15. OP16 22 16. OP27 18 (1) (a) 17. OP33 24 The Responsible Individual must ensure that the Organisational Complaints Procedure is revised to include the local office contacts details of the Commission i.e. Southwark Office. The Registered Individuals must ensure that a full review is conducted of the new staffing levels to assess if these are sufficient to meet the needs of the service users and ensure the effective running of the home. The Registered Individuals must ensure that service users and relatives are aware of the Commissions’ reports on the home. 31/03/06 31/07/06 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP11 Good Practice Recommendations The Registered Manager should ensure that a note is made on service users’ file if they or their family do not wish to discuss issues of death or dieing. Rose Court DS0000029619.V271675.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Court DS0000029619.V271675.R01.S.doc Version 5.0 Page 28 - 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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