Inspection on 15/05/07 for Roseacre

This inspection was carried out on 15th May 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Roseacre 09/01/06

Roseacre 20/01/05

Roseacre 12/09/04

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

CARE HOMES FOR OLDER PEOPLE Roseacre Roseacre Holly Hill Drive Banstead Surrey SM7 2BD Lead Inspector Joseph Croft Unannounced Inspection 15th May 2007 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Roseacre DS0000013771.V335325.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. Roseacre DS0000013771.V335325.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Roseacre Address Roseacre Holly Hill Drive Banstead Surrey SM7 2BD 01737356685 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) Banstead, Carshalton & District Housing Society Limited Mrs Sandra Parr Care Home 40 Category(ies) of Dementia - over 65 years of age (3), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (3), Old age, not falling within any other category (40), Physical disability over 65 years of age (5) Roseacre DS0000013771.V335325.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Of the 40 residents accommodated up to 3 may fall within the category MD(E) or DE(E) The age range for those accommodated will be 65 Years and over. Of the 40 residents accommodated up to 5 may fall within the category PD(E) 9th January 2006 Date of last inspection Brief Description of the Service: Roseacre was purpose built to accommodate older people in the early 1960s. Since that time the home has been subjected to modernisation and development, now providing a good standard of accommodation. The home is sited in its own grounds with good sized and well-maintained gardens accessible to residents. There are car-parking facilities to the front of the home. The home is well presented providing accommodation for up to 40 older people. The home has one bedroom, which can be used as a double, for occupancy by a couple if required. All the other bedrooms are for single occupancy; eleven of which have en-suit facilities, two with full bathrooms. The home has four-day rooms and a separate dining room with a private alcove, which service users can use when they entertain their visitors to a meal. Stairs or a passenger lift accesses the upstairs accommodation. The weekly fees for the home are £415. Roseacre DS0000013771.V335325.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit on the 15th May 2007 using the new ‘Inspecting for Better Lives’ (IBL) process. This visit was undertaken by Regulation Inspector Mr Joe Croft and was assisted throughout the site visit by the manager and responsible individual who were representing the establishment. This site visit took place over a period of seven hours, commencing at 10:30 and concluding at 18:00. The inspection process included a tour of the premises and sampling of residents’ care plans and risk assessments. Other documents sampled included the staff duty rota, menu, policies and procedures and records of medication. The Inspector had discussions with five members of staff on duty and the cook. In depth discussions took place with residents who were part of the case tracking process, and informal discussions took place with other residents present during this site visit. Residents informed the Inspector that they were very happy living at the home, that the staff look after them well, and the food is good, with alternative meals being offered. During observations residents were seen to be appropriately cared for, with staff attending to and supporting individuals as and when required. Staff and residents were interacting in an appropriate manner, and residents were being addressed by their preferred names. The pre-inspection questionnaire completed by the home and comment cards received from residents, their relatives and other associated professionals have been used as a source of evidence in this report. The inspector would like to thank the responsible individual, manager, members of staff and residents for their cooperation during this visit. Feedback was provided to the manager and responsible individual at the end of this site visit. What the service does well: People who use services are provided with information about the home. Assessment documentation is in place to ensure the individual needs of residents can be met. Residents’ lifestyles matched their needs and preferences, and where possible they are able to maintain contact with family, friends and the local community. People who use the service are offered a healthy balanced diet. Physical and health care is offered in such a way as to Roseacre DS0000013771.V335325.R01.S.doc Version 5.2 Page 6 promote service users’ privacy and dignity. Residents and their relatives have access to a satisfactory complaints system that enables them to raise concerns. Staff having knowledge, training and an understanding of adult protection issues protect residents. People using the service are provided with good communal and individual living space making it a safe and comfortable place to live. There is an effective quality assurance system in place to ensure residents are provided with a good quality of care. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Roseacre DS0000013771.V335325.R01.S.doc Version 5.2 Page 7 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 Roseacre DS0000013771.V335325.R01.S.doc Version 5.2 Page 8 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): Standards 1, 3 and 6 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use services are provided with information about the home. Assessment documentation is in place to ensure the individual needs of residents can be met. EVIDENCE: The home has a Statement of Purpose that is provided to residents and their relatives. Residents have their own copy of the Service Users Guide. These were observed in the bedrooms viewed during the site visit. Comment cards received from residents indicate that they were provided with information about the home. Four care files of the most recent admissions and one funded placement to the home were sampled as part of the case tracking process. These contained pre-admission assessments that had been undertaken prior to residents Roseacre DS0000013771.V335325.R01.S.doc Version 5.2 Page 9 moving into the home. The manager stated that a local authority supports a number of residents financially and where this is the case, residents have been assessed under the care management process. A copy of the care management assessment for one resident had been obtained and was viewed. The home has an Admission and Referral policy and procedure that is followed when referrals are made to the home. The manager informed the Inspector that prospective residents are invited to stay at the home for one to three weeks to enable them to make an informed decision as to the suitability of the home to meet their needs. This was confirmed during discussions with residents. The manager informed the Inspector that the home offers short-term respite care. Roseacre DS0000013771.V335325.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are protected by the home’s medication procedures. Physical and health care is offered in such a way as to promote service users’ privacy and dignity. EVIDENCE: The care files sampled had individual care plans that had been signed and dated by residents. Evidence that care plans had been reviewed on a monthly basis was observed. Care plans included information in regard to religion, medical conditions, mobility, personal care, and sensory and emotional needs. During discussions some residents could not remember if they had a care plan, others stated they had signed their care plans. Staff informed the Inspector that they key work with two to three residents, and were able to give an account of the care plans. Staff stated they review care plans on a monthly basis. Roseacre DS0000013771.V335325.R01.S.doc Version 5.2 Page 11 Care files of residents sampled included a risk assessment in regard to falls and the environment. However, other risk assessments must be produced to minimise the risk of identified hazards. For example, the home has hot water boilers in the kitchenettes for residents to make a hot drink, one resident is a smoker, and there is easy access in and out of the home. The manager informed the Inspector that this would be attended to. Health care needs had been recorded in care plans, and records of appointments are maintained in the diary and daily notes. Evidence that residents are registered with the GP, Dentist, Optician, and Chiropody were viewed. Records of nutrition and monthly weights were observed in the care files sampled. It was noted that staff had not received training in regard to tissue viability. This must be addressed. The district nurse visits the home every two days and oversees residents who have pressure sores. During discussions, residents informed the Inspector that the GP will visit them in the privacy of their bedrooms or they can attend the surgery. Residents also stated that their medication is always administered on time. Comment cards returned to the Commission For Social Care Inspection informed that residents always receive the medical support they need. The pre-inspection questionnaire informed that the home has a policy and procedure in regard to the administration of medicines. This had been reviewed in March 2006. The home uses the blister packs that are provided by the local pharmacy, and Medical Administration Record sheets (MARs) for the recording of medicines. Records of medicines received in to the home were sampled, however, the manager informed the Inspector that the records for the return of medicines were at the pharmacy for signing. Medication recording charts sampled evidenced that there was one medication administered that had not been signed for. The manager informed the Inspector that this had happened on previous occasions, and had been addressed with the members of staff concerned. The manager and Responsible Individual immediately investigated this omission. A requirement has been made that the recording of medications must be robust to ensure the residents are protected by the homes’ medical policies and procedure. It was observed that one blister pack contained multiple tablets, which made it difficult for an audit trail to be concluded. There was a list naming the tablets in this blister pack, but the manager could not identify all the tablets. The manager informed the Inspector that she has organised a meeting with the pharmacist to discuss this, and would inform the Commission For Social Care Inspection of the outcome. One resident who was being case tracked self-administers their medication. A lockable space is provided in their bedroom. The manager had produced a hand written assessment for this person, and stated that this will be formalised and put in the care plan. The manager was advised to include timescales for review, and ensure the assessment is robust. A copy of this has since been forwarded to the Commission For Social Care Inspection. Roseacre DS0000013771.V335325.R01.S.doc Version 5.2 Page 12 Medicines are kept secure in a locked medical trolley. The manager informed the Inspector that only the senior staff that have received the training administer medication. The lunchtime medication was observed during this visit. The person administering medicines stayed with the resident until they had taken their medication. Residents informed the Inspector that they are treated with dignity and respect. Some residents have their own landline telephones in their bedrooms. Residents were wearing their own clothes. Staff informed the Inspector that they respect residents’ privacy through attending to personal care needs in private, knocking on bedroom doors and addressing residents by the names they preferred. One comment card informed that in their opinion staff treat residents with the utmost respect and dignity. Roseacre DS0000013771.V335325.R01.S.doc Version 5.2 Page 13 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): Standards 12, 13, 14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ lifestyles matched their needs and preferences, and where possible they are able to maintain contact with family, friends and the local community. People who use the service are offered a healthy balanced diet. EVIDENCE: The home organises activities twice a day for residents to take part in if they wish to. These are displayed on the residents’ notice board. Activities include bingo, quiz, memory games, mobile library, and external trips to the seaside, garden centres, theatres and boat trips. Residents were observed taking part in a quiz activity during this site visit. Records of residents’ hobbies and interests were recorded in the care plans sampled. One resident has her own sewing machine that is kept in a room. This person informed through her comment card that this takes up most of her time. Other comment cards informed that there is a choice of activities provided that includes visiting entertainers and regular outings. Comment cards received from relatives and visiting professionals were complimentary about the activities offered. Roseacre DS0000013771.V335325.R01.S.doc Version 5.2 Page 14 Current residents living at the home are of White British origin. The main religions are that of Roman Catholic and Church of England. Residents and staff informed the Inspector that a weekly religious service is provided. Residents are able to attend the Church services of their choosing. Residents’ religions were recorded in the care plans sampled. Staff stated that racial, religious and cultural needs of any resident living at the home would be respected and promoted. The home employs a diverse staff team. It was noted that no male carers were employed at the home. The registered individual informed the Inspector that this was not by choice. Staff informed the inspector that residents have regular contact with their relatives and friends, and there are no restrictions on visits. Residents can go out with their visitors and return in the evening if they wished to. This was confirmed during discussions with residents. On the day of the site visit the Inspector was not informed of any visitors present. However, the visitors’ book maintained by the home evidenced that the home has regular visitors. During discussions residents and staff informed the Inspector that residents are able to exercise choice and control over their lives. Residents are able to choose what they do, activities they wish to take part in, and the food they like to eat. The home uses a three-week rolling menu that is changed according to the time of year. The menus submitted with the pre-inspection questionnaire and sampled during the site visit evidenced that meals are balanced with fresh meat, fish, fresh and frozen vegetables and fresh fruit. An alternative meal is provided on the menu five days a week. On the other two days roast dinners are provided, but residents can choose an alternative if they did not like the meal offered. The home employs two cooks, one of who was on long term sick leave at the time of the site visit. During discussions the cook informed the Inspector that the meat is always fresh and is ordered from the local butcher, and fresh vegetables are bought from the greengrocer. The cook maintains records of alternative meals taken by residents. Daily records of fridge/freezer and cooking temperatures were observed. Special diets are catered for, and foods are cut to smaller pieces for those who require this. Comment cards and discussions with residents informed that the food is very good. One comment card received informed that they only sometimes liked the meals at the home, that they would prefer more salt. Residents informed the Inspector they always have a choice of meals. A cooked breakfast is provided for those who request it, and porridge, cereals and toast are always available. Staff have had training in regard to food hygiene, and do help out at times in the kitchen. Lunch was observed during this site visit. This was an unhurried and relaxed occasion. The dining room tables had fresh clean linen tablecloths, fresh Roseacre DS0000013771.V335325.R01.S.doc Version 5.2 Page 15 flowers and personalised napkin holders. Residents informed the Inspector that the dining room is always like this. There was sufficient numbers of staff available to offer support as and when required. Roseacre DS0000013771.V335325.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): Standards 16 and 18 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have access to a satisfactory complaints system that enables residents and their families to raise concerns. Staff having knowledge, training and an understanding of adult protection issues protect residents. EVIDENCE: The home has a Complaints Policy and Procedure, a copy of this is included in the Service Users Guide, and is displayed on the residents’ notice board. The Complaints procedure includes the timescales for responding to complainants, and informs that the Commission For Social Care Inspection can be contacted if the complainant is not satisfied with the outcome of a complaint. Residents spoken to state they would talk to the home’s manager if they needed to make a complaint, however, they have never had the need to. Comment cards received from residents, relatives and professional visitors informed that they all knew how to make a complaint, but they were satisfied about the care residents receive. The complaint book evidenced that the home had received one complaint during the last twelve months. The manager and registered person had appropriately resolved this. The home has a Protection of Vulnerable Adults Policy that had a review date of 2006. However, the home did not have a copy of the Surrey Multi-Agency Roseacre DS0000013771.V335325.R01.S.doc Version 5.2 Page 17 Procedures of February 2005. The Responsible Individual informed the Inspector that this would be addressed immediately, and the Protection of Vulnerable Adults policy would be reviewed to ensure it is written in line with the Surrey Multi-Agency guidelines on the Protection of Vulnerable Adults of February 2005. The manager and head of care have attended the Surrey Multi-Agency training in the Protection of Vulnerable Adults. The manager informed the Inspector that she has provided in-house training to all staff. During discussions staff provided an accurate account of the procedures to be followed in the event of abuse or suspected abuse of residents, and stated they would report bad practice. The home has a Whistle Blowing Policy and Procedure that was reviewed in March 2007, and which staff stated they had read. The home had an anonymous complaint that was dealt with through the Surrey Multi-Agency Protection of Vulnerable Adults Procedure, but this was found to be unsubstantiated. Roseacre DS0000013771.V335325.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): Standards 19 and 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are provided with good communal and individual living space making it a safe and comfortable place to live. EVIDENCE: A tour of the premises was undertaken. Accommodation is situated on two floors. The home has a lounge, TV room, and two smaller rooms that residents can use when they entertain their visitors. Stairs or a passenger lift accesses the upstairs accommodation. The home has one bedroom, which can be used as a double, for occupancy by a couple if required. All the other bedrooms are for single occupancy, eleven of which have en-suite facilities, two with full bathrooms. Bedrooms and communal spaces were brightly decorated, and residents had their own personal possessions that included photographs, televisions and Roseacre DS0000013771.V335325.R01.S.doc Version 5.2 Page 19 radios. Bedrooms viewed had call bells within easy reach of residents. The manager informed the Inspector that bedrooms are redecorated as when required, and also when they become vacant. Comment cards and residents spoken to stated that the bedrooms are pleasantly decorated and the home is always very clean and tidy. All communal areas are accessible to residents. The home has grab rails that help residents to maintain their independence. Work was in progress in regard to improving the fire alarm system. It was noted that the lounge had a damp patch in the ceiling. The responsible individual informed the Inspector that this would be addressed. There is a large appropriately maintained garden to the rear of the property where residents can sit during the warmer months. On the day of the site visit the home was very clean, tidy and free from offensive odours. Roseacre DS0000013771.V335325.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): Standards 27, 28, 29 and 30 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing are satisfactory, ensuring staff have the qualities and training to meet the needs of residents. The home has a recruitment policy and procedure in place; however, this has not always been followed when recruiting staff, therefore not fully protecting the residents. EVIDENCE: The duty rota viewed evidenced that there are six staff on duty during the early shift, five on the late shift and three waking night staff each night. The home employs two cooks, seven domestic staff and a laundry person. The pre-inspection questionnaire informs that 7.4 of the care staff hold the minimum of the NVQ 2. One member of staff is a qualified Nurse. The manager informed the Inspector that the head of care and one senior member of staff are to commence NVQ level 3, and ten care staff are to commence NVQ level two in May 2007. Staff are to complete this training within one year, therefore the home will meet with the National Minimum Standard of 50 care staff qualified to the NVQ 2 or above. Roseacre DS0000013771.V335325.R01.S.doc Version 5.2 Page 21 The home has a Recruitment Policy and Procedure that details the procedure to be followed when recruiting staff. This includes requesting two references, POVA first checks and Criminal Record Bureau clearances. Three staff files were sampled, which included an application form, proof of identification and Criminal Record Bureau clearances. However, two of the files did not contain two written references or reasons for gaps in employment. A requirement in regard to this has been made. Two staff had POVA first checks undertaken. It was noted that one member of staff had commenced employment before the outcome of the POVA first check was received. The responsible individual informed the Inspector that this member of staff was undertaking training and did not work with residents until all checks had been completed. The manager must ensure the outcome of POVA first checks have been received before staff commences working in the home. From information provided in the pre-inspection questionnaire, and training records sampled during the site visit, staff had received training in regard to induction, Palliative Care, Depression in the Elderly, Malnutrition and Continence. The manager informed the Inspector that staff had received training in regard to Dementia. Other training to be organised by the home are Tissue Viability and Infection Control. During discussions, the responsible individual stated that registering staff with Skills For Care is to be explored. Roseacre DS0000013771.V335325.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): Standards 31, 33, 35, 36, 37 and 38 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect. There is an effective quality assurance system in place to ensure residents are provided with a good quality of care. EVIDENCE: The manager informed the inspector that she has been working for the organisation for eighteen years, and became the manager in 1996. The manager stated that she has completed the NVQ Registered Managers Award (RMA) in October 2006, and is an NVQ assessor. She is due to commence the NVQ level 4. Roseacre DS0000013771.V335325.R01.S.doc Version 5.2 Page 23 The manager is supported by the Responsible Individual for the Banstead, Carshalton and District Housing Society, and carries out the role of administrator for the home. The Inspector was informed that the Responsible Individual attends the home on a daily basis. A head of care oversees the dayto-day care of residents and provides further support to the manager. The manager informed the Inspector that a quality assurance survey was supplied to residents in 2006. The survey covered accommodation, care, food and activities and a summary of the outcomes was provided at the inspection. The manager informed the Inspector that residents conduct their own financial affairs, but small amounts of residents’ monies are kept secure in the home’s safe. The monies sampled during this site visit balanced with the records maintained by the home. During discussions with staff it was clear that formal one to one supervision was not being undertaken on a regular basis. The manager informed the Inspector that each member of staff has supervision on a six monthly basis. A recommendation has been made in regard to this. During the examining of accident records it was noted that the home is not notifying the Commission For Social Care Inspection of all events in the care home which adversely affect the well-being or safety of any resident. Discussions took place in regard to this, and the manager and Responsible Individual were advised to look at the Commission For Social Care Inspection website for further information. Sampling of staff training records provided evidence that staff are receiving the mandatory training as required. The manager informed the Inspector that training in regard to Infection Control will be organised immediately. The pre- inspection questionnaire forwarded to the Commission for Social Care Inspection Surrey Local Office provided evidence that health and safety records are appropriately maintained and up to date. Substances Hazardous to Health were appropriately stored in a secure locked cupboard. Roseacre DS0000013771.V335325.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 Roseacre DS0000013771.V335325.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13 (2) Requirement The recording of medication administered to residents must be accurately maintained to ensure residents health and welfare are protected by the homes’ policies and procedures for dealing with medicines. Recruitment files must contain all the information and documents specified in paragraphs 1 – 9 of Schedule 2 of the Care Homes Regulations 2001, as amended, prior to staff commencing work at the Care Home. Timescale for action 15/06/07 2. OP29 19 (1) (b) 15/06/07 Roseacre DS0000013771.V335325.R01.S.doc Version 5.2 Page 26 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 OP36 Good Practice Recommendations It is strongly recommended that all staff receive a minimum of six one-to-one formal and recorded supervision sessions per year. Roseacre DS0000013771.V335325.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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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