CARE HOMES FOR OLDER PEOPLE
Rose Court Rose Court 253 Lower Road Rotherhithe London SE8 5DN Lead Inspector
Sue Meaker Unannounced Inspection 10:00 24 January 2008
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.V345100.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 Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Rose Court Address Rose Court 253 Lower Road Rotherhithe London SE8 5DN 0207 394 2190 0207 394 0123 lucy.ross@anchor.org.uk sharon.blackwell@anchor.org Anchor Trust 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) 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.V345100.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 17th October 2006 Brief Description of the Service: Rose Court is a purpose built residential care home registered for 64 older people and opened in 2002. It is owned and run by Anchor Trust. Since December 2005 the first floor has provided respite care for people with dementia and also has permanent service users needing dementia care. 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 and off road parking to the side. 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.V345100.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 STAR. This means the people who use this service experience GOOD quality outcomes. This was a very good inspection; discussions were held with the Home Manager and the Area Manager for the service both of whom were very helpful and knowledgeable about the service they provide. The Home Manager had completed the Annual Quality Assurance Assessment giving comprehensive information relating to the service provided, the building, about people who use the service, the management and staff of the home and quality assurance. On the day of the inspection there were fifty-eight residents accommodated in four units two of which are medium dependency; one unit is specifically for people with dementia and one unit for people with more complex needs including five respite care beds. The inspection comprised of a visit to the care home, a tour of the building meeting the people who use the service, some relatives who were visiting the home and the staff of the home. Documentation including six care plans, four personnel files along with the complaints file, policies and procedures, health and safety and quality assurance documents. Copies of the menu and the activities programme were also seen; the registration and insurance certificates were seen. What the service does well:
Rose Court provide a safe, warm and welcoming environment for people who use the service to live. The home is well maintained, furnished and decorated in a homely fashion. All bedrooms are of a good size allowing personal possessions to be accomodated. All rooms have un-suite toilet and shower facilities. The home has full disabled access. Staff receive a comprehensive induction and training programme that is job focussed . Feedback from the people who use the service and their relatives comfirmed that they fell safe and well cared for, relatives spoken to felt that the staff of the home provided a good quality of care and that their relaive s were happy in the home. The staff observed, during the tour of the home, appeared to be are caring, friendly and professional.- recognising the individuals right of choice, privacy, dignity and individuality all of these issues are identified and reflected in the individuals plan of care. A pre-assessment process prior to admission of the person who is gong to use the service and this theme is continued through the implementation of person centred care planning.
Rose Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 6 The home is able to cater for all religious denominations and are abe to organise various religious festivals to reflect the various cultural and diverse needs of the people who use the service. The management of the home are able to access help from local interpreters should a problem arise with people who speak different languages. What has improved since the last inspection?
After the lasinspection a number of requirements and recommendations were made; the home manager addressed these and had sent an action plan of how they were to be addressed; it was good to see that all the requirements and recommendations had been met. A new method of care planning was introduced by the organisation; this is a much better system that was in place and caters more to the specific needs of the person who uses the service; the documentaion is comprehensive and is peerson centred and the assessed personal, health and social care needs are clearly identified and detailed ways of meeting needs is clearly recorded. The new plans are in the process of being implemented and currently care plans are being rewritten in the new format; six of the new care plans were seen at the time of the inspection; the content of the new care plans was a definete improvement on the old ones and the information given was more specific to the individual and it was evident that the people who use the service and their relatives had input into formulating the plan and there was evidence of these plans being regularly reviewed and updated throughout the year. Through Catercraft the catering staff is training to produce a better quality of food. The home in consultation with the people who use the service and their relatives and the staff of the home, have changed the main meals to supper time which has a positive effect on the resident; they are eating more and sleeping better. The home has discontinued the pre-ordering of food and replaced it with the people who use the service deciding what they would like to eat and when they would like to eat. The home has been re-decorated in consultation with the people who use the service and their relatives; also looking at ideas from dementia care specialists relating to what sort of colours and shades of colours should be used so that people with dementia could regonise different areas within the home; carpets in some areas had also been replaced. The majority of staff received one day Dementia traning, 10 of staff the accredited 13 weeks Dementia training and 98 received Recognising / reporting Vulnerable Adult training. The home has recently appointed an activity co-ordinator and has introduced a more structured weekly activity plan which is now fully operating. The staff at the home all wear name badges; this has been recently introduced
Rose Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 7 and makes the staff more recognisable. The home ensures that the care plans are reviewed and updated on a monthly basis and all changes are discussed and recorded. The home manager has introduced a suggestions box to encourage comments from the people who use the service, their relatives, healthcare professionals who visit the home and the staff of the home; the home also sends out a questionnaire annually as part of their quality assurance policy. The management and staff of the home is continuing to to promote the yearly diversity celebrations. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request.
Rose Court DS0000029619.V345100.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 Court DS0000029619.V345100.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. (please note that standard 6 is not applicable in this instance). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives are able to access information about the care home enabling them to make a decision as to whether the home can meet their assessed personal, health and social care needs. Prospective residents are assessed, prior to admission, by the home manager making sure that the staff have the necessary specialist skills and ability to care for the individuals who are admitted to the home. Individuals are provided with a statement of terms and conditions/contract before admission to the home; that gives basic information on what people who live in the home can expect for the fee they pay, and sets out the terms and conditions of occupancy.
Rose Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 10 EVIDENCE: The home has a comprehensive Statement of Purpose setting out the aims and goals of the care services offered by the organisation; there is also a corporate Statement of Purpose for the organisation was introduced in 2006. The organisation has a Service User Guide giving specific information relating to the home and what the prospective resident can expect when they take up their placement. The organisation also has a brochure and photo album to enhance it, and is in the process of looking at the possibility of using a digital format to allow a visual tour of the home specifically for the hearing impaired. The Statement of Purpose and the Service User Guide is not allways updated when changes occur, the home manager endeavours to keep these documents up to date and they are in the process of being reviewed and updated. Individuals are provided with a statement of terms and conditions/contract before admission to the home; that gives basic information on what people who live in the home can expect for the fee they pay, and sets out the terms and conditions of occupancy. All prospective residents have a full assessment of their personal, health and social care needs prior to being offered a place in the home; the assessment is undertaken by a skilled, competent and experienced member of the homes’ management team making sure that the assessment is conducted professionally and sensitively involving the person who is going to use the service and if they choose input from family members. People who use the service and relatives spoken o at the time of the inspection confirmed that they were involved in the assessment process and in some cases had visited the home prior to their relative being admitted. No pre admission visits in emergency admissions due to lack of time. However, a new pre-admission process has been developed within the in Service Users Care Plan and staff have received training in methods of assessment at Service Users Care Plan training. The prospective resident is invited to spend time in the home prior to admission, either for the day or just a meal; they are encouraged to participate in the social activities on offer and are able to choose their room. The admission only takes place if the service is confident that staff have the skills, ability and qualifications to meet the assessed needs of the prospective person are met. The home is able to use the new person centred care plan document to incorporate the assessment document ensuring that care needs identified in the assessment and that input from the person using the service and their relatives is fully recorded. Staff endeavour to fully update the lifestyle
Rose Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 11 agreement and care plans; more staff trained and how to complete new Service Users Plans and continue to update the respite Service Users Plan according to the changing needs of the residents. To completment the assessment process the staff of the home are receiving dementia care specialist training so they are able to identify specific care needs at the time of the assessment making sure that the staff at the home are able to meet the individual complex care needs of a person with dementia. All staff are receiving training in the implementation of Service Users Plan and the auditing process of the care plan; all team leaders are to complete asessment training. Rose Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive, in the care home of their choice, is based on their assessed individual specific care needs and that the principles of respect, dignity and privacy are put into practice. People who use the service are assured at the time of their death, staff will treat them and their family with care, sensitivity and respect. EVIDENCE: Six care plans were looked at , in detail, at the time of the inspection. The care plans contained an assessment document detailing the required care needs of the individual; it was evident that the person using the service and
Rose Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 13 their relatives had input into formulating the care plan so that it is person centred and personalised to the individual. The new care plan documentation includes a Health Assessment and Holistic assessment tools to enable effective identification of individual need. There is a referral system in place to ensure access to other health and social care professionals and specific health care interventions and appointments are outlined in Blue Section of Service Users Plan to ensure appointments are not missed. The organisation has robust medication polices and procedures in place; staff confirmed that they received specialist training in the Safe Administration of Medication. Medicines were checked on one of the units; medication was stored correctly, a nomad system is in place supplied by Boots Pharmacy. The medication file contained computerised MARS sheets each with a photograph of the resident; Mars sheets checked were found to be completed accurately and complied with the nomad dispenser. The organisation has developed an auditing system for medication where the dispensing of medication is monitored on a monthly basa and the outcomes are recorded as part of the quality assurance process. The storage and dispensing of controlled medication was inspected the method of recording and the documentation used complied with regulation and in line with the guildelines set by The Royal Pharmaceutical Society Misuse of Drugs Regulations 1973. The organisation has policies and procedures in place to protect the privacy and dignity of the people who use the service; staff are made aware of respecting the privacy, dinity, choice and independence of the people in their care this is done through the indution training process and specialist training; confidentiality is respected be the implementation of the Data Protection Act 1998. Staff observed during the inspection demonstrated that they treated the people in their care with respect offering assistance in a sensitive and compassionate manner and it was evident the the people in their care responded to them in a positive manner; relatives visiting at the time said that the staff were always kind and understood the way that the people in their care wanted to be cared for and were aware of how much help to give without comprimising the independence of the person. On the tour of the building it was noted that all the residents had their own single rooms with ensuite facilities. The Statement of Purpose sets out what the home offers and the staff that deliver the care. Residents needs are clearly outlined in their Service Users Plan. Changing needs are documented through a daily recording system, review and evaluation processes. Specific preferences on choice of male and female carers are outlined in care plan. Residents at Rose Court are registered with two General Practitioners; those who lived in the area may chose to remain with the GP. Rose Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 14 End of Life care had been a focus for 2006/07 and staff have received specialised training in how to respond to a person who is dying providing appropriate care and comfort to the individual and their family ensuring that their death is handled with dignity and propriety, and their spiritual needs, riltes and functions are observed. In the event of a death in the home the person’s photograph is displayed, (if agreed by the person their family), in the front entrance of the home with a red rose stating the time of death; this remains up until day after the funeral. Residents in the home who wish to attend the funeral are accompanied, and a floral tribute is sent Rose Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the services provided are involved in taking decisions about how they live their life within the home; ensuring that they play an active role in planning the care and support they need to meet their assessed needs. EVIDENCE: The organisation responsible for the management and running of the home Statement of Purpose is to Improve the lives of older people and to focus on person centred care. People who use the service enjoy flexibility in all areas of daily living and activities; during the inspection the activity co-ordinator was helping a group of knitters in making a blanket for a charitable organisation; some residents were watching television and staff were chatting to other residents; it was
Rose Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 16 evident that there was good social interaction between the staff and the people they cared for there was a general home from home atmosphere in the home; relatives spoken to said that there was always such a nice atmosphere when they visited, they said they always felt welcome and offered refreshments and that the staff always had time to chat and listen to any concerns they may have had about their relative. Social interaction / activities are specific to the needs of the individual and the likes and dislikes of the person is detailed in the plan of care and the activity programme is tailored to those needs. It was evident from speaking to the staff and the people they care for; the activities of the day are tailored to the requirements of the individual and that the activities provided are of a flexible nature. Community participation is actively encouraged comprising of occasional visits from local school children, visits from the local library, weekly exercise therapy, the home is able to access external groups, for example the local Church and Day Centre. The home operates an open visiting policy and there are rooms for relatives to stay and they are also able to use a private lounge area for meetings and social occasions. The home encourages families to have a meal at the home as part of their visit to their relative. The right to choose is paramount to service delivery, this is evidenced in the provision of different routines for individuals resident in the home. Decisions- making is integral to the person centred care planning system. Independence is encouraged, with the provision of the following personal facilities, e.g. en-suite facilities and unit kitchens, telephone points in all rooms and SKY TV connection point in all rooms. The organisation and management of the home have realised the importance of good food with healthy eating options, the need for the individual to eat when they want to and the need for the people who use the service to be involved in the menu planning. The home has recently introduced a system whereby there is no pre- ordering of the menu choices - a choice is available at every meal. Individual cultural needs are assessed and provided for as required. It was noted that there are a range of hot and cold beverages and snacks on offer throughout the day. Activities are provided in a sensitive way according to the persons individual assessed needs and are outline in the plan of care. The home has a comprehensive Activity programme for home, and Activity Co-ordinator in place. The working day is set by the care planning process and individual needs on a daily basis. There was evidence of monthy residents meetings, outings to the seaside, local parks, cinema, a trip to see the Christmas Lights and shopping trips to the local shoping centre. Weekly visits to Healthy Ageing café. Weekly happy
Rose Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 17 hour - singing with residents. Visits from the Southwark therapy exercise group. The home is planinng to install a sensory garden area for those residents who have visual and hearing impairements. To donate funds towards purchase of mini bus- which we will have regular access too, to take residents out more frequently. To promote and encourage staff awareness around activities and in particular, person centred activities. Encourage more residents participation in cultural events and festivals within local community. Monthly coffee morning to encourage relatives to participate in homelife. To start a resident and relative association. Develop knowledge of the workforce to ensure fulfillment of the person centred plan of care through Person Centred care training. Look at how risk assessment can be simplified so no impairment is made to life style choices. Develop picture boards for menu choices where communication is a barrier. Rose Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 18 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service and their relatives and advocates are able to make a complaint or express their concerns about the service provision; by having access to a robust, effective complaints policy and procedure. People who use the service can be sure that they are protected from abuse and have their rights respected because of the policies and procedures relating to the Protection of Vulnerable Adults. EVIDENCE: Complaints processes are published in Service User Guide, Statement of Purpose, leaflets and on notice boards. Response times to complaints strictly adhere to and monitored. All participants in home fully informed of the complaints outcomes relating to them All complaints are recorded in the Complaints log, this was inspected at the site visit and was found to adhere to the policies and procedures of the organisation detailing the substance of the complaint, details of the complainant, the subsequent investigation, the outcome and resolution.
Rose Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 19 Complaints and feedback is actively welcomed, as mechanism to improve service provision. Robust complaint process are in place ( for the organisation and CSCI) and documented in the Statement of Purpose, notice boards, leaflets, Service Users Guide. Documentation process for all complaints and fixed response times with action taken. The organisation advoctes Rights & Responsibility training for all staff this is done in Induction training. Lifestyle decisions openly encourage through the person centred care planning process- in the Lifestyle Assessment Comfidential information kept securely in compliance with the Date Protection Act 1998. The organisation has a robust Protection of Vulnerable Adults Policy and Procedure supplemented by the local authority’s guidelines and those of the local multi-disciplinary teams. The organisation has recently appointed a specfic person ( Care Specialist) to support a consistent approach to Adult Protection, and ensure assurance processes are in place to monitor and feedback themes and lessons learnt. Quality Monitorng on complaints and adult protection issues within the home , and collation of statistical information to inform change. Safeguarding adults process in place outlined in a policy Alert Training ( POVA training) for all staff has taken place and staff spoken to confirmed they had received training and that they were confident in knowing what to do in the event of an allefgation of abuse being made; they were also confident in identifying the different types of abuse. The organisations Care specialist is available for advice and support particularly with staff who have issues relating to “whistle-blowing”; and the investigation of any allegations of abuse. The organisation is reviewing all Adult Protection processess, and will communicate the outcomes to the management and staff of the home, any changes in policies and procedures will be discussed before implementation, and the management and staff of the home wil be supported in making necessary changes to their way of working. Rose Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 20 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The location, design and layout of the home enables the people who use the service to live in a safe, well-maintained, clean and comfortable environment: ensuring that their privacy, dignity choice and independence is encouraged. EVIDENCE: The location, design and layout of the home is welcoming and provides a friendly homely athmosphere, decorated aand furnished to a high standard with personal touches includinf fresh flowers and plants, pictures, photographs and ornaments appropriate to the surroundings. Each of the four units have their own lounge, dining room and kitchen.
Rose Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 21 All the single rooms have ensuite facilities of a good quality which have been designed for the specific purpose. The bedrooms seen on the tour of the home are decorated and furnished to a high standard, people who use the service have been encouraged to personalise their rooms with small items of furniture, pictures, books, photographs and ornaments and televisions, radios and music centres. Kitchen and Laundry facilities are available; the laundry is well organised and the clothing and linens seen were of a good standard and in a state of good repair. The kitchens are to be refurbished as part of a facelift for the home, enabling the people who use the service, their families and staff to use the fscilities for activities and for social events. The home has a rolling maintenance programme in place - to ensure continuous improvement this plan is supported by the organisations Surveyor Team. The home is decorated in dementia colours, to enable those with dementia to find their way around the home enabling them to identify areas by colour. Whilst touring the home it was noted that the home was in a clean and hygienic condition with a pleasant odour. The organisation has a robust Infection control policy and procedure in place which is adhered to by a competent housekeeping team. Staff are trained in all aspects of infection control and have attended appropriate training courses; hand washing is promoted at all time and procedures are in place to make sure the environment is clean, pleasant, tidy, hygenic and odour free at all times. Information provided by the organisation’s surveyor through regular inspection and monitoring by reg. 26 visits helps to formulate the annual maintainence programme and to assign a realistic budget. The home has a highly motivated and committed housekeeping team. The people using the service are encouraged to individualise their rooms with personal items. Staff receive Infection Control training and are aware of the need to monitor and audit their procedures. The home has recently:• Upgraded CCTV system. • Re- decorated bedrooms • Re-decorated communal areas • Replaced flooring in toilets,/bathrooms and carpets to the main entrance and large lounge • upgraded 4 small offices on each unit • upgraded hairdressing room • Refurbished 4 unit kitchens • Air- conditioning in the lounges • Replaced carpets in the corridor / lounge and dinning on Millpond and
Rose Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 22 • • • • Mayflower unit. Upgrade ventilation in Plant room Room to Clinical store Door maintenance Upgrade garden pathway. Infection control: The organisation is to review Department of Health Essential Steps to Infection Control and develop an action plan for all of their Homes Develop a new hand-washing training programme and audit. Develop auditing tools for homes on infection control processes Monitor and collate information relating to transferable infection Rose Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 23 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Healthcare Assistants employed at the home are trained, skilled, competent, experienced and have the ability to support the people who use the service, in line with their terms and conditions of their placement, and to support the smooth running of the home. EVIDENCE: The organisation has robust recuitment and selection policies and procedures in place that are supported by the recuitment team. The organisations Human Resource department develops clear job profiles and adverts, to facilitate recruitment and selection of suitable staff combining the formal interview process. The home implements appropriate staffing levels; this was evidenced by the staff rotas in place at the time of the inspection. A variety of training programmes are available including the organisations generic courses, and training courses via the local authority and external training providers. It was evident from inspecting four personnel files that the recruitment and
Rose Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 24 selection policies and procedure of the organisation were adhered to and complied with regulation. There was evidence, in the form of certificates awarded, of staff training taking place this training incded mandatory induction training that all staff complete prior and during the firs six weeks of employment. Training offerred by the organisation includes the following:_ • Fire training • Health and Safety • Moving and handling • Safe Administration of Medication • Food Hygiene • First Aid • Dementia • Infection Control • Person Centred Care Planning Processes There is a comprehensive NVQ 2 and 3 training programme in place, with 4 trained assessors; management training available for senior team. Staff satisfaction survey was completed in a 2006; and staff meetings are held monthly. Staff supervisions and annual appraisals are conducted as part of the Personal Development process for all management and staff. PDD process are in place Recuitment policies and procedures The home manager is in the process of improving access to clinical /care training, e.g. Continence promotion, pressure areas and Diabetics. The • • • • • • • • • • organisation is in the process of making improvements to the following;Access to the organisations corporate Recuitment Team Improve the recuitment policies Publishing People Strategy for the organisation Improvements to the organisations net for Corporate information sharing Introduced PDD process for senior staff Further development of HR policy suite HR policy training To have full complement of permanent staff To recuit the right calibre of staff to suit the needs of the Home To introduce PDD to all other levels of staff Rose Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 25 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect; the home effective quality assurance systems developed by a qualified, experienced and competent manager. EVIDENCE: The Registered Managers has the following qualifications these being an RN, CMS, A1 Assessor and RMA.
Rose Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 26 Deputy Manager qualifications are an RN, A1 Assessor The home manager and her deputy attend regular training events in order to maintain their skills and competency and to update their knowledge; they also attend the organisatin regular management meetings. Home Business Plan outlines the development of the service and the plans for the future. A complete set of the organisation’s Policies and procedures ( reflecting Nartional Legislation) which are followed and included in staff induction. Self Assessment Manual Documentation Finanncial and home occupancy information is produced monthly for the homes, as well as access to computer system to support appropriaite processe The home has administration support on site The home is supported by Corportate service and expertise in finance, human resources , care provision, training, H&S, surveyors, and catering. Records on the home busioness are kept in secure and in an orderly way for auditing. Qualifications of all the staff in the home are in the Statement of Purpose and the Service User Guide and is also documented in their personal files As part of the business plan the organisation plans to:-. • • • • • • • Regularly review and update policies and procedures. Budget statements Hyperion reports Publish Reg 26 visit reports Improve communicaton with Multi - disciplinary team Develop Deputy Manger and Team Leaders in management Improve Audits Rose Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 27 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Rose Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Rose Court DS0000029619.V345100.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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