Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 09/03/06 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 9th March 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.

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

The care plans were excellent. They contained a lot of important information about what the residents needed help with, and how they were to be cared for. Activities were considered to be an important part of the residents` day. The activities person who worked at the home was aware of what each resident liked, and was able, to do. The residents live in a clean and pleasant environment.

What has improved since the last inspection?

Great importance is attached to ensuring that staff undertake training, especially in relation to nutrition. An additional shower area has been provided. This is a good facility. The way that the unwanted medicines are now returned to the pharmacy was much safer and more efficient.

What the care home could do better:

Management must continue with the redecoration and refurbishment programme, paying particular attention to the toilets and bathrooms. Management must make sure that the way they recruit staff is done safely. They must make sure that staff do not start work for them unless they have received at least 2 written references from previous employers.

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 9th March 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rose Court Nursing And Residential Home DS0000017336.V277633.R01.S.doc Version 5.1 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.V277633.R01.S.doc Version 5.1 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 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 Mrs Catherine Mary Shawarby Care Home 109 Category(ies) of Dementia (3), 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 (64), Physical disability (1) Rose Court Nursing And Residential Home DS0000017336.V277633.R01.S.doc Version 5.1 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) 21. Both sexes. Over 65 years of age. Sandringham Unit. Older People (OP) 43. Both sexes. Over 65 years of age. Physical Disability (PD) 1. Both sexes. Over 55 years of age. Earl of Wilton Unit. Dementia (DE)(E) 40. Both sexes. Over 65 years of age. Dementia (DE) 1 Female under 65 years of age. Dementia (DE) 1 Male under 65 years of age. Dementia (DE) 1 Both sexes. Over 50 years of age Mental Disorder (MD) 1 Male 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 Earl of Wilton Unit and suitably qualified and experienced registered nurses must provide 24 hour nursing care on this unit. Once placement for the three named service users (2 DE and 1 MD) has ended the previous registration category (DE)(E) will be reverted to. Suitably qualified and experienced registered nurses must provide 24 hour nursing care on the Sandringham Unit. 6th September 2005 2. 3. 4. Date of last inspection 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 units. On the ground floor there is Clarence Unit. This unit is for elderly residents who have social care needs. On the first floor there is Sandringham Unit. The elderly residents on this unit have either nursing or social care needs. On the Rose Court Nursing And Residential Home DS0000017336.V277633.R01.S.doc Version 5.1 Page 5 top floor is the Earl of Wilton Unit. This unit is for mainly elderly residents who have dementia. The units on the first and second floors are reached either by stairs or a passenger lift. This report is about the Earl of Wilton Unit. The unit has two large lounge/dining areas. Accommodation is provided in mainly single bedrooms, 4 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. Rose Court Nursing And Residential Home DS0000017336.V277633.R01.S.doc Version 5.1 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. This was an unannounced inspection. The Inspector spent 8 hours on the Earl of Wilton Unit. During this time she looked at care and medicine records to ensure that the health and care needs of the residents were being met. The inspector also looked at how many nursing and care staff were on duty. To make sure that the home and the equipment in it was safe, the Inspector looked at the maintenance and service records. She also looked at how the management recruit their staff and how they handle the residents’ spending money. The Inspector then looked around the building at the bedrooms, bathrooms toilets and sitting areas to check if they were clean and well decorated. She then visited residents in their own bedrooms to check out the care that was being provided for them. In order to obtain information about the home, the inspector also spent time speaking to 2 relatives, 2 registered nurses, 1 care assistant, the activities organiser and the registered manager. Not all the National Minimum Standards were looked at on this visit. During the next inspection the inspector will look at the rest of the Standards that are considered to be important for residents safety and wellbeing. These are the Standards that have to be inspected at least once a year. What the service does well: What has improved since the last inspection? Great importance is attached to ensuring that staff undertake training, especially in relation to nutrition. An additional shower area has been provided. This is a good facility. The way that the unwanted medicines are now returned to the pharmacy was much safer and more efficient. Rose Court Nursing And Residential Home DS0000017336.V277633.R01.S.doc Version 5.1 Page 7 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 Nursing And Residential Home DS0000017336.V277633.R01.S.doc Version 5.1 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.V277633.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 6. Information needs to be provided specifically about Rose Court so that an informed choice can be made, and people can find out if the home is what they are looking for and whether or not it can meet their needs. EVIDENCE: Corporate Statement of Purpose and Service User Guide templates have been formulated but the home has not yet been provided with a Statement of Purpose and Service User Guide that are specific to Rose Court. Standard 6 does not apply. The home does not provide intermediate care. Rose Court Nursing And Residential Home DS0000017336.V277633.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&8 The care plans reflected the support needs of the residents. Care practices ensured that the residents were treated with respect and their dignity was upheld. EVIDENCE: Individual care plans were in place for each resident. The care plans of four residents were examined: They gave clear instruction and guidance on how the care needs of the residents were to be met when problems had been identified. The daily report was kept with the care plan. This is good practice. The care plans were evaluated as and when necessary, but at least on a monthly basis. Risk assessments were in place and covered such areas as moving and handling, nutrition, pressure sores, the use of bed rails, general safety, falls absconding and aggression. The nursing staff on the unit had devised a summary of the residents care needs and this summary was kept in each residents’ bedroom. This is good practice. It was noted however on one wing of the unit the care needs were displayed on the outside of the wardrobe. This is not good practice. It allows anybody visiting etc, access to confidential information. In addition it looks very institutionalised. The residents were weighed at least on a monthly basis and the weight recorded on a chart kept in their care plan. The home also has a Malnutrition Rose Court Nursing And Residential Home DS0000017336.V277633.R01.S.doc Version 5.1 Page 11 Universal Screening Tool. This allows close monitoring of weight loss and nutritional risks. Inspection of care records identified that the residents had access to other health care professionals such as dentists, opticians and chiropodists. The residents receiving social care had access to the community nursing services when needed. Equipment necessary for the prevention and treatment of pressure sores was available within the home. Continence aids were in use and the staff were aware of how to contact the continence nurse advisor for advice, if deemed necessary. The medication system was not inspected but it was identified that the medicine storage keys were given out to members of staff on the unit who were not qualified nurses. The medicine keys must be kept with the qualified nurse in charge. It was further identified that there was only one set of medicine keys although there were two nurses on duty who had responsibility for a separate set of medications. The Inspector was informed that the unwanted medicines are now returned to the supplying pharmacist who has a contract to remove clinical/medical waste. Rose Court Nursing And Residential Home DS0000017336.V277633.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 14 & 15. The home enables residents to exercise as much personal freedom and choice as possible and enjoy the activities within the home. The residents’ dietary needs were met EVIDENCE: 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, in the passenger lift and on each unit. In addition the activities organiser keeps a file for each unit in which she documents the activities that have taken place. The residents have a bingo night on a monthly basis and residents from the nearby sheltered housing accommodation are invited to join them. There is a small cost but this does include a supper. Activities such as arts and crafts, reminiscence sessions and board games are undertaken. In addition outside entertainers are brought in on a regular basis. The activities organiser was in the process of ordering outdoor games for the spring/summer. The “Wilton Arms”, a reminiscence pub is situated on this unit. Residents on this unit have access to it on a Monday between the hours of 2pm to 4 p.m. There is also a tuck shop within the home. Residents can buy sweets, drinks and toiletries. Rose Court Nursing And Residential Home DS0000017336.V277633.R01.S.doc Version 5.1 Page 13 A discussion with the staff confirmed that the residents were able to receive visitors 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 Inspector did not dine with the residents but observed lunch being served. The lunch was served from a heated trolley. There was a choice of meals and the residents were asked at the time of serving what they would like to have. The meals served were of ample portion and looked appetising. The tables were nicely set with place mats and cruets. Rose Court Nursing And Residential Home DS0000017336.V277633.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 17 & 18. The complaints system in place enabled relatives to feel that their concerns were listened to and acted upon. Staff have a good knowledge and understanding of adult protection procedures thereby reducing the possible risk of harm or abuse. EVIDENCE: A discussion with relatives indicated that they were aware of how to make a complaint. The complaints procedure was displayed in the reception area and on the unit. During the last 12 months there have been 3 complaints made to the CSCI. One was made in relation to care issues, 1 in relation to the conduct of the care staff at night and 1 in relation to funding issues and care. Management investigated the complaints thoroughly. 1 was partially substantiated, 1 could not be substantiated and 1 remains unresolved. Most of the residents on the unit lack the capacity to vote in any election. The home facilitates access to advocacy services. There is an abundance of information in the reception area. A copy of the Local Authorities Vulnerable Adults Procedure was in place and a discussion with staff identified that they were aware of the procedure to follow in the event of any allegation of abuse. A discussion with the staff on the unit showed that the majority of them had undergone training in the protection of vulnerable adults. The staff that had not undergone training were identified on a training needs programme Rose Court Nursing And Residential Home DS0000017336.V277633.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 24 & 25. The residents live in clean, safe and comfortable surroundings. 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 reception area is welcoming and this is where the administrators’ and the managers’ offices are situated. The Earl of Wilton Unit is situated on the second floor and is accessed either by stairs or the passenger lift. The Inspector walked around the unit. There is a large lounge/dining room on either side of the unit. Both lounges were bright, clean and well decorated. There was a unit in one of the dining areas that had labels on to identify the contents such as serving spoons etc. This looked very institutionalised. There is no designated lounge for smoking. Residents can smoke only in a designated area of the lounge at designated times. There is a small kitchen on the unit that has the facility of a fridge, microwave, hot water geyser and storage cupboards. This kitchen was not clean and was in need of redecoration. There were food particles on the worktops and Rose Court Nursing And Residential Home DS0000017336.V277633.R01.S.doc Version 5.1 Page 16 cupboard handles. The microwave and fridge were not clean and the floor was badly stained. This kitchen needs to be refurbished. This unit also houses the “Wilton Arms” pub. It is a reminiscence room and can be accessed by all the residents in Rose Court. It had murals on the walls depicting men playing dominoes and drinking and smoking. There was also a mural of a dartboard and a fireplace. It had a bar with beer pumps and various forms of alcoholic drinks. There was a table and four chairs for the residents to use. The corridors throughout the unit were decorated with various themes, such as a garden area, a local street and public house and the seaside. Each corridor was given a local street name. The corridor exit doors were painted with a mural. Staff told the Inspector that this seemed to stop the residents from trying to get out of the door. The corridor carpet was however, very stained. Toilets were within close proximity of communal spaces. Each toilet and bathroom had a lock on the door to ensure privacy and the facilities were all clearly marked. Several of the baths were unassisted but the staff on the unit felt that the assisted bathing facilities that they had, were sufficient for the needs of the residents. A new assisted shower had been provided in one of the bathrooms. This offered a good disabled facility. The toilets and bathrooms were not in a good decorative state. The tiles in all the rooms were cracked. The majority of the bedrooms were decorated to a good standard. The bedroom doors had recently been painted. In addition to having the residents’ name on, the doors had been painted in different colours. This was to assist the residents to identify their own room. The majority of bedrooms were highly personalised. Several of the bedrooms had matching new furniture. It was evident that there had been ongoing refurbishment. This must be continued to ensure that all the rooms have matching furniture. Some of the bedrooms were in need of redecoration. The carpets in bedrooms 107 and 80 were in need of replacement. One was very stained and one had a hole in it. Some of the bedrooms had a partially obscured window. These were the bedrooms that overlooked the houses at the side of the home. Management must consult with any prospective residents/families to ascertain if an obscured window is acceptable to them. The bedroom doors had an overriding door lock and a lockable facility was provided in several of the bedrooms. It was identified that the qualified nurses did not carry a master key to the bedrooms. To ensure the health and safety of the residents the qualified nurses on duty must carry a master key. . Rose Court Nursing And Residential Home DS0000017336.V277633.R01.S.doc Version 5.1 Page 17 The heating within the unit was adequate. All the rooms were centrally heated with radiators that were suitably protected. Thermostatic control valves were in place on immersion baths and showers. The unit was clean and apart from bedroom 93 free from odours. Hand washing facilities were in place in bedrooms, bathrooms and toilets. They were not however, in place in the en-suite bedrooms. Clinical waste was handled appropriately and the home had a contract for the removal of clinical waste. Rose Court Nursing And Residential Home DS0000017336.V277633.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 29 & 30. The residents were cared for by sufficient numbers of staff that were suitably qualified, experienced and trained and therefore had the knowledge and skills to meet the residents’ needs The inadequate recruitment procedure could place residents at potential risk of harm EVIDENCE: The unit is divided into 2 separate areas and there are 2 separate duty rotas. There is Buckingham on one side and Kensington on the other. The registered nurses have responsibility for a designated area. The duty rotas did not identify the designation of the staff. Examination of the duty rotas and a discussion with the staff identified that there was sufficient care staff on duty to meet the needs of the 35 residents. The personnel files of three staff members were inspected. They had a completed application form, an enhanced CRB disclosure check and health status declaration. Only one of the personnel files actually had 2 professional references. One file had no references at all and the other file had a document that stated “verification report re reference letters”(this was an overseas employee) A structured induction process was in place and further training continues to be provided in moving and handling, medication, health and safety, infection control, fire safety, nutrition and protection of vulnerable adults. The training details were kept in staff files. Rose Court Nursing And Residential Home DS0000017336.V277633.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 & 39. The experience and qualifications of the manager ensures there is effective leadership and guidance to the staff thereby ensuring that the residents receive consistent quality care. Arrangements need to be in place for the reviewing of the service provisions to ensure that the home delivers a quality service. A satisfactory accounting system was in place that ensured the residents’ interests were protected. Current practices within the home in relation to the maintenance of a safe environment, promoted and safeguarded the health, safety and welfare of the people using the service. EVIDENCE: The registered manager is a Registered General Nurse who has extensive experience of working within the field of caring for the elderly. Her area of specialist clinical interest is Gerontology. She has obtained a Masters degree in this subject. Rose Court Nursing And Residential Home DS0000017336.V277633.R01.S.doc Version 5.1 Page 20 The manager has a qualification to NVQ Level 5 in management and also a certificate in Nursing Home Management. The manager was able to demonstrate that she had undertaken periodic training to update her skills and knowledge. At present there is no formal quality assurance system in place. The system in place for the management of residents’ money was good. The home did not take responsibility for residents’ personal allowance, however they handled any money that relatives had left on a residents’ behalf. The accounting system in place was good. Receipts were retained for all financial transactions. The equipment and services within the home were serviced on a regular basis in accordance with the individual requirements. Rose Court Nursing And Residential Home DS0000017336.V277633.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x 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 2 3 2 x x 2 3 x STAFFING Standard No Score 27 3 28 x 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 1 x 3 x x 3 Rose Court Nursing And Residential Home DS0000017336.V277633.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement A Statement of Purpose and a Service User Guide must be formulated in relation to Rose Court and a copy forwarded to the CSCI. The medication keys must remain with the qualified nurses. The small kitchen on the unit needs to be kept clean and redecorated. An action plan must be forwarded to the CSCI by the time frame of 30/04/06 The corridor carpet and the carpets in bedrooms 80 & 107 must be replaced. An action plan must be forwarded to the CSCI by the time frame of 30/04/06 The toilets and bathrooms must be redecorated/retiled. An action plan must be forwarded to the CSCI by the time frame of 30/04/06. The ongoing programme of furniture provision and redecoration for the bedrooms must continue. DS0000017336.V277633.R01.S.doc Timescale for action 31/05/06 2. 3 OP9 OP19 13 23 09/03/06 30/04/06 4 OP19 16 30/04/06 5 OP21 23 30/04/06 6. OP24 16 & 23 30/04/06 Rose Court Nursing And Residential Home Version 5.1 Page 23 7 OP24 23 8. OP24 23 9 OP25 13 10 11 12. OP26 OP27 OP29 13 17 19 13 OP33 24 14. OP38 23 An action plan must be forwarded to the CSCI by the time frame of 30/04/06. (Previous timescales of 31/3/05 & 31/01/06 not complied with) A lockable space must be provided in each residents’ bedroom. An action plan must be forwarded to the CSCI by the time frame of 30/04/06 (Previous timescales of 31/3/05 & 31/01/06 not complied with) Management must ensure that they consult with residents/relatives before any resident is admitted to the rooms that have partially obscured windows. Staff hand washing facilities must be in place in the en-suite bedrooms An action plan must be forwarded to the CSCI by the time frame of 30/04/06 (Previous timescales of 31/3/05 & 31/10/05 not complied with) The odour in bedroom 93 must be eradicated The designation of all staff must be documented on the staff rotas. At least 2 professional references must be obtained before any person is employed by the home. These references must be available for inspection. The home must have an effective quality assurance and quality monitoring system in place. A report in respect of any quality review must be forwarded to the Commission and a copy made available to residents or their representatives The qualified nurses on the unit must have a master key for the bedrooms. DS0000017336.V277633.R01.S.doc 30/04/06 09/03/06 30/04/06 10/03/06 10/03/06 10/03/06 30/06/06 10/03/06 Rose Court Nursing And Residential Home Version 5.1 Page 24 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 OP7 OP20 Good Practice Recommendations Care needs should not be prominently displayed. The labels on the dining room unit should be removed. Rose Court Nursing And Residential Home DS0000017336.V277633.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Nursing And Residential Home DS0000017336.V277633.R01.S.doc Version 5.1 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!