Inspection on 01/04/08 for Rose Lodge Care Home

This inspection was carried out on 1st April 2008.

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

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

Other inspections for this house

Rose Lodge Care Home 26/06/07

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Rose Lodge Care Home Walton Road Wisbech Cambridgeshire PE13 3EP Lead Inspector Elaine Boismier Unannounced Inspection 1st April 2008 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 Lodge Care Home DS0000069320.V361510.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 Lodge Care Home DS0000069320.V361510.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rose Lodge Care Home Address Walton Road Wisbech Cambridgeshire PE13 3EP 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) 01945 474449 01945 474735 www.barchester.com Barchester Healthcare Homes Ltd Mrs Janet Olwyn Rippengill Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60), Physical disability over 65 years of age of places (60) Rose Lodge Care Home DS0000069320.V361510.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of places not to exceed 60 at any one time Date of last inspection 18th January 2008 Brief Description of the Service: Rose Lodge, owned by Barchester Healthcare Homes Ltd, provides care for people over 65 years of age assessed to need both personal and nursing care. The home has 49 bedrooms that have ensuite facilities; 3 single bedrooms that have hand washing facilities and all the four shared bedrooms have ensuite facilities. There is a medium sized car park at the front of the home and large gardens that surround the building. The home is close to the centre of the market town of Wisbech that offers a range of leisure and shopping facilities. Current fees range between £343 and £811.00. Additional costs include those for chiropody, hairdressing, confectionary and toiletries. Further information about fees can be obtained directly from the home. A copy of the inspection report is available on request at the home or via the CSCI website. Rose Lodge Care Home DS0000069320.V361510.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good, quality outcomes. This summary includes information about the home since the last key inspection, in June 2007, and up to this key inspection, of the 1st April 2008. 22nd June 2007 Following the key unannounced inspection of 22nd June 2008 we served a statutory requirement notice as the home had failed to obtain full and satisfactory information about staff before they moved into the home. 2nd August 2007 On 2nd August 2007 we carried out an unannounced inspection. The reason for this inspection was to assess compliance with two immediate requirements made at the time of the key unannounced inspection of 26th June 2007 and the statutory requirement notice dated 28th June 2007. We assessed that all of these requirements had been met. 19th December 2007 The reasons for this unannounced inspection were two-fold. Firstly to assess some of the standards assessed that had not been met during the key unannounced inspection of 22nd June 2007 and secondly to assess if there had been sustained improvements in those areas assessed as met during the random inspection of 2nd August 2007. We assessed that the home had met 7 requirements. These were with regards to admitting people inside the categories and conditions of registration; pressure area care and prevention of pressure sores; infection control; medication; the provision of activities; staffing numbers; staff training in infection control; staff training in care of people with dementia and staff training in safe moving and handling and fire safety. Two requirements were assessed as not met and were carried forward with new timescales. These requirements were for consulting people about their care plan and medication. Rose Lodge Care Home DS0000069320.V361510.R01.S.doc Version 5.2 Page 6 Two new requirements were made. Firstly for care plans to be specific in detail and revised when service users have a change of need. Secondly for full and satisfactory information to be obtained before staff worked at the home. It was disappointing that although there was an improvement in the staff recruitment procedure, following the statutory requirement notice of the 22nd June 2007, this improvement had not been sustained. 18th January 2008 On the 18th January 2008 we carried out an unannounced inspection. The reason for this inspection was to assess those standards that were considered not met during previous inspections of the home. A requirement was carried forward with a new timescale for action, as people had not been consulted about their care plans. A requirement was carried forward with regards to medication and two new requirements were made; these were also regarding medication. It was pleasing to note that a requirement had been met with regards to information about staff. Although we had made no requirement we noted that, during the inspection of the 19th December 2007, staff had not attended any fire drill since February 2007. We expected the home to manage this issue and we noted that, during the inspection of 18th January 2008, staff had attended fire drills. Requests for copies of the unannounced inspection reports, for 2nd August 2007, 19th December 2007 and 18th January 2008, can be made at our CSCI office, Cambridge. Improvement strategy Due to our increased concerns about the safety of people living at Rose Lodge we issued a warning letter and requested a written response to our Improvement Plan. Both of these documents, sent on the 23rd January 2008, clearly identified the breaches of regulations and explained what action needed to be carried out, to comply with these regulations. We required Barchester Healthcare Homes Limited, the Registered Owner of Rose Lodge, to tell us what action it had taken to ensure that people were safe. The date this required information was due by was the 25th February 2008. We had no record of receipt of this information, by the 25th February 2008, and as a result we sent a reminder letter, on the 27th February 2008, requesting this information. During the inspection we spoke with the Regional Operations Director, via the telephone, and agreed that the Improvement Plan would be emailed directly to Rose Lodge Care Home DS0000069320.V361510.R01.S.doc Version 5.2 Page 7 the Lead Inspector by 15:00 hours of the 2nd April 2008. We received the Improvement Plan, via email, before this agreed deadline. 1st April 2008 We, The Commission for Social Care Inspection, carried out this key inspection between 10:00 and 14:45 and it took 4 hours and forty-five minutes to complete. The inspection was unannounced and was carried out by two Inspectors. We looked at documentation, had a tour around the building, spoke with people, staff, Manager and visitors to the home. We observed staff whilst they were working. Before the inspection we received surveys from staff, visitors and residents. We also received a completed Annual Qulaity Assurance Assessment (AQAA) from the Manager. For the purpose of this report people who live at Rose Lodge are referred to as “people” or “residents”. What the service does well: What has improved since the last inspection? What they could do better: Staff must provide care according to the care plan, to reduce the risk of pressure sore development. We expect the home to manage this, rather than we make a requirement on this occasion. Rose Lodge Care Home DS0000069320.V361510.R01.S.doc Version 5.2 Page 8 The records made when medication is given to people must be improved to demonstrate that people have received the correct medication. A requirement has been made previously about this and it has been rolled forward with a new timescale for action. When people are on day-trips or short-term absence from the home need to be given medication, the procedure in place must be improved to safeguard residents. A requirement has been made about this and a requirement has been made to ensure that staff on day-trips who give medication are trained and assessed as competent to do so. The home should provide means for people to call for assistance, when they are sitting in the lounge areas. We expect the home to manage this issue. There should be a review of the needs of the residents to assess if the numbers of staff are sufficient to provide individual care and to offer choice. Any risk of harm to people, must be identified and managed by the safe keeping of scissors. We expect the home to manage this, rather than we make a requirement on this occasion. 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 Lodge Care Home DS0000069320.V361510.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 Lodge Care Home DS0000069320.V361510.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 Quality in this outcome area is good. People have a good standard of information about the home to help them in their decision where to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Fourteen of the 15 surveys from residents said that the person had received enough information about the home, before they moved in. A copy of the inspection reports for June 2007 and January 2008 were available in the main foyer of the home. According to the AQAA prospective residents “have a large amount of information before coming into the home” and “All residents are fully assessed ensuring appropriate admission to the home” and we found this to be the case during our examination of people’s care records. Rose Lodge Care Home DS0000069320.V361510.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. People are safer as there has been an improvement in the standard of care provided although medication practices could be better. This judgement has been made using available evidence including a visit to this service. EVIDENCE: According to the AQAA “Full care profile reviews undertaken with residents and their significant others” and “All residents have complex person centred care plans which identify all needs. Residents take part in care planning.” The AQAA identified that person centred care planning and consultation with residents or their relatives could be improved upon. There were two requirements made about care records and both of these requirements have been met. The care plans that we examined indicated that there has been an improvement in the content of the care plans; there was sufficient guidance to inform staff how to meet the assessed needs of the person. There was also recorded evidence that residents, or their relatives, had Rose Lodge Care Home DS0000069320.V361510.R01.S.doc Version 5.2 Page 12 been consulted about their care plan and consent had been obtained for the assessed care to be carried out. Both of the relatives’ surveys said that their relative’s care needs were always met. Seven of the 15 residents’ surveys said that the person always received the care and support they needed; 6 of these surveys said that the person usually received the care and support that they needed; the remaining 2 surveys said that the person sometimes received the care and support they needed. The majority of these surveys said that the person always or usually received the medical support they needed with one of the surveys saying that the person sometimes received the medical support when they needed it. Examination of people’s care records indicated that people have access to a range of healthcare professionals including chiropodists, GPs and dieticians. According to the AQAA there have been, in the last 12 months, two residents for whom the home could no longer meet their needs. According to the Manager these people’s needs had changed and a full review of their care needs had taken place; a more suitable place for these people to live had been identified thereafter. There has been some slippage in an improvement in care of people at risk of pressure sores. Examination of a person’s care records (who had been assessed as at high risk of pressure sore development and who had acquired a pressure sore whilst living at the home) was carried out. It was noted that the care plan recorded the person was to be repositioned, in bed, every 2 hours. Examination of the repositioning charts indicated that some times, but not always, this person was repositioned every two hours. On the other occasions there was evidence that the person was not repositioned for 4-5 hours. For example: repositioning records for the 26th March 2008 indicated that the person was placed on their left side, at 19:45 and the next time was placed on their right side at 00:30 hours on the 27th March 2008 i.e.4 hours 45 minutes later. Repositioning records for the 30th March 2008 indicated that at 00:15 the person was placed on their left side and was next repositioned on to their right side at 4:55 i.e. 4 hours 40 minutes later. We noted, following discussion with staff and examination of the resident’s care records, that the person’s pressure sore was healing. As a result of this healing we have made no requirement on this occasion, but expect the home to manage this issue. A specialist pharmacist inspector examined the practices and procedures for the safe handling, use and recording of medications. The facilities provided for storing medication are well controlled and secure. A previous requirement to Rose Lodge Care Home DS0000069320.V361510.R01.S.doc Version 5.2 Page 13 ensure the safety of residents by safely storing medicine has been met, as has the requirement about keeping medication beyond its prescribed period of use. There are good records of when medicines come in to the home and when they are disposed of. Although there have been some improvement in the quality of records made when medicines are given to people, these could be improved since there were an unacceptable number of gaps in these records giving no indication of whether these people had been given their medicines or not. A requirement was made following the inspection on 18th January 2008 for records of medication, receive, administered (or not) to be accurate and complete; this has therefore not been met in full and the requirement has been given a new timescale for action. Some people hold and administer their own medicines. Their ability to safely to so and the risks to other people in the home had been assessed and management by a good and well documented risk assessment process. When people who are out of the home on day-trips or other short-term absence need to be given medication the home’s policy on the handling of medication in these circumstances states: “medicines should not be placed in envelopes or temporary containers”. We asked staff about this procedure as an incident was reported to us in February 2008 when a person was given the wrong medication. Staff were unaware of what the home’s policy was and stated that medication would be provided in “the blister pack” , and another staff member said that it would be “put into a bottle to be taken out”. A procedure where medication is removed from a correctly labelled and identifiable container for later administration is unsafe and produces an unacceptable risk to residents. The person who is responsible for residents on day trips said that she had not received any training on the safe use and handling of medicines. A requirement has been made to introduce a procedure that is safe and to ensure that staff who are required to administer medication on day-trips have been trained and assessed as competent to do so. People we spoke to said that the staff were good and we noted that staff interacted with people in a kind and caring manner. We saw blinds pulled over people’s bedroom door windows when they were having their care provided by staff. Rose Lodge Care Home DS0000069320.V361510.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. People are provided with opportunities to live a good quality of life that continues to be improved upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: According to the AQAA residents have been involved in “the planning of activities”. All of the residents’ surveys said that the home always or usually provided suitable activities. On the day of the inspection a small group of residents were going out on a day trip, as planned in the activities programme. Staff described to us arrangements of forthcoming activities for the week and these were seen in the activities programme. Records of activities for people, who were unable to leave their rooms, showed that they had 1:1 activity sessions with staff. Both of the surveys that we received from relatives said that their relative was able to live the life they chose. One of the residents’ surveys said however,” It Rose Lodge Care Home DS0000069320.V361510.R01.S.doc Version 5.2 Page 15 is now 10am and no staff member has arrived to dress me. Sometimes 11pm before I am put to bed.” Staff felt that choice could not always be offered due to staffing numbers (see Standard 27 of this inspection report). We saw people receiving their guests; and records of when people had contact with their friends and relatives were seen. The AQAA told us that following views of residents there have been “Alterations to menu and more choice and that residents are involved in menu planning.” Eight of the 15 residents’ surveys said that the person always liked the meals; 2 of these surveys said that the person usually liked the meals whereas 5 of these surveys said the person sometimes liked the meals. People we spoke with said that the food was very good. There is a three course lunch available and hot options for suppertime. Dining tables were pleasantly set out with tablecloths and vases of fresh flowers. Rose Lodge Care Home DS0000069320.V361510.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. People are safe and, on the whole, are listened to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA told us that there has been an improved method for recording complaints that shows what action has been taken in response to the complaints made. Examination of the record of complaints was carried out and a complaint received, in March 2008, showed that the complaint was responded to, in a listening manner. The minutes of the residents’/relatives’ meeting, held in March 2008, showed that concerns posed to the Manager were responded to in an open and listening manner. We have had no complaints about the home. A resident said that they had no need to complain, as Rose Lodge was “The tops”. All of the four surveys from staff said that the person knew what to do if a complaint was made known to them. Both of the relatives’ surveys said that the person knew how to make a complaint and the home had responded, to their concerns, in a satisfactory way. Visitors to the home said that they knew who to speak to if they had to make a complaint. Rose Lodge Care Home DS0000069320.V361510.R01.S.doc Version 5.2 Page 17 Fourteen of the 15 residents’ surveys said that the person knew who to speak to if they were unhappy about something and how to make a complaint. The remaining survey said that the person sometimes knew who to speak to if they were unhappy about something but did not know how to make a complaint. Of the 15 residents’ surveys 12 of these said that the person felt staff acted on what the person said to them although the remaining 3 surveys said that staff did not act on what was said to them. We were given no other information from these 3 surveys to tell us why the person felt they were not always listened to. All the staff we spoke with described what they would do if they saw an incident of abuse occurring in the home and their descriptions were satisfactory. Rose Lodge Care Home DS0000069320.V361510.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22 & 26 Quality in this outcome area is good. People live in a homely, comfortable and clean home although there is some risk to their dignity and safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is surrounded by very well maintained gardens and plans to have a summer house built were discussed at a relatives’ and residents’ meetings; minutes of this meeting, held in March 2008, were seen. We saw a vacant bedroom was in the process of redecoration and there was a good standard of decoration, maintenance and furnishings for people to live in a comfortable place. We spoke with staff who told us that although people do not have individual means to call for assistance, when they are in the lounge areas, staff are Rose Lodge Care Home DS0000069320.V361510.R01.S.doc Version 5.2 Page 19 within the location, either when walking by or when sitting at the staff desk. Nevertheless when we arrived on the first floor of the home, all the members of care staff were away from the lounge area. We expect the home to manage this issue. All of the 15 residents’ surveys said that the home was clean and fresh and we found this to be the case. Rose Lodge Care Home DS0000069320.V361510.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. People’s individualised care might be compromised although people are safely cared for by well-recruited and well-trained staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We received four surveys from staff that said the induction programme covered things about the job, so the member of staff was prepared in their new role. These surveys also told us that there was usually enough staff on duty and that recruitment checks had been carried out before the member of staff started to work at the home. One of the staff surveys said that although there was enough staff on duty to provide personal care, it was felt that there should be an increase in the number of care staff so that they could assist with activities, such as taking residents into the garden. Staff told us that although people’s care needs are being met, it was felt that person-centred, individualised care, including choice, was not always possible due to the numbers of staff on duty. Although staff said that agency staff are seldom used we saw that agency staff had been used by the home. Rose Lodge Care Home DS0000069320.V361510.R01.S.doc Version 5.2 Page 21 Staff considered that there has been an increase in the needs of people although they felt that an increase in care staff has not taken place. On the day of the inspection there were 47 residents living at the home and staff were carrying out their work in an unhurried manner. Call bells were answered promptly although staff said that sometimes this was not the case and people had to wait for assistance. Ten of the 15 residents’ surveys said that staff were available when they were needed although 5 of these surveys said that staff were sometimes available when needed. One surveys said, “When you ring the bell staff can walk past your door but dont enter. Could be 1/2 hr or more. Dont always return when say they will”. We suggest a review is taken place of people’s care needs and compare these with staffing numbers. The AQAA informed us that of the 30 members of care staff, 19 of these have an NVQ level 2 in care i.e. 63.3 . This standard has been met. The AQAA told us that the recruitment process has improved and there have been audits of staff files. Examination of two staff files indicated that there has been an improvement in the presentation of the files. We also noted that all information had been obtained about staff with the exception of a copy of a nurse’s certificate of qualifying as a nurse. Nevertheless there was proof of their current registration status, and as such we have taken a reasonable view not to make a requirement about this piece of missing information. It was pleasing to note that action had been taken to request written information from staff to explain any gaps in their employment history. Staff told us that they have attended training in dementia care, palliative care and infection control. The staff files, that we examined, showed that staff, who have not been newly appointed, have “re-visited” the induction-training programme, that covered such topics as care practices and health and safety matters. Rose Lodge Care Home DS0000069320.V361510.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is good. People benefit from a safer and better-managed home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Following our inspection on the 18th January 2008 we sent an improvement plan for the registered company to complete and for this to be returned to us by the 25th February 2008. Due to our increased concerns about the standard of care and standard of management of Rose Lodge the Improvement Plan told the registered owner what action was to be carried out to ensure that people who lived at the home were kept safe. Rose Lodge Care Home DS0000069320.V361510.R01.S.doc Version 5.2 Page 23 We had no record of receipt of this Improvement Plan and as a result we sent a reminder letter, to again request the Improvement Plan. During the inspection we spoke with the Regional Operations Director for, the home, about this issue. We agreed for this information to be sent directly to the Lead Inspector on the 2nd April 2008 by 15:00 hours and this was done. The Manager, a registered nurse, informed us that she has completed her registered manager’s award and this is waiting to be signed off by her assessors. There has been compliance with regulation 37 as we receive required notifications of any untoward incidents or deaths occurring at the home. There has been a reduction in the number of requirements made, since the inspection of June 2007, indicating that there has been an improvement in the standard of management of Rose Lodge. The completed AQAA was due to be returned to us by the 18th March 2008 although we had no record of receiving this. We sent a reminding letter on the 20th March 2008 and we received the completed AQAA on the 26th March 2008. This was the first time the home has completed an AQAA and it was completed in an adequate manner. It identified areas that the home does well and identified areas that the home could improve upon. It is our expectation that the AQAA will be improved upon, for example more information to be provided, of how improvements are to be made, and closer reference to the standards, such as health and safety matters (Standard 38). Copies of the regulation 26 reports for January and February 2008 were seen and these contained views, about the home, from relatives and residents. According to the Manager Barchester Healthcare Homes Limited has carried out a residents’ survey although the result of these were not seen at the inspection. The home is responsible for one person’s personal allowances. Records of these were seen to be satisfactory. Safety checks and tests for temperatures of hot water, temperatures of the food fridges and freezers, portable appliance equipment, hoists and passenger lifts, fire alarms and emergency lights were seen and these were satisfactory. Staff training records for fire training were generally in date and according to the Manager, fire training is arranged for staff to attend in April 2008. The AQAA told us that 100 of catering staff and 50 of care staff have attended training in safe handling of food and 62 members of staff have attended training in infection control. Rose Lodge Care Home DS0000069320.V361510.R01.S.doc Version 5.2 Page 24 During the tour of the premises we entered an unlocked sluice room. We found a pair of scissors hanging on a hook on one of the walls, by the side of a notice that provided guidance on what the scissors were to be used for. According to staff no current resident walks without the supervision of staff and therefore would not be able to access the scissors. We have made no requirement on this occasion, based on the current situation of the home. Rose Lodge Care Home DS0000069320.V361510.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 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x 2 x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Rose Lodge Care Home DS0000069320.V361510.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) 17(1)(a) Requirement Complete and accurate records must be kept of all medication administered, or not, together with a reason why the medicine was not given, in order to demonstrate that residents receive the medicines prescribed for them. This is a repeat requirement. Previous timescale of 31/01/08 not met. 2. OP9 13(2) Residents must be protected by safe procedures when medication is provided for shortterm absence from the home. All staff who administer medicines, including when residents are away from the home, must be trained and assess as competent to do so. This will protect residents from harm 30/04/08 Timescale for action 30/04/08 3. OP9 13(6) 18(1)(a) 30/04/08 Rose Lodge Care Home DS0000069320.V361510.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Rose Lodge Care Home DS0000069320.V361510.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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