Inspection on 01/08/07 for Rosecroft

This inspection was carried out on 1st August 2007.

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 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

Rosecroft 12/08/08

Rosecroft 27/11/06

Rosecroft 25/04/06

Rosecroft 06/09/05

Rosecroft 20/05/05

Rosecroft 25/11/04

Rosecroft 01/07/04

Similar services:

Springfield House

The Shelley

Thorndene

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Rosecroft 8 Cross Road Southwick West Sussex BN42 4HE Lead Inspector David Bannier Unannounced Inspection 09:30 1 August 2007 st 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 Rosecroft DS0000014687.V341341.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. Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosecroft Address 8 Cross Road Southwick West Sussex BN42 4HE 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) 01273 597326 Mr D R Clark Mr D R Clark Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19), Physical disability (1) of places Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Total of 19 persons at any one time, one of whom is in the category of Physical Disability, aged 60-65 years. 27th November 2006 Date of last inspection Brief Description of the Service: Rosecroft is a care home, which is registered to accommodate up to nineteen residents in the category (OP) old age, not falling within any other category. This number can include resident how may have a physical disability. It provides personal care only. Rosecroft is a two storey detached building which has been adapted fro its current use. The accommodation for residents is located on ground floor and first floor levels, which are served by a passenger lift. The property is located in Southwick overlooking the green. It is close to shops and a local post office. A spacious garden is available to residents to the rear of the premises. The fee levels range from £330 to £400 per week. Additional charges are made for hairdressing and chirpody. The registered provider is Mr D Clark, who is also the registered manager responsible for the day to day running of Rosecroft. Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection has followed the Inspecting for Better Lives methodology and is called a key inspection as it assesses those standards determined by the Commission as key standards. This inspection will also determine the frequency of inspections hereafter. The registered provider returned an Annual Quality Assessment Form (AQAA) prior to the inspection. Five residents and their relatives were sent surveys by the Commission entitled “Have Your Say.” Surveys were also sent to three social workers. These are designed to enable residents, relatives and other stakeholders to give their opinions about how the care home is being run. Two surveys completed by relatives were returned to the inspector. The information received from each of these documents will be referred to in this report. A visit to Rosecroft was made on Wednesday 1st August 2007 to meet with and talk to residents, the Manager, staff on duty, observe care practices, see residents’ accommodation and to examine a selection of records. As this was an unannounced inspection the care home had no notice of this visit. It lasted approximately six hours. What the service does well: Residents told the inspector they are satisfied with the care and service provided. They appreciate the manner in which it is provided by staff who they describe as “kind”. Individual lifestyles are accommodated so that residents can choose their own routines. Some residents have lived at the home for a number of years. They consider it to be their home and have developed good relationships with the provider and staff at the care home. The home aims to enable residents to stay with them until their death if their needs can be met. Staff have also worked at the care home for many years. The residents and the provider see this as a positive feature. Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 6 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 Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care needs of prospective residents are assessed before admission. Rosecroft does not provide intermediate care. EVIDENCE: The names of four residents, who had been admitted on a permanent basis, were identified for case tracking purposes. The inspector spoke to each of them and also looked through their care records. The inspector also spoke to other residents who were not part of the case tracking exercise. No new residents had been admitted since the last inspection. It was therefore not possible to assess the process of admitting residents to the care home. Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 10 However, at the last inspection there was sufficient evidence to confirm that the needs of prospective residents are assessed before admission. Residents said that they were satisfied with the care and services provided to them. One resident said, “ My family live locally, they can visit me when they are able.” Another resident said, “My sister lives in Scotland and the rest of my family live some distance away. But I have nice room with a good outlook.” Surveys returned by relatives of residents confirmed they had received enough information about the care home before moving in so they could decide if it was the right place for them. Information supplied by the registered provider confirmed that, “Any prospective resident, relative or friend is encouraged to view the home before any decision is made. The manager will visit them prior to admission to assess their needs.” Rosecroft DS0000014687.V341341.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans have been drawn up for each resident which sets out the level of care they require to ensure their care and health care needs have been met. The home’s policies and practices for dealing with medicines protect residents. Residents feel they have been treated with respect. EVIDENCE: During the last inspection evidence seen confirmed that, “The care plans were not clear in identifying all the resident’s needs and the level of care that is provided.” At this inspection there was evidence that led the inspector to conclude improvements have been made to care plans. They had been drawn up from the information gathered when residents’ needs were assessed. Care Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 12 plans were informative and include appropriate information and instructions which staff are expected to follow. This will ensure residents’ care is provided in a consistent and continuous manner. Records seen also demonstrated that care plans and assessments are reviewed on a regular basis to ensure they are up to date. Care plans included a record of nursing interventions made by District Nurses and visits made by GP’s to provide residents with medical treatment. The care records of one resident indicated they required a stay in hospital in order to receive medical treatment. On completion of the treatment the manager visited the resident to assess if they were ready to return to the care home. However, the manager had not made a record of this assessment. Following discussion the manager agreed to ensure that, in future, a record is made. This will ensure the manager can provide evidence of the findings of the assessment in order to confirm the care home is able to continue to provide the level of care required by the resident. From direct observations, residents appeared to be relaxed when talking with staff; they also appeared to be well cared for. One resident told the inspector, “The staff are very good. They do anything that I want done.” Another resident said, “The staff who look after me are very nice. I need help getting in and out of bed, dressing and bathing.” Following discussions about the needs of identified residents, staff on duty were able to demonstrate they were fully briefed about the level of care they required and what was expected of staff to ensure they have been met. Surveys returned by the relatives of residents confirmed the care home always meets the needs of their relative. One relative commented, “My mother has told me that she is very happy there.” Another resident commented, “The staff are very caring and helpful.” The inspector examined medication records. Records had been well maintained and were up to date. A monitored dosage system (MDS) employing blister packs is used to administer medication. The inspector was advised that the current practice is for medication to be given to residents directly from packs and containers marked by the dispensing chemist, with the name of the resident the dosage and strength and time the medication is to be given. The staff member giving medication is expected to check these details before medication is administered. There were no residents administering their own medication at this time. Information supplied by the registered provider confirmed, “All residents are assisted with all their personal care needs and are treated with dignity and with respect. Every effort is made to enhance their day. Health is monitored regularly and any changes are reported to the manager or the senior carer to be dealt with. No resident is left, if unwell a doctor is requested. All other professionals are contacted immediately when required. Only trained and Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 13 assessed staff are allowed to administer medication, supplies are kept safely stored. Any query regarding any medication is referred back to the doctor for clarification. All residents are referred to by the name of their choice.” Rosecroft DS0000014687.V341341.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The lifestyle residents experience in the care home matches their expectations and preferences. Residents are able to maintain contact with family and friends as they wish. The registered provider has ensured residents receive a wholesome appealing and balanced diet EVIDENCE: The manager advised the inspector that there is no activity programme. However, from time to time reminiscence sessions are arranged or a musician comes in to entertain residents. There were no activities taking place during this inspection. A group of four residents were sitting in the lounge watching Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 15 television. Other residents were in their own rooms. Two the three residents who were in their own room when the inspector spoke to them were also watching television. The third resident was lying on their bed. One resident said they like to watch television and to stay in their own room for meals. From direct observations the inspector noted that staff have respected this resident’s wishes. Another resident said, “ I am well looked after. Everything is done for me.” Relatives’ surveys confirmed that the care home supports residents to live the life they choose. Information supplied by the provider confirmed that, “We are trying to encourage residents to participate more in some kind of activity. We are seeking the help of community volunteers to spend some time reminiscing. In the summer we try to encourage residents to have afternoon tea in the garden. Also to engage someone to do light exercise with the residents that wish to participate.” Visitors are welcomed to Rosecroft. One resident told the inspector, “My family live locally. They visit me when they can. I see my daughter when she is not working. My grand children and great children also live locally. They visit me at Christmas time.” Surveys completed by relatives confirmed that the care home always helps them to keep in touch with their relatives. Information supplied by the registered provider confirmed, “ Relatives and friends are welcome at any time during the course of the day and are invited for meals if they wish to eat with their relatives. All visitors are offered either a hot of cold drink.” On the day of his visit the inspector noted that the lunchtime meal was toad in the hole, mashed potatoes, carrots, cabbage and cauliflower followed by fruit crumble and custard. The inspector was told that, as an alternative, residents could have fried fish or ham. The inspector went into the dining room during lunch. Residents told the inspector that they were enjoying their meal. From menus seen the inspector concluded that residents have been provided with a varied, wholesome and balanced diet. Comments made about the food provided were varied. One resident told the inspector, “You sometimes get a repetition of meals at midday. Otherwise they are not bad.” Another resident said, They bring my meals to my room. The food is quite good. It is a lot better than when I first came here.” A third resident told the inspector that they prefer their own company and like to have their meals in their own room. Rosecroft DS0000014687.V341341.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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was no documentary evidence to confirm complaints received from residents or their relatives have been listened to, taken seriously and acted upon. The registered provider has ensured that residents are protected from abuse EVIDENCE: The registered provider has drawn up a written complaint procedure. This clearly identified who residents, or their relatives should speak to if they wished to make a complaint. This has been included in the care home’s statement of purpose. The procedure also sets out the steps any investigation would go through and the timescales by which the complainant would be notified of the outcome. Information supplied by the registered provider confirmed that two complaints had been received in the last 12 months; they have been resolved within 28 days of receipt. When asked to produce a record of complaints Mr Clark was unable to do so. He seemed unaware that he should kept such a record, including the nature of the complaint, the outcome Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 17 of his investigations and the action taken to put right any shortfalls identified in the service provision. This has been made a requirement. Mr Clark was advised that he must be able to provide documentary evidence to confirm complaints have been taken seriously and acted upon. Surveys returned by relatives of residents confirmed they did not know how to make a complaint. However, they have also confirmed that the registered provider has responded appropriately when concerns have been raised about the care of residents. Residents spoken confirmed they knew who they should speak to if they needed to complain. One resident said, “If I wanted to complain I would speak to Mr Clark.” Information supplied by the registered provider confirmed that, “Any complaint is talked through as soon as it is brought to our attention. The staff daily ask all residents if there is any problem. Any complaint is taken seriously. We are confident that complaints are acted upon. The complaints procedure is clearly written and is included in the Service User’s Guide. Complaints are talked through with the person concerned and resolved as soon as possible.” According to records seen training provided to staff includes training in Adult Protection procedures. It was also noted that the registered provider has a copy of the Adult Protection procedures published by West Sussex Local Authority. Staff on duty, who were spoken to, were able to tell the inspector about different types of abuse and to whom they should report any instance they may find. Information supplied by the registered provider stated that, “The staff are aware of Safeguarding Adults and the importance of reporting any incident to the manager or the person with managerial responsibility.” Rosecroft DS0000014687.V341341.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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered provider has carried out maintenance work to the premises in a satisfactory manner to ensure it is safe for residents to live there. However, further work was identified during this visit which needs to be done to ensure the premises remain safe. The home has been kept to a satisfactory standard of cleanliness. EVIDENCE: A number of issues regarding the environment were identified as requiring attention during previous inspections. Old sockets and wiring left over from an unused call bell system had not been removed. Some lampshades were Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 19 missing. Paintwork on skirting boards and doors were chipped and worn due to use of walking frames and wheelchairs. There was a broken ladder and broken lounge chair in the garden, which made it look unkempt. In addition, a requirement had been made to ensure radiators have been guarded and to have water temperatures regulated in order to reduce the risk of scalding to residents. The inspector noted that the registered provider had made the necessary improvements to ensure the care home has been appropriately maintained and is safe for residents. Information supplied by the registered provider prior to the visit indicated that the premises has been visited by the Fire Officer and Environmental Health officer to ensure it is safe and meets requirements in terms of fire safety and health and safety regulations. The registered provider has also confirmed that any shortfalls identified have been rectified. Equipment such as gas installations, electrical wiring and equipment have been regularly checked and maintained to ensure they are safe to use. A further requirement, which had been made at a previous inspection, has been to improve access into and out of the premises for people in wheelchairs. Mr Clark informed the inspector that the resident who required such access was no longer living at Rosecroft. Mr Clark had decided this was no longer a priority. It was also noted that scaffolding had been put up around the front of the premises. Mr Clark told the inspector that he had been redecorating the front of the care home. However, during this process he has discovered that some of the woodwork needed to be replaced. Mr Clark confirmed this work was being carried out to ensure the safety of the premises. Residents spoken to confirmed they were satisfied with the accommodation and the overall cleanliness in the care home. One resident said, “I have a very nice room with a nice outlook of the front garden.” Another resident said, “My room is big enough for my needs. I also have an ensuite WC.” The inspector viewed the rooms of those residents he spoke to and also sat with residents in the lounge/ dining room. The overall standard of cleanliness was satisfactory; there were no unpleasant odours present. However, the communal areas would benefit from being tidied up. Paperwork filled the tops of a sideboard in the lounge and a table in the dining room. It was not clear what the paperwork was about nor was it clear why it was not stored away safely. The inspector spoke to Mr Clark about edges of carpets, which had started to fray and might result in a resident or member of staff tripping over. Mr Clark agreed to attend to these straight away. The inspector also viewed the laundry area. This area was located some distance away from the kitchen area which ensured laundry did not have to be taken through areas of the home where food is prepared, cooked or served. Again the standard of cleanliness was satisfactory. A facility for staff to wash Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 20 their hands after handling linen was also available. However, Mr Clark was advised to ensure towels and soap is provided to assist with the prevention cross infections. Information supplied by the registered provider confirmed that, “The home has a friendly, homely atmosphere and all our residents have chosen the way they would like to live in their room. They are able to bring in items of furniture and possessions to make the room more of their own identity. Rooms are redecorated as a room becomes vacant. The garden has a woodland feel, with home grown vegetables and fruit, which encourages wild life for the residents to watch.” Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered provider has ensured there are enough staff on duty to meet the current care needs of residents accommodated. The registered provider has ensured residents are in safe hands at all times. The registered provider has ensured staff are trained and competent to do their jobs. EVIDENCE: The inspector noted that four care staff were on duty. One member of staff is expected to prepare and cook the main meal whilst the other staff are expected to undertake cleaning duties during the course of their work. One member of staff was due to return later in the evening to carry out the night duty. Residents spoken to confirmed they were satisfied with the care provided. One resident said, “The girls who look after me are nice.” Another resident said, “I have my bell. If there is something I can’t manage they will come and help me.” The inspector spoke to all the staff on duty. They informed him they had worked in the care home for some years. They also Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 22 confirmed they believed there was enough staff on duty to meet everyone’s needs. Following observations of care practices, talking to residents and staff, and examining the staff rota and a selection of care records, the inspector concluded there were sufficient staff on duty to meet the needs of residents currently accommodated. Information supplied by the provider confirmed that, “We have staff members who have been employed at Rosecroft for a number of years. This means that residents have continuity of care. Additional staff are on duty at peak times of the day.” The inspector noted that no new staff have been appointed since the last inspection. It was, therefore not necessary to examine staff recruitment records. This was also the case at the last inspection, where the inspector noted some shortcomings in the way the last members staff were recruited. For example, two written references were not always taken up and the criminal record check (CRB) was a standard check and not enhanced as required. Mr Clark confirmed that he would ensure he obtains all the necessary checks and information before appointing any new staff to work at the care home. Information supplied prior to the inspection confirmed, “All new staff will have a CRB check, at an enhanced level. We are confident that residents are in safe hands at all times.” Records of training provided were also examined and demonstrated that training for all staff has included mandatory training such as fire safety, adult protection and health and safety. It was also confirmed that the manager is in the process of ensuring staff go on refresher courses to ensure training is up to date. Information supplied by the registered provider confirmed that five of the twelve staff employed at the care home have obtained the National Vocational Qualification (NVQ) in Care at Level 2, whilst one member of staff is working towards the same qualification. Surveys returned by residents’ relatives confirmed that care staff have the right skills and experience to look after people properly. One relative commented, “My relative has to have a nurse in now and again to change dressings.” The inspector spoke to two staff who were on duty the confirmed the training they had received. They were also able to explain to the inspector about the current care requirements of four residents who had been identified for case tracking purposes. Information supplied by the registered provider confirmed that, “The majority of staff are NVQ 2 trained. Ongoing training as and when it becomes available is taken up. Staff are clear about their designated roles. Through supervision, observation and feedback from residents and carers the strengths and weaknesses of the whole team are assessed daily.” Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 23 Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 24 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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate action has been taken to ensure Rosecroft is being managed to ensure residents, needs have been met. The manager has not ensured the Commission is notified of incidents affecting the wellbeing of residents. The registered provider has taken appropriate action to ensure the health and welfare of residents and of staff. Some work has been identified as needing to be carried out to ensure the safety of residents and staff. Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 25 EVIDENCE: The registered manager for Rosecroft is Mr Clark, who is also the registered provider of this care home. He has obtained the NVQ in Care at Level 4 and also the Registered Manager’s Award (RMA). Staff on duty who were spoken to confirmed there have been regular supervision sessions and staff meetings to ensure everyone knows what is expected of them. Supervision sessions include discussions about the care needs of each resident, any training required by the member of staff and a general discussion about their role in the care home. staff meetings take place every day, following the handover between each shifts. Staff are encouraged to talk about the running of the care home and to make suggestions. Surveys returned by relatives of residents confirmed that the care home supports residents to live the life they choose. Information supplied by the registered provide confirmed that, “The registered manager is qualified in management. The foundation of the home attributes to the manager’s abilities to provide a home for residents that are settled and at ease with themselves. They are confident that the daily activities will include all that is required – free to choose, free to express an opinion. All these things are fundamental to the wellbeing of the residents.” During the last inspection it was noted that Mr Clark was establishing a quality assurance system. It consisted of recording the direct care given to residents; Mr Clark and his deputy would then monitor this. Mr Clark agreed that it needed to be developed further to take into account residents’ views and those of other involved with the care home, such as visiting professionals. At this inspection Mr Clark was able to demonstrate that he has sent out appropriate questionnaires to residents and their relatives, an number of which have been completed and returned to him. Mr Clark was advised at this inspection that the next steps he must take is to consider the responses made and put together a means of recording them. The information should them be used to formulate a plan to implement any useful suggestions or to make any improvements identified to the care and services provided. Mr Clark confirmed that it is the policy of the care home not to be involved with residents’ personal finances. It is expected that the resident, or their family, deals with this. It is the current practice to keep good records of any accidents or incidents affecting residents. The inspector noted that, following a fall, one resident had cut their forehead and required hospital treatment. Mr Clark was unable to Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 26 confirm the Commission had been notified of the incident as required. Following discussion, Mr Clark was advised of the type of incidents and accidents to residents when the Commission should be notified. This has been made a requirement. Frayed carpets in some areas of the premises were identified during the inspection. These were brought to Mr Clark’s attention, who agreed to carry out the necessary work to rectify this. Mr Clark was able to demonstrate that he had carried out improvements to ensure requirements identified at the last inspection had been met. For example radiators considered to be dangerous to residents had been fitted with covers and hot water temperatures were now being regulated. This means the risk of residents scalding themselves has been reduced. Apart from this the premises have been well maintained, ensuring a safe environment in which residents can live and staff can work. The registered provider has supplied information that indicates equipment such as boilers, other gas installations and electrical equipment have been regularly serviced and maintained. Residents have told the inspector that they are very satisfied with the accommodation and services provided. According to training records staff have been provided training in such subjects as moving and handling, food hygiene, infection control, health and safety. Staff on duty, who were spoken to confirmed the training they had received. Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 27 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 2 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 N/A 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X N/A X X 3 Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 28 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 OP16 Regulation 22 Requirement The registered provider must keep a record of complaints received including details of the investigation and its outcome. The registered provider must notify the Commission of any events in the care home which affect resident’s wellbeing. Timescale for action 29/08/07 2 OP38 37 29/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. Extracts may not be used or reproduced without the express permission of CSCI Rosecroft DS0000014687.V341341.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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