Inspection on 11/10/06 for Rose Lawn

This inspection was carried out on 11th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

Other inspections for this house

Rose Lawn 16/07/08

Rose Lawn 15/08/07

Rose Lawn 22/02/06

Rose Lawn 05/08/05

Rose Lawn 16/02/05

Rose Lawn 09/11/04

Rose Lawn 01/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Rose Lawn Rose Lawn All Saints Road Sidmouth Devon EX10 8EX Lead Inspector Teresa Anderson Key Unannounced Inspection 11th October 2006 10:00 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 Lawn DS0000022020.V296865.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 Lawn DS0000022020.V296865.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rose Lawn Address Rose Lawn All Saints Road Sidmouth Devon EX10 8EX 01395 513876 01395 579519 roselawnsidmouth@aol.com www.keychange.org.uk Key Change 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) Mrs Margaret Mary Haxton Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Rose Lawn DS0000022020.V296865.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is permitted to admit one resident under 65 years of age at any one time 22nd February 2006 Date of last inspection Brief Description of the Service: Roselawn provides personal care and accommodation for up to 29 older people. It is owned by Key Change, a not for profit organisation, which has a Christian and spiritual ethos. The home is situated a few minutes walk from the town centre, shops, local amenities and seafront of Sidmouth. Communal areas are made of a reception area with seating, two lounges, a quiet room, conservatory and a large dining room. The kitchen is equipped to a very high standard. The area to the rear of the property is paved and some rooms having direct access onto this through patio doors. There are views over the local rugby ground at the rear of the property. Bedroom accommodation is provided on the ground and first floors of the home, and floors are linked by a passenger lift. All bedrooms have en suite facilities. There is level access throughout the ground floor. The current level of fees range from £280 - £600.00. This does include services such as hairdressing, chiropody and transport. Information about the home is available direct from the home or from the Key Change website www.keychange.org.uk Rose Lawn DS0000022020.V296865.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place as part of the normal programme of inspection. The site visit started at 10.00 and finished at 16.00. During that time the inspector spoke with 3 residents in-depth and with approximately 12 other residents, with 1 visitor, the manager, 3 members of care staff and the cook. The care and accommodation offered to 3 people living at the home was case tracked. This involves looking at the services and care offered to these people and helps us to understand the experiences of the people living at the home. The inspector saw all communal and service areas of the home and the majority of bedrooms. She looked at records in relation to care planning, medication, staff recruitment and residents monies. Prior to the site visit the manager supplied the commission with information about the home in a pre-inspection questionnaire. Surveys (asking for comments) were sent to 10 residents and 6 were returned; to 20 staff and 5 were returned and to health and social care staff and none were returned. What the service does well: Residents receive enough information about this home on which to base their decision to move in. Many said they did not need this information, as they already knew the home from visiting other people who had lived there. One visitor said that they had visited the home many times (not always announced) before their relative had moved in and had always been happy with what they saw. Resident’s healthcare needs are well met with appropriate referrals being made to healthcare professionals. Residents say they feel very well cared for and the majority say they get the care, support and medical support they need. The home is very close to the town, amenities and seafront of Sidmouth. Those who are able go into town as they like and others are, time permitting, and offered help by carers. There is good contact with the local community and many residents have lived near by. Visitors say they are always warmly welcomed and kept up to date. Residents say they are able to make choices about how they live their lives, for example in their preferred routines, what they wear and what and where they eat. Without exception residents are extremely complimentary about the food served at the home. They say there are plenty of variety and choice and ample portions. Descriptions include ‘excellent’, ‘marvellous’ and ‘wonderful sweet trolley (which offers a choice of 6 deserts). The food is exceptionally well presented and each meal is an occasion. Rose Lawn DS0000022020.V296865.R01.S.doc Version 5.2 Page 6 Residents feel safe, secure and well cared for. Staff receive training in safeguarding adults and demonstrate a good understanding of this. This home is exceptionally well kept. It is always clean and fresh, well maintained, furnished and decorated. Staff understand and follow infection control procedures to help prevent cross infection. Staff are described as ‘excellent’, ‘lovely’ and ‘always go that extra mile’. There are usually 5-6 carers on in the morning, 4 – 5 in the afternoon and evening and 2 at night. Residents say they seldom have to wait for attention. The manager is much appreciated by the residents for her thoughtfulness and kindness. She is very experienced and exceptionally committed and has managed the developed of the home to its current compliment of 29 residents. What has improved since the last inspection? What they could do better: Care plans for those residents who are more dependent do not provide sufficient information about how their needs should be met. The management of some aspects of medication are potentially placing residents at risk. Some residents would prefer to receive care from female carers only. Not all residents are completely satisfied with the arrangements for meeting their social and leisure needs. Some residents would benefit from the addition in the home of raised seats to help with mobility and independence. Staff induction arrangements are not based on the guidance issued by ‘Skills for Care’. Recruitment policies are not always being followed to the full. Rose Lawn DS0000022020.V296865.R01.S.doc Version 5.2 Page 7 Quality assurance procedures have not been developed to ensure the home is being run in the best interests of residents. The management of resident’s monies is generally good, but receipts should be obtained for all transactions. The number of people who have received 1st Aid training should be increased to ensure there is a member of staff on each shift who has this qualification. 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 Lawn DS0000022020.V296865.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rose Lawn DS0000022020.V296865.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3 (this home does not provide intermediate care). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents have enough information about the home before they move in enabling them to make an informed choice. Assessments of residents prior to admission ensure that staff have enough information in order to know and meet their needs. EVIDENCE: In surveys all 6 residents said that they have a contract and that they had enough information about the home before moving in. Many said that they had visited the home before moving in or had known people who had lived in the home previously. One relative said they had visited the home 3 times, not always announced, and was very impressed. Their relative has now lived at the home for some time and they remain happy with the decision made. Before being admitted to the home the manager visits and assesses every prospective resident. She uses this information to make a decision about Rose Lawn DS0000022020.V296865.R01.S.doc Version 5.2 Page 10 whether the home can meet that person’s needs. However, in surveys the majority of the 5 staff who responded say that they are only sometimes personally introduced to the new resident and do not always understand the plan of care to be delivered to this person. One person thought that the way that people are introduced to other residents and staff could be improved. Rose Lawn DS0000022020.V296865.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The arrangements in place for planning resident’s care do not ensure that all residents consistently get the care they need in a way that suits them. The healthcare needs of residents are well met with evidence of multidisciplinary involvement. The systems for the management and administration of medications are good, however because not all staff are following them residents are being placed at potential risk. Personal support is generally offered in a way that protects residents’ privacy and dignity. However, the practice of not asking residents if they would prefer to receive their personal care from a male or female carer is compromising their dignity. Rose Lawn DS0000022020.V296865.R01.S.doc Version 5.2 Page 12 EVIDENCE: Each person living at the home has his or her own plan of care. Whilst the majority of residents do not need detailed care plans, a number of people with higher dependency needs do. The inspector looked at 3 care plans in depth. Two of the care plans seen (of less able residents) did not identify all of the needs of the resident and therefore did not provide information for staff on how these needs should be met. None contained information on the likes, preferences or routines of the resident. None contained meaningful reviews or evaluations of the care given. All 3 care plans contain assessments that identify risks in relation to pressure area damage and falls. All identify risks relating to these areas but plans on how to minimise the risks identified have not been recorded. However, it is notable that only one person has a pressure sore (which did not develop in the home) and that the number of falls in the home is low. This may indicate that staff are using their skills to manage these issues but are not recording this. In relation to nutrition all 3 care plans contain risk assessments. All 3 identify some level of risk, however none contain instructions on how staff should manage this risk. None contain the details of the resident’s food likes and dislikes. One care plan shows that the resident was last weighed in July. This person reports they are losing weight. Records are not kept about how much they eat and does not list their favourite foods or food dislikes. This person told the inspector and a carer what their favourite and second favourite food is. They also said what they did not like. Staff on duty reported they had not known this. In addition there was some confusion amongst staff as to whether this person needs help with eating. The inspector observed them eating and noted that they dropped a lot of their food into their lap. A carer had noted that this person looked ‘dry’ and thought they might not be drinking enough. They made sure to keep popping in to see the resident to encourage them to drink. However, the care plan does not give staff instructions to do this, which may result in inconsistency of care delivery. No records are kept of how much fluid this person drinks; the cup in which hot drinks are offered is very heavy and the resident was observed struggling to pick it up. This person has their bedroom in a part of the home where they cannot be easily observed. However, staff report that they are usually taken downstairs to the dining room to have lunch. Rose Lawn DS0000022020.V296865.R01.S.doc Version 5.2 Page 13 In surveys the majority of residents say they always get the care and support they need; one indicated that the quality of care could be variable. Staff (in surveys) say that communication about some residents needs could be improved and some staff think that some residents had become more dependent and need more care. There is good evidence in care plans, in surveys and from discussions with residents that all residents have their healthcare needs met. Timely referrals are made to for example GP’s, district nurses, chiropody and dentists. Residents are assisted to attend hospital and specialist appointments. The home has policies and procedures in place for ordering, storing, administering and returning medication. Staff receive training in the administration of medication. However, it was noted during inspection of medication records that medication bought into the home by one newly admitted resident was not recorded safely. The person accepting the medication had not signed for this and it would appear they had not checked this with a second person, as there was not a second signature. The home has a fridge for storing those medicines that need to be kept cool. However, this does not have a lock meaning that these medicines are not kept secure. The manager reports a lockable fridge is on order. During the inspection one resident reported that they had a medical problem, which had been treated with a particular medication when they had been at home. They report (and records confirmed) that they are not receiving this medication in the home, and talked to the inspector and to a carer of their discomfort. The carer said that this person did not have this problem but the manager says that a referral for advice has been made to the GP. Residents say that their privacy is respected. For example, all care is given in private and staff always knock on bedroom and bathroom doors before entering. All residents are dressed in clothes of their choice that are very well cared for. However, some female residents said they would prefer not to have male carers as they felt this affected their dignity. The manager reports that residents are offered a choice of male or female carer, but does not record this. Rose Lawn DS0000022020.V296865.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Links with the community and visitors are good and residents, on the whole, have their social care needs met. Support is offered in a way that promotes choice and flexibility. The meals offered are excellent providing choice, lots of variety and meet nutritional needs. EVIDENCE: Roselawn is located in the heart of Sidmouth and the majority of residents come from the local area. Visiting is open (within reason) and visitors and residents report that visitors are always made welcome and offered refreshments. In surveys 3 residents say that they are always offered activities that they can take part in, 1 that they usually are and 2 that they sometimes are. The home does not offer a programme of events but does arrange music to movement once a week. The manager reports that this is attended by between 5 and 10 people. When asked by the inspector, many residents who need help said they Rose Lawn DS0000022020.V296865.R01.S.doc Version 5.2 Page 15 would like to go out more often. Some residents said they get bored. Care plans seen do not contain information about residents’ previous interests or their social preferences. The home has consistently excelled at using meals and parties to celebrate events such as birthdays and festivals. Tables are always laid and decorated. Without exception residents say the food served is excellent. Comments include ‘marvellous sweet trolley’, ‘liberal helpings’ and ‘particularly good’. One resident commented how helpful the cook had been when they had not been well. The cook had used their knowledge of food and the resident to tempt them to eat and therefore to help them to get better. Those residents who require a soft diet have their food presented in a manner that ensures it looks attractive. The meat is minced and the vegetables are served soft. This is very good practice. Residents say they are offered lots of choices. For example they choose the food they eat and where they eat it, what they wear and how they spend their time. Each resident was seen to be treated as an individual by the staff. They understand their idiosyncrasies and respond to these. Rose Lawn DS0000022020.V296865.R01.S.doc Version 5.2 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 the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has a satisfactory complaints system that residents feel confident in using if they need to. Residents feel safe and well cared for and staff’s knowledge of safeguarding adults ensures that residents live in an environment where they are protected from abuse. EVIDENCE: In surveys all residents say that they always know who to speak with if they are not happy and that they know how to make a complaint. During the inspection some residents said that they were so grateful for living in such a beautiful home with such good staff that they wouldn’t dream of making even a slight complaint to the manager. One person thought it would be a good idea to bring back the ‘suggestions box’ that the home used to have. The inspector discussed this with the manager during the inspection. One complaint was received about this home by the commission. The complaint was investigated by the manager of the home who reports that it was not upheld. The inspector asked for a written report about this at the time but has yet to receive this. This was discussed again with the manager who has agreed to send this to the commission. Rose Lawn DS0000022020.V296865.R01.S.doc Version 5.2 Page 17 Staff spoken with demonstrate a good understanding of safeguarding adult issues and confirm they receive training from the manager and by watching the ‘No Secrets’ video produced by the Department of Health. Residents say they feel safe and secure. Rose Lawn DS0000022020.V296865.R01.S.doc Version 5.2 Page 18 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, 22 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The environment of this home provides residents with a homely, clean and safe place to live. The addition of some specialist equipment to promote independence and mobility would further enhance the lives of residents. EVIDENCE: In surveys and during discussions with residents, all said that the home is always clean and fresh and that the cleaners work hard to keep it this way. Residents say the home is beautifully furnished and they enjoy the clean and fresh environment. One resident showed the inspector her shower room that she ‘loves’. All bedrooms are personalised to the taste of the resident and are kept clean and fresh. Rose Lawn DS0000022020.V296865.R01.S.doc Version 5.2 Page 19 Staff were observed following infection control procedures to prevent infection. During the inspection it was noticed that a number of chairs in the home are quite low. The inspector observed some residents having to ask for help to rise from them and some residents ‘flopping’ into them. This was discussed with the manager who says that some new higher chairs have already been ordered to aid mobility and independence. One person thought it would be a good idea to have a seat outside the lift for residents to sit on whilst waiting. Rose Lawn DS0000022020.V296865.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. The quality outcome in this area is adequate. This judgement has been made using available evidence including a site visit. Staff receive appropriate training to provide residents with the support and care they need. They are employed in sufficient numbers to meet resident’s needs. The recruitment procedures designed to protect residents are not always being followed, potentially putting residents at risk. EVIDENCE: In surveys returned by residents the majority said that they always get the care and support they need, all said that staff listen to and act on what they say and the majority say that staff are always available when needed. Descriptions of staff include ‘lovely’, ‘excellent’ and ‘always go that extra mile’. Staff were heard interacting with residents in a most respectful and helpful way. For example, one was heard explaining to a very frail what was for lunch, asking them if that was all right and offering salt and pepper. Staff receive induction and training. However, it became apparent during discussion with the manager that the induction training might not be based on ‘Skills for Care’ as it should be. The manager reports that 50 of staff are trained to NVQ Level 2 or above as is recommended. Rose Lawn DS0000022020.V296865.R01.S.doc Version 5.2 Page 21 Three staff recruitment files were inspected. One member of staff had started work without having a police check carried out. Whilst this is acceptable if a POVA 1st check is carried out and if the member of staff is always supervised (until the police check has been returned), in this case a POVA 1st was not carried out. Rose Lawn DS0000022020.V296865.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit. Resident’s safety and input into the home could be improved if management systems were more fully developed and those in place were always followed. EVIDENCE: Roselawn is managed by a very experienced and exceptionally committed manager. She holds the Registered Managers Award and has successfully managed the development of the home to its current compliment of 29 residents. Residents are extremely complimentary about her skills and grateful for her kindness and thoughtfulness. Rose Lawn DS0000022020.V296865.R01.S.doc Version 5.2 Page 23 Residents say that meetings between them and the manager used to take place but were suspended during the building work. They are yet to recommence. Staff report that staff meetings have yet to commence and the manager reports that arrangements are in place to have one shortly. At the last inspection the Operations Controller told the inspector that she was trialling a quality assurance system at another home. The manager reports this is about to be introduced into this home. An incident occurred at the home that the manager reported verbally. It is required under law that this be reported in writing and the inspector asked for this when the outcome of the investigation was reported. This has not yet been done. The inspector checked the management of some resident’s personal allowances. These are kept safely and always checked by two people. The accounts of those checked balanced. However, it was noted that receipts for hairdressing are not issued, as is good practice. In the pre-inspection questionnaire the manager reports that all policies and procedures are reviewed and up to date; that maintenance contracts are in place; that all mandatory training is undertaken and that appropriate fire checks and drills take place. During the inspection the fire alarms were being tested and outcomes recorded. The pre-inspection questionnaire completed by the manager shows that 4 members of staff have received training in 1st Aid. This means that it cannot be guaranteed that every shift will have a person on duty that has this training. It was noticed during the inspection that staff using the office near to resident’s bedrooms are not always adhering to the homes policy on confidentiality. Rose Lawn DS0000022020.V296865.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x x 2 x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 1 x 2 x 2 2 Rose Lawn DS0000022020.V296865.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (1) Requirement You must ensure that each resident has a written plan as to how their in respect of health and welfare are to be met and you must keep these plans under review. (This is an outstanding requirement from 30/06/06) You must ensure that arrangements are in place for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. (This relates to the need to ensure that all hand written entries on the MAR charts are signed by two members of staff and that the fridge is lockable). (This is an outstanding requirement from 31/03/06) You must ensure that the home is conducted in a manner that respects the dignity of all residents. (This refers to the need to ensure that all residents are asked if they would prefer a male or female carer and that DS0000022020.V296865.R01.S.doc Timescale for action 30/01/07 2. OP9 13 (2) 30/11/06 3. OP10 12 (4) (a) 30/11/06 Rose Lawn Version 5.2 Page 26 4. OP16 37 (1) (g) (2) 19 (5)(d) 5. OP29 staff do not discuss residents private information where this can be overheard). You must notify the Commission of any allegation of misconduct and any notification given orally shall be confirmed in writing. The registered person must ensure that full and satisfactory information is available, as per Schedule 2, for each member of staff who works at the home. (This is an outstanding requirement from 31/03/06) You should ensure that a system is in place to review and improve the quality of care provided and this system should provide for consultation with service users and their representatives. (This relates to the lack of quality assurance processes). You should ensure that you make suitable arrangements for the training of staff in first aid. 30/11/06 30/11/06 6. OP33 24 31/03/07 7. OP38 13 (4) 31/03/07 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. Refer to Standard OP7 Good Practice Recommendations You should ensure that the care plan for each resident is drawn up with their involvement, is recorded in a style that is accessible to them and is agreed and signed by the resident. You should ensure that each care plan is reviewed to reflect changing needs and current objectives for health and personal care and that appropriate action is taken. You should ensure that nutritional screening is undertaken and a record maintained of nutrition, including weight loss or gain, and appropriate action taken. DS0000022020.V296865.R01.S.doc Version 5.2 Page 27 2. 3. OP7 OP8 Rose Lawn 4. 5. 6. OP12 OP22 OP30 You should ensure that the lifestyle that residents experience matches their social interests and needs. You should ensure that has raised chairs and appropriately placed seats for residents with mobility problems. You should ensure that induction training meets the guidance issued by ‘Skills for Care’. Rose Lawn DS0000022020.V296865.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Devon Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Lawn DS0000022020.V296865.R01.S.doc Version 5.2 Page 29 - 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. 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