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Inspection on 17/07/07 for Rose Court Nursing And Residential Home

Also see our care home review for Rose Court Nursing And Residential Home for more information

This inspection was carried out on 17th July 2007.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Management make sure that the home only cares for those people whose needs the staff can meet.The residents` care plans contain a lot of important information about what they need help with, and how they are to be cared for. Activities are considered to be a very important part of the residents` day. The activities person who works at the home is aware of what each resident likes, and is able to do. 1 resident said: The food is good, my room is great to sleep in, what else can I say? The home makes sure that they check care staff out properly and safely before offering them a job. The Company is making sure that the staff are properly trained. Management are good at checking out the quality of care and the services provided for the residents

What has improved since the last inspection?

The way that medicines are managed is much safer. Mealtimes are considered to be an important part of the residents` day. The variety, content and the serving of meals have improved. Management has made a start on improving the facilities in the bathrooms. A senior nurse from the Company is presently working in the home in the capacity of a project manager. A major part of her role is to improve the care and facilities provided for the residents with dementia. Most of the things that needed doing from the last inspection have been done.

What the care home could do better:

To make sure that the residents live in a clean and pleasant environment, the programme of redecoration and refurbishment must continue.

CARE HOMES FOR OLDER PEOPLE Rose Court Nursing And Residential Home 44-48 Water Street Radcliffe Manchester Lancashire M26 4DF Lead Inspector Grace Tarney Unannounced Inspection 17th July 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rose Court Nursing And Residential Home DS0000017336.V337470.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 Nursing And Residential Home DS0000017336.V337470.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rose Court Nursing And Residential Home Address 44-48 Water Street Radcliffe Manchester Lancashire M26 4DF 0161 724 9040 0161 724 5357 rosecourt@schealthcare.co.uk 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) Southern Cross Home Properties Limited ** Post Vacant *** Care Home 109 Category(ies) of Dementia (7), Dementia - over 65 years of age registration, with number (40), Mental disorder, excluding learning of places disability or dementia (1), Old age, not falling within any other category (60), Physical disability (4) Rose Court Nursing And Residential Home DS0000017336.V337470.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 109 service users to include the following: Clarence Unit. Older People (OP) 18. Both sexes. Over 65 years of age. Within the 18 (OP) there can be up to 1 (PD) Physical Disability (PD) 1 Male (Named individual under 65 years of age) Dementia (DE) 1 Female (Named individual under 65 years of age) Dementia (DE) 1 Male (Named individual under 65 years of age) Sandringham Unit. Older People (OP) 42. Both sexes. Over 65 years of age. Within the 42 there can be up to 1 (PD) Dementia (DE) 1 Male (Named individual under 65 years of age) Mental Disorder (MD) 1 Female (Named individual under 65 years of age) Earl of Wilton Unit. Dementia (DE)(E) 40. Both sexes. Over 65 years of age. Dementia (DE) 2 Females (Named individuals under 65 years of age). Dementia (DE) 1 Male (Named individual under 65 years of age) Dementia (DE) 1 Both sexes under 65 years of age The service should employ a suitably experienced and qualified manager who is registered with the Commission for Social Care Inspection. The named service users must be cared for on the designated units. Once placement for the 8 named service users (3 DE (female) 3 DE (male) and 1 MD (female) and 1 PD (male) has ended the previous registration categories will be reverted to. Suitably qualified and experienced registered nurses must provide 24 hour nursing care on the Sandringham and Earl of Wilton Units. 2. 3. 4. Rose Court Nursing And Residential Home DS0000017336.V337470.R01.S.doc Version 5.2 Page 5 Date of last inspection 15th August 2006 Brief Description of the Service: Rose Court is a purpose-built detached property that is situated in a residential area of Radcliffe. The home is close to main bus routes and is not too far from the motorway network. A variety of shops are close by. There is plenty of parking to the front and the side of the home for the use of staff and visitors. The front door of the home allows a level access for wheelchair users and people who have problems climbing steps. The home is registered to care for residents with a variety of needs. The home is divided into 3 separate houses. On the ground floor there is Clarence House. This house is for elderly residents who have social care needs. On the first floor there is Sandringham House. The elderly residents in this house have either nursing or social care needs. On the top floor is Wilton House. This house is for mainly elderly residents who have dementia. The houses on the first and second floors are reached either by stairs or a passenger lift. Each house has large lounge and dining areas. Accommodation throughout the home is provided in mainly single bedrooms, several of which have an en-suite facility of toilet and wash hand basin. Most of the toilets and bathrooms have aids to assist any resident with a disability or mobility problem. The manager told the Inspector that the weekly fees within the home ranged from £355.11 for people who have social care needs and have their care paid for by the local authority and for nursing residents, £355.11 plus the fee paid by the PCT (previously known as the Health Authority) for the “free nursing care” contribution. For privately funded residents the fees range from £467.00 for people who have social care needs to £469.00 plus the fee paid by the PCT (previously known as the Health Authority) for the “free nursing care” contribution. Additional charges are made for private chiropody, hairdressing and newspapers. This information was received on the 17th July 2007. A copy of the last inspection report is kept in the reception area. Rose Court Nursing And Residential Home DS0000017336.V337470.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The home was not told that this inspection was to take place although the home was aware that an inspection was due. This was because several weeks before the inspection questionnaires were sent out to the residents, their relatives and to the home itself. The questionnaires that were sent out to the residents and relatives were called “Have Your Say” and they asked what people thought about their care and of the quality of the service provided for them. 7 questionnaires were returned. Some of their responses are detailed in different sections of this report. 2 Inspectors visited the home and were there for 8 hours. 1 Inspector spent most of the time on Clarence House and the other Inspector spent most of the time on Wilton House. Sandringham House will be inspected in more detail on the next inspection. During this time they looked at care and medicine records to ensure that the health and care needs of the residents were being met. They then visited residents in their own bedrooms or in the lounge areas. The Inspectors then looked around the home at some of the bedrooms, bathrooms and toilets to check if they were clean, well decorated and suitably adapted for disabled use. The Inspectors also looked at what the residents had for their lunch and evening meal. They also looked at how many staff were provided on each shift to make sure the residents needs were being met, and also looked at how management recruit and train their staff. How the home manages the residents’ spending money was also looked into. To make sure that the home and the equipment in it were safe some of the maintenance and service records were looked at. In order to get further information about the home the Inspectors also spent time talking to 5 residents, 3 care staff,2 nurses, the activities organiser, and the office and management staff. What the service does well: Management make sure that the home only cares for those people whose needs the staff can meet. Rose Court Nursing And Residential Home DS0000017336.V337470.R01.S.doc Version 5.2 Page 7 The residents’ care plans contain a lot of important information about what they need help with, and how they are to be cared for. Activities are considered to be a very important part of the residents’ day. The activities person who works at the home is aware of what each resident likes, and is able to do. 1 resident said: The food is good, my room is great to sleep in, what else can I say? The home makes sure that they check care staff out properly and safely before offering them a job. The Company is making sure that the staff are properly trained. Management are good at checking out the quality of care and the services provided for the residents What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Rose Court Nursing And Residential Home DS0000017336.V337470.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 Nursing And Residential Home DS0000017336.V337470.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): 3. Quality in this outcome area is good. People are properly assessed before they are admitted to the home and this gives an assurance to everybody that a person is only admitted if the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Before any resident was admitted to the home an assessment of their needs was undertaken, either by the manager or a senior member staff from the home. The assessment looks at what help and support the resident may need. The Inspectors looked at 3 of the assessments that were done before the residents were admitted to the home.They were detailed and gave a clear indication of the residents’ needs and what they could and could not do for themselves. Standard 6 does not apply. The home does not provide Intermediate Care. Rose Court Nursing And Residential Home DS0000017336.V337470.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 & 10. Quality in this outcome area is good. Care plans and care practices, ensure that the residents’ needs are met in a safe, caring and dignified way. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Individual care plans were in place for each resident. The care plans of 5 of the residents were looked at. Care plans detail the individual care and support needs a resident may have and also describe how these needs are to be met by staff. Such a record helps to ensure that the care and support that the residents receive is consistent. The care plans were very detailed and gave clear instruction and guidance on how the care needs of the residents were to be met. All but 1 of the care plans showed that the resident or family had been involved in drawing up the care plan and had signed to state that they agreed with it. 1 of the care plans looked at, showed that the resident was of the Jewish faith. Staff told the Inspector that the resident was “Not Orthodox”. This information was written Rose Court Nursing And Residential Home DS0000017336.V337470.R01.S.doc Version 5.2 Page 11 in his care plan but there was however, no eating and drinking plan and it was difficult to identify what this resident would actually eat in line with their faith. During the inspection the nurse agreed to write an eating and drinking plan, showing clearly what foods the resident would or could eat. The care plan did show that the resident was involved with the Jewish Federation The staff looked at whether or not there was any risk in relation to the residents developing pressure sores and also if they were at risk due to problems with their diet and fluid intake. These are called risk assessments. Risk assessments were in place for whether a resident was at risk of falling. They also looked at and they wrote down, how any resident was to be assisted with being moved around and by how many members of staff and what equipment, if any, was to be used to assist in safe moving and handling. Inspection of the care files showed that the residents had access to health care professionals, such as dentists, opticians and chiropodists. Equipment necessary for the prevention and treatment of pressure sores was available and in use. : The medicines on Wilton House and Clarence House were looked at. A safe system was in place on Wilton. Overall a safe system of medicine management was in place on Clarence however the following things need to be put right: • 1 resident was having injections that were being given by the community nurse. There was a handwritten name on the box instead of a pharmacy label. This is unsafe practice. Staff must make sure that the medicines are properly labelled and if not they must be returned to the pharmacy. Records showed that medication had not been supplied that month for several residents and it was not clear why that had happened. There was no information to show that the medicines had been discontinued or that other existing stock was being used The door to the office, where the medicines were stored, was not being locked when unoccupied. • • The residents looked clean and well dressed. Staff knocked on bedroom and toilet doors before entering and they spoke to residents in a quiet and respectful way. Rose Court Nursing And Residential Home DS0000017336.V337470.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 & 15. Quality in this outcome area is good. Residents dietary needs are met, they have a choice in how they spend their day and most find enjoyment with the activities available. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents’ routines of daily living and their social interests were recorded in their care plans. The home has full time activities organiser who arranges activities throughout the home. There is a varied programme of activities throughout the week and the programme of activities is displayed in the reception area and in each house. In addition the activities organiser keeps a file for each unit in which she documents the activities that have taken place. Activities such as arts and crafts, reminiscence sessions and board games are undertaken. In addition outside entertainers are brought in on a regular basis. Whilst at the home the Inspectors saw that the activities organiser took a resident out to the bank and then to do some shopping. The residents in Wilton House were playing dominoes and seemed to be concentrating and enjoying themselves. Rose Court Nursing And Residential Home DS0000017336.V337470.R01.S.doc Version 5.2 Page 13 On Wilton House there is a reminiscence pub called the “Wilton Arms”. This is open to all the houses on specified days and times. Some residents do visit the Wilton Arms for a “pub lunch.” The home has access to a mini bus when available, which can be used for outside activities. There is also a tuck shop within the home. Residents can buy sweets, drinks and toiletries. The inspector had a chat with a couple of the residents whilst they were buying some drinks. In answer to the question on the Have Your Say questionnaire: Are their activities arranged by the home that you can take part in? Comments were: • Yes and no, it depends on my mood. • Always. I love going out. • Sometimes. I feel too old to participate in some activities. • Sometimes. It depends on the activities programme. Sometimes I dont want to participate in activities that dont interest me. • Always. But sometimes, or most of the time, I dont feel like it. I cant walk properly. Residents spoken to said that their friends and families could visit whenever they wanted and that staff made them welcome. Those spoken to said that they preferred to see their visitors in the lounges but their bedrooms could be used if they wanted to see them in private. Residents are encouraged to bring personal possessions into the home. Many of their bedrooms were highly personalised with small pieces of their own furniture, pictures, photographs and ornaments etc. The Inspectors did not eat with the residents but checked out what the residents in Wilton and Clarence had been offered for lunch. There was a choice of main course and dessert. The main meal is at lunchtime with a lighter meal in the evening. The tables were nicely set with tablecloths, napkins, salt and pepper and some had milk jugs and sugar bowls. The food was served from a heated trolley and looked appetising and the portions were good. Hot and cold drinks were being served throughout the day. Members of staff told the Inspector that food and drinks are available out of hours and that milky drinks are always available. In answer to the question on the Have Your Say questionnaire: Do you like the meals at the home? Comments were: Rose Court Nursing And Residential Home DS0000017336.V337470.R01.S.doc Version 5.2 Page 14 • • • Sometimes (2 residents) Always (4 residents) Of course. Any cultural or dietary needs, likes and dislikes were looked at when a resident is first admitted to the home. Rose Court Nursing And Residential Home DS0000017336.V337470.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. People know how to complain and staff have a good knowledge and understanding of what abuse is, thereby reducing the possible risk of harm to residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure was displayed and it is also included in the Service User Guide. It is easy to understand and gives an assurance that complaints will be responded to within 28 days. The CSCI has received 1 anonymous complaint since the last inspection. This was discussed with the management during the inspection. The complainant alleged that the staff did not have moving and handling training. The Inspectors spoke with staff and looked at staff training files and were satisfied that the complaint was not upheld. A comment from the Have Your Say questionnaire was: • Im always happy, no need to speak to somebody. • I am not happy to approach the staff in the front office, would prefer to speak to the deputy manager. A copy of the Local Authorities Protection of Vulnerable Adults Procedure was in place and a discussion with the senior staff identified that they were very Rose Court Nursing And Residential Home DS0000017336.V337470.R01.S.doc Version 5.2 Page 16 aware of the procedure to follow in the event of any allegation of abuse. Training in the protection of vulnerable adults has been undertaken by staff and is ongoing. Records of training were kept on staff files. Rose Court Nursing And Residential Home DS0000017336.V337470.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 24 25 & 26. Quality in this outcome area is adequate. The residents are living in a clean and safe home that is in need, in parts, of redecoration. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is level access to the front of the home with adequate parking both at the front and to the side of the home. As a security measure the front door is kept locked. The home has converted what used to be an office off the entrance hall, into a sitting area. This is a pleasant area for both visitors and residents to sit in. For the purpose of this inspection the Inspectors concentrated on looking at the environment on Clarence and Wilton Houses but visited Sandringham to check out if what was required from the last inspection had been seen to. Clarence House Rose Court Nursing And Residential Home DS0000017336.V337470.R01.S.doc Version 5.2 Page 18 The lounge/dining areas were clean, well decorated and suitably furnished. There is a designated smoke lounge that is situated on the far side of the building on the ground floor. This room was in a poor condition: all the furniture was old and soiled. There is a window in this room that can be opened window, although the residents generally don’t do so. There was no extractor fan. The residents who use this room told the Inspector that they felt it was poor and were unhappy with the arrangement. The bathrooms and toilets had been adapted and fitted with aids to assist mobility and with call bells. The areas requiring attention included: • The toilet opposite room 6 had a heavily marked floor around the toilet and a bad odour. • The toilet opposite the dining room had been out of use for approximately 2 months. The door was found to be unlocked. The staff on duty were advised to lock the room as the room was still be made safe and open electric wiring could be seen as the socket was away from the wall. Several bedrooms were seen. These varied in relation to some having been more recently decorated than others. Some rooms had also had new items of furniture. Rooms had been very personalised by some of the residents. The small kitchen on Clarence was in a poor condition; it had poor décor, the walls and cupboards had been splashed and stained and the sink was also discoloured. Wilton House The lounge/dining areas were warm, clean, well decorated and suitably furnished. They looked very comfortable. The Inspector could see that decorating was in progress. Several of the corridor walls had been painted and the doors to the bedrooms had been painted in different colours. Painting in different colours may help some residents recognise their own room. The corridor carpets were stained and there was a smell of urine in parts of the corridor. There were enough toilets and bathrooms to meet the needs of the residents. Toilets were near to bedrooms, the dining room and the lounge. The toilets were clean and most were suitably adapted for disabled use. Each toilet and bathroom had a lock on the door to ensure privacy. The areas requiring attention included: • Bathroom 13 had been decorated but the floor was badly stained and there was no call bell to the toilet. Rose Court Nursing And Residential Home DS0000017336.V337470.R01.S.doc Version 5.2 Page 19 Bathroom 14 has a new disabled access shower that the staff found very useful. The tiles above the window in this room were cracked however, and the woodwork was in need of painting. • The toilet opposite this bathroom had no aids to assist people to get off and on it. It also had a broken call bell lead. • Bathroom 15 had been redecorated but the flooring was badly stained and there was no call bell to the toilet. • The Parker bathroom had paintwork that was badly marked. Tracking has been installed in 2 of the bathrooms. Hoists are attached to the tracking and this enables residents to be moved safely into the bath. Staff felt that this was very useful. The majority of the bedrooms were clean and suitably furnished and the doors had an over riding door lock to ensure privacy. Some bedrooms had been recently decorated. Some bedrooms had new furniture and a lockable space for storing anything that was of value to the resident. Many of the rooms however were without a lockable space. Bedroom 67 smelt very badly and there were cigarette burns on the carpet. The rooms were individually and naturally ventilated, they were all centrally heated and the radiators were covered. Staff hand washing facilities were in place in bedrooms, bathrooms and toilets. Clinical waste was handled safely. • Rose Court Nursing And Residential Home DS0000017336.V337470.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 & 30. Quality in this outcome area is good. The residents are cared for safely, by staff that are properly trained and recruited. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Clarence House. Inspection of the duty rotas and a discussion with the staff showed that for the 17 residents residing in the house there was not enough staff on duty between the hours of 8am –2pm. Management agreed to provide an extra carer for this shift on a daily basis, starting the following morning. Wilton House. Inspection of the duty rotas and a discussion with the staff showed that for the 34 residents residing in the house there was enough staff on duty for both day and night. Sandringham. Inspection of the duty rotas and a discussion with the staff showed that for the 33 residents residing in the house there was enough staff on duty for both day and night. There were several male residents living at Rose Court and also several male carers and nurses. This gave the residents, at times, a choice of whom they wished to care for them. Rose Court Nursing And Residential Home DS0000017336.V337470.R01.S.doc Version 5.2 Page 21 Information from the questionnaire returned from the home showed that 59 of the care staff had obtained their NVQ Level 2 or above. NVQ training in health and social care is being provided for staff that have not yet achieved these qualifications. A thorough recruitment procedure is operated that helps protect residents from being cared for by unsuitable people. Inspection of 3 staff personnel files showed that these staff had been properly and safely employed. They contained an application form (including a health declaration), 2 written references, a Criminal Records Bureau check, proof of identity and evidence of induction training and further training. Induction training is provided for all newly employed staff. This is to make sure that they understand what is expected of them and that people are cared for properly and safely. Also a wide range of appropriate and ongoing training in moving and handling, abuse, basic food hygiene, fire safety and other relevant topics are provided to staff at the home. Training provided to individual staff is recorded in detail and checked at frequent intervals. Rose Court Nursing And Residential Home DS0000017336.V337470.R01.S.doc Version 5.2 Page 22 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 & 38. Quality in this outcome area is good. Practices within the home protect the health, safety and welfare of the people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is presently without a registered manager but is being managed by a manager from another home that is owned by the Company. This acting manager is supported and on a day-to-day basis by the Senior Nurse who is the Project Manager and by senior management from the Company. Rose Court Nursing And Residential Home DS0000017336.V337470.R01.S.doc Version 5.2 Page 23 The Manager has to do a monthly check of lots of things in the home. She has to check to make sure that there are no hazards around the building and also check the records about care, medicines and any accidents that have happened. Every 6 months management send out comment cards to residents and relatives asking what they think of the quality of the care and the facilities. The comments are received by the company’s’ head office and then shared with the home. In this way the home can take steps to put into practice what has been said about what could be improved. The systems in place for the management of residents’ money were good. Generally only personal allowances are held by the home in a residents’ account. Individual computer records are made of all transactions and balances. Receipts are held for any purchases made and receipts are given to relatives when they deposit any “spending money” for their relative. The home had a detailed Health & Safety Policy. The fire logbook was up-todate. Regular checking and testing of the fire detection system, fire exits and emergency lights was undertaken and documented. Any accidents that happen are properly recorded and monitored. The information taken from the questionnaire that was filled in by the home, plus a random check of some certificates, showed that most of the equipment and services within the home were serviced on a regular basis in accordance with the individual requirements. The random check showed that the following certificates were not available for inspection. The 5yr electric certificate and the servicing of the thermostatic mixer valves on the hot water taps. Management assured the Inspectors that the work had been undertaken and agreed to send over the certificates as soon as they could be located. Rose Court Nursing And Residential Home DS0000017336.V337470.R01.S.doc Version 5.2 Page 24 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 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 2 x x 2 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 2 Rose Court Nursing And Residential Home DS0000017336.V337470.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement Clarence To make sure that the correct medication is given, staff must make sure that the medicines are properly labelled and if not they must be returned to the pharmacy. Clarence Arrangements must be in place to ensure that the medication is held securely and safely and the residents are not put at risk of harm.. Clarence To make sure that the residents receive their medicines when they should, the medicine sheets need to identify the reason why medication has not been supplied or given. i.e.– whether stopped by their GP or stock carried forward from the previous month. Wilton Residents have a right to a clean, pleasant environment so therefore the corridor carpets must be thoroughly cleaned or replaced. DS0000017336.V337470.R01.S.doc Timescale for action 17/07/07 2 OP9 13(2) 17/07/07 3 OP9 13(2) 17/07/07 4 OP19 16(2)(c) 31/10/07 Rose Court Nursing And Residential Home Version 5.2 Page 26 5 OP21 13(4)(a) 6 OP24 23(2)(d) 7 OP27 18(1)(a) 8 OP38 13(4)(a) (Previous requirement of 31/10/06 not complied with). Wilton You must make sure that residents are protected from avoidable risks to their health and safety. Call bells must therefore be fitted to the bathrooms and toilets that are without them. Wilton Residents have a right to a clean, pleasant environment so therefore the carpet in bedroom 67 must be cleaned or replaced. Clarence To make sure that the residents’ needs are met, adequate care staff must be provided. The certificates for the 5 year electrical survey and the thermostatic mixer valves must be in place and available for inspection. Copies must be sent to the CSCI. 03/08/07 31/10/07 18/07/07 31/10/07 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 Refer to Standard OP19 OP10 Good Practice Recommendations To make the environment as pleasant as possible for the residents who do smoke, thought should be given to improving the ventilation in the smoke room. Sandringham & Wilton So that the residents have somewhere secure to store things that are valuable to them, a lockable space should be provided in their bedrooms. Residents have a right to a clean, pleasant environment so therefore the redecoration and refurbishment of bathrooms on all the houses should continue DS0000017336.V337470.R01.S.doc Version 5.2 Page 27 3 OP19 Rose Court Nursing And Residential Home Rose Court Nursing And Residential Home DS0000017336.V337470.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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