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Inspection on 15/02/06 for Rosebridge Court

Also see our care home review for Rosebridge Court for more information

This inspection was carried out on 15th February 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Staff made sure they had the information necessary, to make a decision about whether or not they could provide the care needed, prior to someone moving into the home. Residents spoke positively of their experience within the home and felt that the staff treated them well. There was a system in place for the safe administration of medication. Residents said they were treated with respect and their right to privacy was respected. They were able to keep in contact with family, friends.

What has improved since the last inspection?

The medical cover for residents referred to the Allendale unit has been resolved by the appointment of a Responsible Medical Officer who was due to take up her post in the near future. The home has a manager who will be applying to be registered with the Commission for Social Care Inspection. Staff and residents were happy with Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 6the approach of the new manager. Staff said "he is giving us a clear sense of direction" whilst a resident said " he is kind and always makes sure we are happy each day by checking how we are."

What the care home could do better:

There is a need to ensure that residents are involved in the planning and review of their care. The home must ensure that each resident has a personal interest and activity plan describing how these will be met in and outside the home supported by the staff and the dedicated activities organisers. Although the home has made a start in improving the environment in the communal areas they now need to upgrade all of the residents personal accommodation on both units. An action plan with timescales to be agreed with the Commission is required to ensure that this work is completed in a relatively quick timescale. Not all staff had received training in how to do their jobs properly when they first start work, nor had they all had 3 days training over the past year. More staff need to have training in some important areas to help them to do their jobs properly. Management must meet with care staff 6 times a year to talk about how they do their job, what training they need and how they could improve and to check what training they may need to do in the future. Staff are being employed before all the right checks had been made, which could put residents at risk.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Rosebridge Court Darby Lane Hindley Wigan Lancashire WN2 3DU Lead Inspector Bernard Tracey Unannounced Inspection 15th February 2006 09:30 X10029.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 Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 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 and Care Homes for Adults 18 – 65*. 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. Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Rosebridge Court Address Darby Lane Hindley Wigan Lancashire WN2 3DU 01942 526240 01942 526270 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) Southern Cross Healthcare Services Limited Care Home 46 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number disorder, excluding learning disability or of places dementia (22) Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Within the maximum registered number 46, there can be up to 24 Adults with Dementia over 65 years (DE(E)) and 22 Adults with Mental Disorder (MD). The service should employ a suitably qualified and experienced Manager who is registered by the Commission for Social Care Inspection 22nd June 2005 Date of last inspection Brief Description of the Service: Rosebridge Court is a purpose built care home situated on the outskirts of Hindley town centre, close to shops and other amenities, and is on the main bus route. The home is built on two floors providing nursing care for 24 male and female service users with dementia on the first floor, Darby Unit, and 22 male and female young adults with enduring mental illness on the ground floor, Allendale Unit. Personal accommodation is provided in single rooms with en suite facilities. There are large communal lounges and separate dining rooms on both units. The home is owned by Active Care Partnership a subsidiary of Southern Cross Healthcare Plc. Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced and it took approximately four hours to complete. During this time, the Inspector spent most of the time in discussion with the new manager of the home so as to understand how he was planning to run the home. Resident’s care records and staff files were examined and a tour of the home was undertaken. An in depth look at the way medicines were handled and administered in the home was undertaken. The Inspector also used the information provided by the manager and administrator, to gain evidence of the care and service provided. The Inspector also examined a selection of documents including records of complaints and compliments received at the home, staff files and training records. Also, he looked at the bedrooms of residents and the communal parts of the accommodation. The Inspector did not examine all of the Standards on this occasion. Consequently, the reader is asked to look at the previous Inspection Report to get a full picture of how the home is performing. What the service does well: What has improved since the last inspection? The medical cover for residents referred to the Allendale unit has been resolved by the appointment of a Responsible Medical Officer who was due to take up her post in the near future. The home has a manager who will be applying to be registered with the Commission for Social Care Inspection. Staff and residents were happy with Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 6 the approach of the new manager. Staff said “he is giving us a clear sense of direction” whilst a resident said “ he is kind and always makes sure we are happy each day by checking how we are.” 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. Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Older People) 2 (Adults 18-65) Standard 6 does not apply A thorough assessment of each resident is made prior to admission to ensure that residents’ needs would be met at the home. Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 9 EVIDENCE: New residents are admitted following an assessment undertaken by members of staff, usually by the registered manager and the relevant unit manager, who normally undertake a joint assessment of the individual. When the home is contacted the initial reasons for the referral are established and a pre admission assessment is the arranged. Because of the nature of the client group admitted to the older people’s service, it is more appropriate that the resident’s representative visits the home to assess the facilities and have the opportunity to meet with the staff to discuss the way their needs of their relatives’ will be met. Younger adults are invited to view the facilities and meet both residents and staff before making a decision to move into the home on a trial basis. Adequate time and opportunity to make a decision regarding the placement is afforded the individual and this opportunity enables them to discuss how the home can meet the person’s individual requirements. Clear and detailed information concerning trial visits and the length of the ‘settling in’ period is included in the Statement of Purpose. Emergency admissions are avoided as far as possible. The home develops a care plan based on the assessments made prior to admission to the home. There is evidence within the care plans, and in discussion with the residents, that any potential restrictions on choice, freedom, services or facilities, likely to become part of the residents’ daily life, had been discussed and agreed with the individual during assessment. Any changes in status are agreed with the resident and their representatives and recorded within the care plan. Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 9 (Older People) 19 20 (Adults 18 –65). Policies and procedures in relation to the handling of medication promote the safety and wellbeing of the residents. Residents admitted from outside the district now have adequate medical cover from the home to ensure that access to consistent specialist medical advice is provided. EVIDENCE: There is always a Registered Nurse on duty in the home; there is a delegated responsibility for ordering the monthly prescriptions. Due to Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 11 the recent changes in the procedure for returning drugs to local chemists a system to deactivate drugs on site has been implemented. This procedure is safely managed with the support from a company that the home has engaged to oversee this process. The medications system was safe. Medications were securely stored; the prescription administration sheets were filled in accurately and there was an accurate record of medicines received into the home and returned. Designated and appropriately trained staff administered medicines. The Registered Provider has completed the process of recruitment of a Medical Officer with specific responsibility for residents admitted to the home from outside the district. The newly recruited doctor was in a position to take up the post within four weeks of the inspection. Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 12 14 (Adults 18-65) The home has made some progress in implementing an activities programme that reflects the expressed wishes of the residents, to ensure that the leisure needs of residents are met. Opportunities for integration into community life and leisure activities need to be further expanded so that residents can develop their skills and live more independent and fulfilling lifestyles. Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 13 EVIDENCE: The Inspector concentrated on the activities and routines of daily living on the adult mental illness unit. It was apparent from discussion with the newly appointed manager that he was aware that there is not an adequate activity programme to meet the needs of this resident group either individually or collectively. At the time of the inspection the home had advertised for an Activities Person to take responsibility and particular interest in providing a varied programme and encouraging individuals to participate, supported by the nursing and care staff. Enquiries have been made by the home to access adult education classes and links with a local mental health resource centre. It is envisaged that by the next inspection of the service that these facilities and access to wider activities both in and out of the home will become a part of the individual programme for each resident. Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) 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 (Older People) 22 23 (Adults 18-65) There was a clear procedure for dealing with complaints, which ensured that residents complaints and concerns would be dealt with appropriately. Staff had a thorough understanding of adult protection issues ensuring that any allegations would be dealt with appropriately. EVIDENCE: The complaints procedure contained the appropriate information about how complaints would be handled. There had been two complaints made directly to the Commission since the previous inspection, both in relation to the Allendale Unit. The owners of the home were asked to investigate the complaints and did so satisfactorily. The procedure was displayed and residents said they knew who to complain to. Staff spoken with were aware of how to receive and deal with complaints. Protection of vulnerable adults training through the local authority is arranged by the home and some staff had attended training sessions, with further training planned in the near future. Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 15 Staff spoken with were aware of the issues and their responsibilities in reporting any allegations. One member of staff mentioned the whistle blowing policy and another talked about the POVA register. Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) 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 26 (Older People) 24 30 (Adults 18-65) The standard of the decoration and furnishings within the home is poor. Both the communal and personal accommodation does not present as an attractive and homely environment for the residents to live in. Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 17 EVIDENCE: At the time of the inspection redecoration work had commenced on Darby Unit. The manger provided the inspector with details of Phase 1 refurbishment of the home that included: A programme of decoration and renewal, with detailed timescales to address the following: • Re-decoration and renewal of furniture and fabrics in all personal accommodation • Decoration and replacement furniture curtains and fabrics in lounges. • The work to convert one toilet into a dedicated clinical room. • Refurbishment of the hairdressing room • Refurbishment of the bathrooms. • Redecoration of the corridors A similar programme with timescales should be provided to the Commission for Social Care Inspection to address the same refurbishment of the Allendale Unit. Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the 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 (Older People) 32 34 35 (Adults 18-65) Staffing levels were adequate to meet the needs of the residents on both units. The procedures for the recruitment of staff do not always provide the safeguards to offer protection to people living in the home. New staff are not receiving induction training to the National Training Organisation (NTO) specification, which may result in them not caring for the residents properly. Whilst some staff had undertaken mandatory health and safety training, some had still not undertaken the necessary training which could place residents at risk. EVIDENCE: From checking rotas and speaking to residents and staff, it was determined that both units were adequately staffed both day and night, to make sure the residents’ needs were being met. In the main, residents were satisfied with Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 19 the support they were given and described staff as “ok”, “nice people”, “alright”, “find time to listen” and “good”. Sufficient ancillary staff were employed e.g. domestics, laundry and kitchen assistants, cook and handyman. Random inspection of 3 care staff files, showed that not all the required recruitment checks had been made prior to employment. One of the care assistant files only contained one reference and Pova First and Criminal Record Bureau checks had not been undertaken. In order to protect residents, staff should not be employed before all relevant checks have been made and the manager must ensure that all staff personnel files are checked to ensure they contain the relevant checks. The manager had recently updated the training matrix, to show which staff had undertaken mandatory and other training. The information on staff training provided by the manager indicated that there are a significant number of employees who had not done any of the mandatory training. This shortfall must be addressed. It was also noted that staff personnel files did not contain a training profile showing exactly what training each person had undertaken nor were there always copy certificates in place. The manager must ensure that all staff undertake induction and foundation training to the Skills for Care specification within the first 6 months of employment. Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) 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 38 (Older People) 37 39 42 (Adults 18-65) The home was well managed and run in the best interests of residents by a manager who since his appointment had demonstrated a clear sense of direction and leadership. Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 21 EVIDENCE: The home had been without a registered manager for over 12 months. The present manager has been in post since his appointment in January 2006. He will be applying for registration with the Commission for Social care Inspection. The manager is a qualified nurse who has who has many years experience in caring for people with a mental illness. This is his first appointment as manager of a care home. Since his appointment the present manager had demonstrated a clear sense of direction and leadership and had made positive changes at the home with regard to management systems, day-to-day supervision and oversight of care planning meetings to determine how residents care needs will be met. Throughout the inspection the inspector was able to evidence the professional, capable and approachable manner in which the manager undertook his role when dealing with residents, staff and visitors. Staff and residents said he was easily accessible and welcomed his ‘open door’ policy as well as providing structure and a sense of direction through more formal meetings. Residents said he made sure he spoke to them on her arrival at the home each day to check out how they were feeling. All safety equipment was regularly serviced in accordance with the manufacturers instructions, and the appropriate documentation to support this was available for examination. Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 22 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 X 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 1 20 X 21 X 22 X 23 X 24 X 25 X 26 2 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 X 36 X 37 X 38 3 Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA12 Regulation 16 Requirement The home must ensure that a programme of meaningful activities, agreed with the individual resident is implemented and supported by the care staff. (Outstanding requirement in the timescale of 1st August 2005) A programme of decoration and refurbishment to all of the personal accommodation must be provided within the timescale stated.( Outstanding Requirement in the timescale of 1st August 2005) A programme of decoration and refurbishment to all of the corridors and communal lounges must be provided within the timescale stated .( Outstanding Requirement in the timescale of 1st August 2005) All staff personnel files must be checked to ensure all the necessary checks have been undertaken. All staff must undertake all the mandatory health and safety training courses. DS0000005696.V285004.R01.S.doc Timescale for action 30/04/06 2. YA24 13 30/03/06 3. YA24 13 30/03/06 4. OP29 19 30/04/06 5. OP30 18 30/06/06 Rosebridge Court Version 5.1 Page 24 6. OP30 18 7. OP30 18 8. YA37 8 All new staff must receive induction and foundation training within the first 6 months of employment and records must be held on file of such training. The manager should complete a training and development programme which identifies all staff’s training needs. The manager must make an application to be registered with the Commission for Social Care Inspection. 30/06/06 30/04/06 30/03/06 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 Rosebridge Court DS0000005696.V285004.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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. 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