CARE HOMES FOR OLDER PEOPLE
Rose Farm Care Home Main Street Styrrup, Doncaster South Yorkshire DN11 8NB Lead Inspector
Jayne Hilton Unannounced 15 September 2005 at 9:30 am
th 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 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 Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Rose Farm Care Home Address Main Street Styrrup Doncaster South Yorkshire DN11 8NB 01302 744664 01302 746900 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) RS Care Homes Ltd Mrs Ann Hopson Care Home (CRH) 50 Category(ies) of Dementia (DE) - 25 (Twenty Five) registration, with number Old Age (OP) - 25 (Twenty Five) of places Rose Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: Service Users shall be within the categories OP(25) and DE(25) Date of last inspection 30/3/05 Brief Description of the Service: The home is situated in the quiet village of Styrrup. There is good access to nearby towns of Retford, Doncaster, Rotherham and Worksop. The home comprises three units. The Cottage which caters for 8 service users with low dependency needs, The Barns for 17 service users with varying dependency needs and the Garden Wing offers a safe and a secure environment for other service users with dementia. The Cottage is an adapted building more suited to service users with low dependency needs due to its sizes and layout. The Barns and The Garden Wing are purpose built. The gardens are pleasant and safe. There is ample car parking space at the front of the building. The home appears to be sufficiently adapted to cater for the needs of people with a disability. There is a passenger lift. A call bell is fitted throughout the building. Rose Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place on 15th September 2005 and commenced at 7.50am and completed at 12.20pm. The focus of the inspection was mainly to assess compliance with the previous requirements and recommendations set and to assess the key standards and outcomes for service users residing at Rose Farm Care Home. The methodology used for this assessment, was the examination of five care plans and associated records. Inspection of health and safety record, a sample of staff personal files and training records, A tour of the building, including several service users rooms, inspection of medicines management procedures, staff messages book, menus, accident records and fire safety records. Six service users were spoken with and five staff. The Cottage was not inspected at this visit. What the service does well:
Prospective service users have the information they need to make an informed choice about where to live and have their needs assessed. Service users and their representatives know the home they enter will meet their needs. Service users have comprehensive care plans in place and which could be further improved by including more of service users preferences. Their healthcare needs are generally well met. Medicines management was overall good. Service users feel they are treated with respect and their right to privacy is upheld. Service users can be assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect, however there are some issues to address, which would further improve this. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social and cultural religious and recreational needs and are helped to exercise choice and control over their lives. Service users enjoy their meals and mealtimes. Service users know how to make a complaint and are protected from abuse. Service users live in a clean, safe well maintained environment with access to safe and comfortable indoor and outdoor communal facilities. The washing and lavatory facilities are adequate and the home is equipped with specialist equipment to maximise service users needs. Service users bedrooms suit their needs with their own possessions around them. Service users needs are met by the numbers and skill mix of staff, who are trained to an appropriate standard.
Rose Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 Page 6 Service users live in a home, which is run and managed by a person who is fit to be in charge. A new manager is to undergo the process for registration shortly. Staff, are appropriately supervised and record keeping overall is good. The health and safety and welfare of service users and staff are promoted and protected. What has improved since the last inspection? What they could do better:
The recruitment practices are in breach of the regulations and assessed as poor as a result of this and because this is a second time breach of this regulation. Two staff had been allowed to commence work before the registered person was in receipt of a POVA, CRB and two satisfactory references. Not all of the staff files had photographs and for one other member of staff a CRB dated 2003 undertaken by another employer had been accepted. CRB’s are not transferable between employers. A new CRB application must be obtained immediately for this person. An immediate requirement was set in relation to new staff not starting work before the appropriate checks are in place. This is a second time breach of this legislation and further non compliance/breach will result in enforcement action being taken. There is an issue provision of keys and tables for service users rooms to be addressed. Service users would benefit from large print menus placed on the dining tables. The assessment and care plans could be further improved by
Rose Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 Page 7 including more of service users preferences. There are some minor areas to address regarding medicines management and service users healthcare needs can be further met by the following: One service user who was noted to have had some weight loss issues did not have a nutritional assessment in place and this should be prioritised. The foot care section should have included comments regarding diabetes. It became apparent that care staff, have been taking the blood pressure of service users, which is not, appropriate, as the home does not provide nursing care. Not all service users who were described as ‘aggressive’ had care plans in place for dealing with this and staff need to be clear about what they mean when they state aggressive [see standard 4]. From the daily care notes it was identified that not all injuries/bruising noted on service users had been recorded in the accident book. The inspector recommends that a body map be used for staff to identify marks and bruising and a system put into place where these are assessed by the manager and appropriate action measures taken to identify any unexplained marks or bruising. 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 Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Rose Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 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 standard(s) 1, 3, 4 Prospective service users have the information they need to make an informed choice about where to live and have their needs assessed. Service users and their representatives know the home they enter will meet their needs. EVIDENCE: A new statement of purpose was produced on 16th December 2004; a copy is available on the reception area and in all the three units of accommodation. A large service user guide has been prepared with photographs and is also available for viewing in the reception area. The homes brochure has been brought up to date, however the information needs to be updated again due to change in manager. The provider should decide if to continue to use the brochure a service user guide then it must contain all of the specified information. [Regulation 5 [2] states that a copy of the service user guide shall be supplied to each service user] A comprehensive assessment document is used for all new admissions. Five service users assessment and care plans were examined, all assessments met the standard 3.3 requirements. The home has a new admissions procedure which clearly indicates that new service users are admitted only on the basis of
Rose Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 Page 10 a full assessment undertaken by people trained to do so and which service users and their relative/representative have been party to. The manager visits the service user wherever possible. There is a section on the new care plan system for the manager to sign that the home can meet the needs of the service user. A resident profile compliments the assessment. Social worker assessment were seen for those where provided. The home was granted a variation to the existing registration to 25 beds for service users with dementia and 25 beds for old age. External sources and training has been sought to reflect good practice where possible in dealing with service users with dementia. Staff, appear to be well supervised and supported. Service users were happy with the care offered and reported that staff were kind and respectful. The management of behaviour has been addressed and is included in the care plan system, again the process of evaluation and clearer identification of how the aggression presents, what has worked well in the past etc needs to be included. Within the assessment of need, there were no recorded preferences of bedtimes, getting up, and care plans for personal care were lacking in service users preferences. Rose Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 Page 11 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 standard(s) 7, 8, 9, 10, 11 Service users have comprehensive care plans in place and which could be further improved by including more of service users preferences. Their healthcare needs are generally well met, however there are some good practice recommendations to ensure that the systems in place are robust. Medicines management was overall good, with minor areas to address. Service users feel they are treated with respect and their right to privacy is upheld. Service users can be assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect, however there are some issues to address, which would further improve this. EVIDENCE: A new care-planning format has been introduced, which on the whole appears to be a good system and there was noted improvement in their completion since the last inspection. The review process of care plans has been consistent from March 2005. Care plans were observed to be, reviewed at least monthly and the review included an evaluation of whether the service users needs have changed. There is a service users profile which some only contained brief details and staff should be given prompts for discussion to learn about the persons life experiences of work life, hobbies, what the service user enjoys etc. Care plans were signed by service users or by representatives. The information
Rose Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 Page 12 in the care plans need to address the wishes of the service user and need to be more detailed as to give instruction to staff in how the needs of the service users are to be met. The quality of daily records varied between authors slightly. Some just carried statements that all care completed which is not appropriate. Daily reports should contain holistic evaluations of the service users daily lifestyle, including health and well being status. Assessments were in place for manual handling, mobility, risk of falls, continence and tissue viability. A process for reviewing these monthly has been implemented. Service users, are currently assessed by, the district nurse for pressure sores. The documentation regarding service users health needs was much improved and provided clear records of visits and treatments and follow ups. There was evidence of bowel monitoring and nutritional assessments were being introduced. One service user who was noted to have had some weight loss issues did not have a nutritional assessment in place and this should be prioritised. The foot care section should have included comments regarding diabetes. Authorisation for bed rails was in place and provided detail of the possible risks of placing these. Bumpers were observed on bedrails being used at the time of the inspection. It was reported by a member of the care staff that care staff, have been taking the blood pressure of service users, which is not appropriate as the home does not provide nursing care. Service users psychological health is monitored. Not all service users who were described as ‘aggressive’ had care plans in place for dealing with this, others did and were well documented, however staff need to be clear about what they mean when they state aggressive [see standard 4]. A service user who was on bed rest was noted to have care charts in place. Blood sugar monitoring was seen for diabetic service users. From the daily care notes it was identified that not all injuries/bruising noted on service users had been recorded in the accident book. The inspector recommends that a body map be used for staff to identify marks and bruising and a system put into place where these are assessed by the manager and appropriate action measures taken to identify any unexplained marks or bruising. Medicines management was overall good. The medicines trolley is stored in a locked cupboard and designated staff have been trained in the safe handling of medicines. The treatment rooms were clean and generally tidy. Blister packs are used and a pharmacist report demonstrated overall good practice. All medication administration records including those for controlled drugs were satisfactory. Storage and fridge temperatures were taken. The inspector recommends that copies of the medicines policies are kept in each treatment room and that information regarding what to do in the event of a drug error be at hand. Staff, also need to be reminded that medicines need to be kept for seven days after the death of a resident. A urine sample was stored in the medicines fridge with supplement drinks. The inspector advised that this was not appropriate and that a procedure for storing samples be devised so that everyone is clear.
Rose Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 Page 13 Staff were observed to knock before entering rooms and staff and service users confirmed that service users privacy was respected at all times. Curtain screening is provided in double rooms. At the previous inspection a service user, who cannot manage to use a key to lock his bedroom door, has requested that, this be done for him by staff, to maintain privacy, of his possessions when, not in his room. The manager reported that this had been facilitated, however there was no evidence on the service users care plan regarding this preference/need. Five service users who were spoken with were not aware that they could have a key to their bedroom or lockable facility and this should be addressed within care plans. The wishes of service users at the end of their life had been obtained where possible but this really only contained information regarding funeral arrangements and about resuscitation. The inspector advised that it was not appropriate to seek this information out as the home does not provide nursing interventions and the decision about resuscitation is that made by a Doctor under certain criteria. If service users wish for this information to be passed to a hospital on need for admission then this could be supported, however the decision would still be with the Doctor at the time. It would be beneficial for service users to make any special requests regarding their needs and wishes for any special arrangements to make them more comfortable in their final days and for any special instructions upon their death. Policies and procedures are in place for dealing with dying and death. There have been a number of deaths recently at the home of several long term service users. All have been notified to CSCI. Rose Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 Page 14 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 standard(s) 12, 14, 15 Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social and cultural religious and recreational needs and are helped to exercise choice and control over their lives. Service users enjoy their meals and mealtimes and would benefit from large print menus placed on the dining tables. EVIDENCE: A programme of activities is provided by an activities co-ordinator The staff, and service users spoken with stated that there has been a marked improvement in the quality and level of activities undertaken by the service users. Outings have been co-ordinated on a more regular basis and a full weekly activities program tailored for the varying needs of the service users has been placed. Some of the activities offered include nail care, arts and crafts, games, Bingo, movement to music, quizzes, reminiscence groups, knitting/sewing and film shows. An entertainer/singer is arranged periodically. Participation in activities is recorded. Rooms examined were personalised and service users spoken with confirmed that they were able to exercise personal autonomy and choice. Service users records were kept secure and access facilitated where necessary. Rose Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 Page 15 The menu was displayed on Barnes, although service users stated they did not know what was on offer until they are seated and are offered a choice. It is recommended that a large print version of the menu be provided on each table so that service users can be informed each morning of the day’s menu. The vegetable options provided should be included on the menu. The menu appeared varied and nutritious. Two soft diets were needed on Barnes at the time of the inspection. Service users reported that the food was good and that it was served in portions according to their preferences. Rose Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 Page 16 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 standard(s) 16, 18 Service users know how to make a complaint and are protected from abuse. EVIDENCE: The home has a compliments and complaints procedure, which was clearly displayed in the reception area. There were no reported complaints. On speaking with service users, all stated they were aware of how to make a complaint and said they felt confident they would be taken seriously Three referrals had been referred under the adult protection procedures to Social Services and are awaiting outcomes. The majority of staff have undertaken training in abuse awareness. A new whistle blowing policy has been implemented but this was not examined at this inspection. Rose Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19-26 Service users live in a clean, safe well maintained environment with access to safe and comfortable indoor and outdoor communal facilities. The washing and lavatory facilities are adequate and the home is equipped with specialist equipment to maximise service users needs. Service users bedrooms suit their needs with their own possessions around them, however, the issue of keys and provision of tables needs to be addressed. EVIDENCE: The location and layout of the home appeared to be suitable for its stated purpose and appeared clean smelled fresh overall and was in decorative order. Each unit has it’s own, communal lounge and dining space. The home is a nonsmoking building. Lighting and ventilation is adequate throughout the home. Furnishings are domestic in character and appeared of good quality. Each unit has its own bathing and toileting facilities. Liquid soap and disposable towels are provided in all the communal bathrooms and toilets. On examination those seen appeared clean, safe and functional. The home appears to be sufficiently adapted to cater for the needs of people with a disability. Handrails are fitted throughout. There is a passenger lift. A
Rose Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 Page 18 call bell is fitted throughout the building. Visual cues are sited around the home to assist those service users with dementia. The pre inspection questionnaire reported there had been no change to the building, however an application has been made for the number of beds to be increased. Rooms examined appeared spacious and well furnished. Service users’ rooms appeared comfortably furnished and meet all the requirements under standard 24 apart from the provision of a table. The director reported that room layouts are being reviewed later in the year. Bedroom doors are fitted with approved safety locks but there was no evidence in care plans that service users had been offered a key enabling service users to maintain their privacy if they so wish. Bedrooms are personalised and reflect the taste of each individual. A lockable facility is provided in each room for safe storage of personal medicines, and any item of value. Call bells are reachable from the beds. Service users spoken with on the day said that they were satisfied with their accommodation. [There is an issue re privacy locks see standard 10]. Rooms appeared well lit and naturally ventilated. Rooms are centrally heated and heating may be controlled in the service user’s own room. Central heating radiators are low surface temperature type. Lighting is domestic in character and includes a bedside light. Emergency lighting, which is an integral part of the fire alarm system, is provided throughout the building. There is a fire risk assessment in place and appropriate standards in place for fire alarm testing and equipment checks. The home was overall clean and hygienic. Training is provided for staff in infection control. Laundry facilities were not inspected at this visit. Rose Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 Service users needs are met by the numbers and skill mix of staff, who are trained to an appropriate standard. The recruitment practices are in breach of the regulations and assessed as poor as a result of this and because this is a second time breach of this regulation. EVIDENCE: Rotas were examined and the manager and staff reported that overall staffing levels are maintained. There are occasions when staff ring in sick, which may leave a shift short, however staffing levels are reported to be, much improved. The home has nine care staff on each daytime shifts and six are rotere’d every night, Adequate catering and domestic staff are provided. Eighteen staff have attained NVQ 2 or above and ten are working towards this. The staff team hope to achieve 65 by the end of 2005. A sample of five staff personal files were examined, two were satisfactory, however three files were found to be in breach of legislation. Two staff had been allowed to commence work before the registered person was in receipt of a POVA, CRB and two satisfactory references. Not all of the staff files had photographs and a CRB dated 2003 undertaken by another employer had been accepted. CRB’s are not transferable between employers. A new CRB application must be obtained immediately for this person. [one person was missing a second reference, but had undergone POVA screening but had no returned CRB when employment commenced and there was no evidence of
Rose Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 Page 20 supervision during this period] Another had a start date prior to POVA clearance and their was no evidence of induction or supervision] An immediate requirement was set in relation to new staff not starting work before the appropriate checks are in place. This is a second time breach of this legislation and further non compliance/breach will result in enforcement action being taken. Staff, have terms and conditions. The provision of training for staff is good with all mandatory training being covered. Other training in dementia, challenging behaviour Parkinson’s disease, and Diabetes has also been provided. Future training planned is for basic care of an individual, nutrition in the care setting, stress in the workplace and vulnerable adults. Rose Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 Page 21 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 36, 37, 38 Service users live in a home, which is run and managed by a person who is fit to be in charge. A new manager is to undergo the process for registration shortly. Staff, are appropriately supervised and record keeping overall is good. The health and safety and welfare of service users and staff are promoted and protected. EVIDENCE: The Registered Manager is a registered nurse and has a management qualification as well as being an NVQ assessor. However the day of the inspection was the registered managers last shift before leaving the employ of the home. A new acting manager has been recruited and an application has been submitted for her to be registered as a fit person. The new acting manager has worked at the home for a number of years and has supervisory experience. Staff reported that they were confident in the new acting manager and that she, would be, supported, by them.
Rose Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 Page 22 Staff confirmed that formal supervision is undertaken on a monthly basis. The records examined were all satisfactory. There appeared to be good systems in place for health and safety management. There are systems in place for the prevention of legionella. Risk assessments for all safe working practice topics and fire risk assessments were available. A Health and Safety Poster was observed in the staff room on the Garden Wing. Window restrictors were observed in the home. Training in health and safety was provided to a satisfactory level. There was evidence of the gas safety check being carried out but as there is work to be undertaken the certificate has not been issued yet. The 5 yearly circuit safety check was carried out in July 2004. Policies were in place for health and safety. These must be provided for inspection by CSCI. The Environmental Health officer visited the home in June 2005. There were no issue identified. Overall the health and safety of service users appeared to be safeguarded. Rose Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 Page 23 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x x 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 x 14 3 15 3
COMPLAINTS AND PROTECTION 3 3 3 3 3 2 3 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x x 3 3 3 Rose Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 Page 24 No 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. 1. Standard OP29 Regulation 7, 9, 19 Timescale for action New staff must only commence 15th work on receipt of an up to date, September satisfactory POVA and CRB check 2005 12, and two written references 20pm Ensure that all staff files contain 15th the relevent documentation as October required under schedule 2. 2005 Requirement 2. OP29 7, 9, 19, Schedule 2 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard OP1 OP4 OP7 OP7 OP8 OP8 Good Practice Recommendations Decide whether to use the brochure or the service users guide and have one or the other, particularly as the information is to be changed regarding the manager Encourage staff to enquire as to service users likes and dislikes when completing assessments and care plans. Daily progress records should report holistically on service users daily well-being rather than care tasks performed and monitored. Provide staff with a prompt sheet to assist is completing service users personal profiles. Implement a system/procedure for monitoring unexplained bruising as specified in the report and ensure all \incidents of this type are recorded in the accident book. Cease the practice of monitoring service users blood
C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 Page 25 Rose Farm Care Home 7. 8. 9. 10. 11. 12. 13. 14. 15. OP8 OP9 OP10 OP11 OP15 OP23 OP24 OP38 OP38 pressure as the home provides personal care only. Ensure staff explain what they mean by aggression and detail in the notes, how is this presented by service users Implement a procedure for storing urine and feceas samples Ensure the the request of the service user wishing to have his room locked by staff when not present is documented as a care planrisk assessement Cease asking service users and relatives about resucitation but expand on other needs and wishes for end of life. Provide large print menus on the tables on a daily basis and include vegetable options. Inform the Inspector of the outcomes of the POVA investigations. Provide evidence in care plans that service users are offered a key to their bedroom and lockable facilities unless a risk asessment documents otherwise Provide the inspector with evidence of the gas sefety certificate once the remedial work has been carried out Obtain a new accident report book which is complient with the Data Protection Act 1998 Rose Farm Care Home C03 C53 S61468 Rose Farm V245922 150905 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Edgeley House Riverside Business Park, Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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