CARE HOMES FOR OLDER PEOPLE
Rose Farm Care Home Main Street Styrrup Doncaster South Yorkshire DN11 8NB Lead Inspector
Jayne Hilton Unannounced Inspection 7th November 2007 08:00 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 Farm Care Home DS0000061468.V352271.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 Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Rose Farm Care Home Address Main Street Styrrup Doncaster South Yorkshire DN11 8NB 01302 744664 01302 746900 admin@rosefarmhome.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) R S Care Homes Ltd Mrs Lorraine Ball Care Home 54 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (35), Old age, not falling within any other of places category (19) Rose Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. The total number of beds shall be 54. Within the total number of beds a maximum of 35 may be used for the category DE(E). Within the total number of beds a maximum of 19 may be used for the category OP. Within the total number of beds a maximum of 2 may be used for the category DE. 22nd January 2007 Date of last inspection 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 of 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. The fee range in the service user guide is stated as between £415 and £435 depending on needs. Copies of previous inspection reports and the Service User Guide were on display in the home. Rose Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection took place over 7 daytime hours and was unannounced. Because people with dementia are not always able to tell us about their experiences, we have used a formal way to observe people in this inspection to help us understand. We call this the ‘Short Observational Framework for Inspection’ (SOFI). This involved us observing five people who use services for 2 hours and recording their experiences at regular intervals. This included their state of well being, and how they interacted with staff members, other people who use services, and the environment. The observation took place in the dining room and lounge in the ‘Garden Wing’ of the home. Our overall findings were that the service promises to deliver care to service users in a way, which respects their personal dignity and right to privacy and that this is how care is provided in practice. We found that there were high levels of staff interaction with the service users and the interactions, which were seen, were mostly of good quality to enhance the quality of life of the residents who were observed. We also spoke to the manager, three staff members and five people who use the service who was not part of the observation. We looked at records and documents, including five people’s care plans. What the service does well:
Service users have information about the home and can be assured the home will meet their individual needs and preferences and are supported well to settle into their new surroundings. Service users health, personal and social care needs are set out in an individualised plan of care and their health needs are fully met. Rose Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 6 Service users are treated with respect and their privacy upheld. Records of Relatives consultation confirms that they feel that staff are competent to meet their health and personal care needs and service users spoken with stated they were happy, that their healthcare was looked after well. Through the observation process many positive interactions between service users and staff were demonstrated including warmth, holding, a relaxed pace and atmosphere, acknowledgement, genuiness, facilitation, enabling and belonging, which provided comfort, identity, attachment, occupation and inclusion, resulting in very positive outcomes for people with dementia. There were no times during this observation when the service users with Dementia showed negative mood states of being. A recent audit undertaken by the community pharmacist showed good compliance with medication management in the home and staff told us and and the records confirmed that they have undertaken training in safe handling of medication. Service users find the lifestyle in the home matches their expectations and preferences and satisfies their dietary, social, cultural religious and recreational interests and needs. Services users are able to make decisions on what they would like to see on the menus and activities programmes and service users stated they had recently been consulted about menus and have full say about their daily routines and bedtimes etc. Service users know how to make a complaint and good systems are in place to protect them from harm. Service Users live in a comfortable, homely, clean environment with a choice of communal areas and personalised bedrooms. The up-to-date infection control policy is followed and a safe environment maintained. Service users are protected by the homes recruitment policies and staffing numbers and staff have received training to enable them to meet the needs of residents. The home has a clear and accountable management structure appropriate for its size. The registered provider, staff and service users praised the approach of the manager. Staff said the manager was firm but fair and helpful. Observations of the managers practice on the day demonstrated good leadership and knowledge base of careing for people with dementia. Rose Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 7 The home is run in the best interests of service users and their health and safety is promoted and protected. What has improved since the last inspection? What they could do better:
Revisit the process for auditing staff personal files, to ensure all required documentation is safely stored. Rose Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 8 One requirement has been set in respect of the above. In addition four good practice recommendations have been made as follows: Implement a cross- reference system to ensure blood test results are followed up. Improve the system for bowel monitoring to ensure staff are fully aware of when to take action in promotion of good healthcare for service users at all times. Ensure two people witness any handwritten prescriptions on the medication charts and the policy advocates this practice. Review and increase the hours provided for the activities provision and afternoon catering. 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 Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 9 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 Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users have information about the home and can be assured the home will meet their individual needs and preferences and are supported well to settle into their new surroundings. The home does not provide an intermediate care service. EVIDENCE: The home has produced a Service Users Guide and Statement of Purpose that describes how the individual needs of residents will be met and which details the fees charged and contain a copy of the previous inspection reports on the home. The home has access to interpreters and sign language specialists should
Rose Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 11 these be required. Innovative methods are used to make the material given meaningful and interesting such as a welcome pack. Five service users care plans were viewed. Pre-assessment visits are an integral part of the home’s pre-admission procedure. . A senior member of staff who is trained and skilled in assessment techniques carries out the needs assessment, including that of individuals who are selffunding. Service users are supported and encouraged to be involved in the assessment process. The home has formal documentation in place for carrying out holistic needs assessment. A senior member of staff who is trained and skilled in assessment techniques carries out the needs assessment, including that of individuals who are selffunding. Service users are supported and encouraged to be involved in the assessment process. Two newly admitted residents were observed being supported to feel welcome in the home and they appeared relaxed and comfortable with their new home. As the home is based in a semi-rural community there is less diversity within the service user’s catchment area. However person centred care is provided where the individual is the central focus which areas of diversity impact upon. Policies and procedures also ensure equality and diversity are promoted and incorporated into what they do. Religious needs are met through the local community either by the service users attending a place of worship, or the local clergy coming into the home. Dietary needs of certain religions are addressed pre-admission to ensure the home could meet the service user’s requirements. Rose Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 12 Further development of the personal life history profiles and the assessment documentation would further embrace the individual as a whole person. Rose Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 13 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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users health, personal and social care needs are set out in an individualised plan of care and their health needs are fully met. Service users are treated with respect and their privacy upheld. EVIDENCE: The care plans examined demonstrated that each service user is supported to make their own decisions, the home uses a person centered care planning approach, which is evaluated at regular intervals. Care staff confirmed they are trained in giving choice to service users and in ways in which to facilitate users to make decisions, for example, what to wear and service users spoken with endorsed this.
Rose Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 14 The home operates a policy of knocking before entering a service user’s room to ensure privacy, dignity and respect, which practice was observed on the day of the inspection. Care plans and risk assessments were in place to identify those at risk of pressure damage and what action is being taken to reduce the risk for example pressure relieving equipment. Care plans and risk assessments for identifying and acting upon service users at risk of malnutrition are also in place. The home carries out risk assessments aiming to prevent falls and these are monitored. The home has a policy for the receipt, storage and handling, administration and disposal of medication, however handwritten prescriptions on the medication record chart were noted not signed or witnessed. The policies and practices in respect of these needs to be revisted to ensure appropriate and safe practice at all times. A recent audit undertaken by the community pharmacist showed good compliance with medication management in the home and staff told us, and the records confirmed that they have undertaken training in safe handling of medication. The home assists residents in planning for routine healthcare visits and keeping appointments. Records of Relatives consultation confirms that they feel that staff are competent to meet their health and personal care needs and service users spoken with stated they were happy, that their healthcare was looked after well. Through the observation process many positive interactions between service users and staff were demonstrated including warmth, holding, a relaxed pace and atmosphere, acknowledgement, genuiness, facilitation, enabling and belonging, which provided comfort, identity, attachment, occupation and inclusion, resulting in very positive outcomes for people with dementia. There were no times during this observation when the service users with Dementia showed negative mood states of being. Rose Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users find the lifestyle in the home matches their expectations and preferences and satisfies their dietary, social, cultural religious and recreational interests and needs. EVIDENCE: The home has good links with the community so that service users can access local activities and the community can be involved in the home’s activities. The care home has regular service user forums where ideas on improvements are discussed and taken on board by management. Minutes of meetings and feedback from satisfaction surveys evidenced this. Services users are able to make decisions on what they would like to see on the menus and activities programmes and service users stated they had recently been consulted about menus and have full say about their daily routines and bedtimes etc.
Rose Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 16 The home has open visiting arrangements and has areas where service users can meet with relatives/friends/professionals and not be disturbed. Service users are able to have their own private phone line into their rooms. The care home encourages services users to become involved in activities should they wish. The home will accommodate as much as possible of a service user’s personal possessions which they wish to bring with them into the home. The home offers three meals, together with snacks and drinks each day, special diets are catered for, for example diabetic diet. Soft diets were served in an appetising way and people were assisted to eat by staff in a sensative and enabling way. Service users spoken with did comment that they sometimes would like the option of having a small snack or sandwich at lunchtime, rather than a full roast dinner, but were not sure if this would be facilitated. The meal on the day offered roast beef or roast chicken, roast or mashed potatoes, carrots and cabbage, with Rhubarb crumble for sweet and service users were observed being asked which option they would like. An activities co-ordinator works 18 hours a week and the home offers a wide range of activities including hosting a variety of Theme Days, such as the American Day and Italian Day. A recent Halloween Party was spoken about by staff and service users. The local community has been involved with various projects with in the home for example, the Army Cadet Band joined staff in a Memory Walk for the Alzheimer’s Society. The home has identified the need for complementary therapies such as aromatherapy and massage. Such therapies were very well received by the service users and is now incorporated them into the activities program. Rose Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 17 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users know how to make a complaint and good systems are in place to protect them from harm. EVIDENCE: The Homes policies and procedures on complaints and suggestions for improvement are up to date. The service user guide has clear guidelines on how to make a complaint and the complaint procedure is displayed within the home. Service users and staff spoken with confirmed they knew how to make a complaint Examination of the complaints procedure confirmed that it details how the complaint will be dealt with and the response times. Two complaints had been recorded since the previous inspection, one of which was upheld. Rose Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 18 Complaints made included issues about lost belongings,staffing levels, cocern about service users going outside in the garden and hospital escort arrangements. Service User/Relatives satisfaction surveys confirm that residents are satisfied with the manner in which they can share concerns in relation to their protection and safety. The home has obtained the new procedures and guidance on safegaurding adults. Staff training records confirmed that most staff have been trained in in safeguarding issues. Examination of procedures confirms that a robust whistle blowing procedure is in place, but not all staff spoken with were fully knowldegeable about the contents this. There have been no reported safeguarding issues in the home in the previous twelve months. Agreements are in place with risk assessments for the use of bedrails and staff are trained to deal with challenging behaviours. Rose Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 19 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 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service Users live in a comfortable, homely, clean environment with a choice of communal areas and personalised bedrooms. The up-to-date infection control policy is followed and maintains a safe environment. EVIDENCE: The care home is maintained appropriately to reduce the risk of infection and cross infection. Antibacterial scrubs and protective clothing was observed to be in use at all times. The care home provides infection control training to staff so that they are aware of the importance of prevention.
Rose Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 20 A program of internal and external routine maintenance works is kept within the home. The home complies with the requirements from the local fire service and a risk assessment was viewed in the home. Communal space is available within the home for all service users to access. The home has outdoor space which is accessible to all servise users including those with mobility problems. The home has a nurse call system with an accessible alarm facility in every room. Each room is centrally heated with controls in each service users room. Service user satisfaction surveys results confirmed observations on the day that the home is well maintained, clean, smells fresh and is safe and comfortable. Cleanliness and maintenance are discussed at service user meetings and any comments are acted upon. The homes contracts for maintenance by external contractors are up to date and the maintenance schedule has been followed. All bedrooms have high levels of privacy and locks. All service users are offered a key unless risk assessment proves otherwise. The provider stated in the annual quality assurance assesment “some service users indicated that they would be interested in gardening, therefore this spring the home encouraged service users interested in gardening to get involved with the planting of many of the gardens flower beds. Service users were also encouraged to use the greenhouse. The efforts of these service users was evident in the wonderful gardens this summer”. The garden areas were observed on the day of the inspection to provide pleasant seating areas with ornamental gardens and potted plants. Rose Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by the homes recruitment policies and staffing numbers. Staff have received training to enable them to meet the needs of service users. EVIDENCE: Staff practices observed confirmed that all staff operates in a manner, which promotes liberty and enable users to feel safe and secure whilst promoting independence. Service users said staff were marvellous, hard working and do their best, but felt that there was not enough of them, they also confirmed their needs had never been unmet. The home undertakes a robust recruitment process and carry out various checks on possible employees, for example, CRB, [Criminal Records Bureau] checks references and employment history, however one out of four staff files examined did not have references enclosed. This appeared to be a surprise to the registered provider and registered manager who both said they had previously audited the staff records in detail.
Rose Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 22 Staff records showed staff receive induction training and regular updates. The care home has an appropriately qualified workforce with at least 50 of staff delivering personal care holding an NVQ level 2 or above. All staff working within the home complete mandatory annual training, applicable to their role within the company, for example, manual handling, health and safety, food hygiene, first aid and fire safety. . Examination of list of staff employed by the home and staff rotas confirms that there are sufficient staff available at all times to meet the needs and aspirations of the service users and that the home has a diverse staff team which reflects the culture and/or the gender of residents wherever possible. In house training packs have been introduced, one, which provides training for staff in equality and diversity. Staff said they had covered equality and diversity in NVQ work, but that more in depth training would be beneficial. Staff demonstrated that they have a through understanding of the needs of service users and can deliver highly effective personal care and there are written records of the monitoring of staff performance, however the system for staff supervision has recently lapsed, but action was being taken to get this back on track to ensure all staff receive six sessions a year each. Service user satisfaction survey results confirm that services meet their individual needs. Rose Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 23 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, 32, 33, 35, 36, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of service users and their health and safety is promoted and protected. EVIDENCE: The manager of the home has 2 years management experience in a care setting and is working towards the NVQ 4 qualification in management and care. Rose Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 24 The home has a clear and accountable management structure appropriate for its size. The registered provider, staff and service users praised the approach of the manager. Staff said the manager was firm but fair and helpful. Observations of the managers practice on the day demonstrated good leadership and knowledge base of careing for people with dementia. The manager demonstrated an understanding of equality and diversity. A sample of records were viewed, including health and safety records, care plans, training records and mainteneance checks. Record keeping was found to be satisfcatory The care home regularly analyses the quality of the service, each service user is sent an annual satisfaction questionnaire. Auditing of the Quality Management system takes place and spot checks and monitoring reflects that practice reflects the homes policies and procedures. Service users are able to look at the records about them kept by the care home if they wish to, some service users confirmed they had done this. The home provides a safe place for the service users to keep valuables and money. A record of anything kept within this area is maintained. The home has robust policies and procedures in place to ensure the management of individual’s money. There are clear lines of accountability the home has clear and effective support via the Directors and as required access to professional business and accountancy advice. The insurance cover in place confirms that the home or corporate body are fully insured to meet any loss or legal liabilities. The insurance policy is displayed in the home. The Health & Safety and risk assessment policies and procedures are up to date and staff are trained in all aspects of helath and safety including risk assessment. Heaklth and safety audits were viewed and all records kept up to date. Examination of the accident records confirm that there have been no preventable accidents or clear trends can be demonstrated indicating a steady reduction in the number of preventable accidents. There were no health and safety issues identified at this inspection. Rose Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 4 4 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 4 4 X 3 3 3 4 Rose Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 19 Schedule 2 Requirement Ensure staff personal records contain all documentation as required by regulation. This requirement is in respect of missing references on an existing staff members file. Timescale for action 20/12/07 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 3 4 Refer to Standard OP8 OP8 OP9 OP27 Good Practice Recommendations Implement a cross- reference system to ensure blood test results are followed up. Improve the system for bowel monitoring to ensure staff are fully aware of when to take action in promotion of good healthcare for service users at all times. Ensure two people witness any handwritten prescriptions on the medication charts and the policy advocates this practice. Review and increase the hours provided for the activities provision and afternoon catering. Rose Farm Care Home DS0000061468.V352271.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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