Inspection on 12/08/08 for Rosecroft

This inspection was carried out on 12th August 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 01/08/07

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 20/03/2009.

CARE HOMES FOR OLDER PEOPLE Rosecroft 8 Cross Road Southwick West Sussex BN42 4HE Lead Inspector Annette Campbell-Currie Unannounced Inspection 12th August 2008 10:15 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.V369295.R02.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.V369295.R02.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.V369295.R02.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. Date of last inspection Brief Description of the Service: Rosecroft is a care home that provides personal care and support for up to nineteen older people. The home is located in Southwick, opposite the village green. Local shops and other community facilities are within walking distance. Communal areas include: a lounge that is also used as a dining room. Private accommodation consists of seventeen single bedrooms and one double bedroom. Mr Dennis Clark is the provider and registered manager. An assistant manager is responsible for the day-to-day care provided in the home. The current fees range from £300-£400 per week. Rosecroft DS0000014687.V369295.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is One Star. This means that the people who use this service experience adequate outcomes. The two requirements that were made at the previous inspection have been addressed and eight further requirements have been made following the site visit. Annette Campbell-Currie carried out the site visit for this key unannounced inspection over five and a quarter hours. Mr Clark and the assistant manager assisted with the inspection. The information and paperwork we (the Commission) needed was available. There were thirteen people staying in the home at the time. The assistant manager returned an annual quality assurance assessment form (AQAA) that provided a lot of information about the service and the care provided; the AQAA was used to help in the planning of the inspection. Surveys about the service were received from two people living in the home, and five staff. The responses were positive and the information has been used in making an assessment of the service. The home arranged for an independent person to explain the purpose of the surveys and to help people living in the home complete them. Unfortunately these surveys were not received in time for peoples views to be taken into account. A tour of the building was carried out and included the bathrooms, kitchen, lounge, laundry facilities and some bedrooms. The following documents were read: the case records for three service users, recruitment records for one newly appointed member of staff, some training certificates, the staff rota, the complaints records, medication records and storage, some quality assurance feedback and other relevant information. During the day three people staying in the home were spoken with and two members of staff including the assistant manager. The outcomes for people living in the home were assessed in relation to twenty-two of the thirty-eight National Minimum Standards for the care of older people, including those considered to be key standards to ensure the welfare of people living in the home. Eight requirements have been made following this visit. What the service does well: The home provides a relaxed atmosphere for people who live there. The assistant manager is committed to improving the systems in the home so that Rosecroft DS0000014687.V369295.R02.S.doc Version 5.2 Page 6 progress can be made towards meeting all the standards. People spoken with said the staff are kind and that they get on with them well. Most of the staff have worked in the home for some time and so people benefit from receiving care from people they know well and who understand their needs. The home assists people to stay in familiar surroundings if their health needs increase; with the support of the primary care team. What has improved since the last inspection? What they could do better: Although assessments had been obtained from Social Services staff there was no evidence to show how a decision had been made by the home that they would be able to meet the persons needs or that the person themselves had been involved in this process. A requirement has been made regarding this matter. Policies and procedures should be put in place to make sure that people’s finances are protected. A requirement has been made regarding this matter. An induction and training programme should be devised to make sure that staff have the ongoing training that they need including mandatory training and updates. A requirement has been made regarding this matter. The lift must be kept in working order so that access to all parts of the home is available to people who live in the home regardless of their mobility. A requirement has been made regarding this matter. The registered provider should ensure that the laundry is suitable for the purpose with cleanable flooring and wall covering. Staff hand washing facilities should be accessible to staff to prevent the risk of cross infection. A requirement has been made regarding this matter. The registered provider should ensure that the home is kept clean to prevent the risk of cross infection. A requirement has been made regarding this matter. Rosecroft DS0000014687.V369295.R02.S.doc Version 5.2 Page 7 Materials hazardous to health should be stored in a lockable facility in order to keep people safe. A requirement has been made regarding this matter. The surface temperatures of all radiators that are used in cold weather should be kept at a temperature that protects people from the risk of burns. A requirement has been made regarding this matter. 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. Rosecroft DS0000014687.V369295.R02.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.V369295.R02.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 Rosecroft does not provide Intermediate Care. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff from the home do not always carry out an assessment before people move to the home to make sure they can provide for the person’s needs. EVIDENCE: The case records of three people were seen and showed that social workers and healthcare staff had provided assessments before people moved to the home. Although assessments had been obtained from Social Services staff there was no evidence to show how a decision had been made by the home that they would be able to meet the persons needs or that the person themselves had been involved in this process. A requirement has been made regarding this matter. Rosecroft DS0000014687.V369295.R02.S.doc Version 5.2 Page 10 The assistant manager is developing a format so that a comprehensive assessment can be carried out before a decision is made about the person moving in. She said that the prospective resident and their relatives would be involved in this process. It is important to ensure that the staff team have the skills and the home has the facilities to provide for the care needs of people who want to move to the home. The case records seen showed that an initial assessment had been carried out on admission with a little detail about health needs, diet and eating habits, interests, wishes following death, emotional and spiritual needs with space for the person to sign their agreement. Rosecroft DS0000014687.V369295.R02.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. People’s health, personal and social care needs are set out in an individual plan of care. People’s health care needs are met. The medication policies and procedures protect people living in the home. Privacy and dignity are respected by staff. EVIDENCE: There is a format for care planning and review. The assistant manager has reviewed and improved the care planning forms to show more detail of aspects of people’s daily needs and the actions required by staff. The case records of three people were read and showed that the key aspects of their care and health needs were clearly documented. The forms included information about personal hygiene, communication, physical abilities and general health. The background information was detailed and provided guidance for staff about the way to support people. There was an Rosecroft DS0000014687.V369295.R02.S.doc Version 5.2 Page 12 emphasis on supporting people with their independence. The care plan for one person noted: ‘allow S to act independently offering encouragement and support’; for another person: ‘use questions that require a one word response’ and ‘monitor closely in case of isolation’. Service users and relatives had been involved in the care planning and staff spoken with said they understand people’s needs. There were no photographs on care plans and this needs to be in place so that any new staff can clearly identify each person. The care plans had been reviewed each month and changes of need noted. The assistant manager said that she makes sure that any change of need is communicated to staff; the surveys that were returned by staff also indicated that this is the case. Risk assessments had been carried out for mobility; risk of falls and the Waterlow scale had been used for one person. In addition the assistant manager has carried out environmental risk assessments for individuals and where a specific need has been identified a risk assessment has been carried out with guidance for staff. People’s health care needs were noted and it was clear that people are supported to attend hospital appointments as required. On one care plan there was guidance for staff about getting someone ready for appointments so that she looks smart. Contact with GPs and district nurses was noted in the daily recording sheets. The assistant manager said that the home make arrangements to try to ensure that people can stay in the familiar environment of their home as their health needs increase. Community nurses are involved in the care of people who need additional health care support; they also provide guidance for staff. The assistant manager is drawing up fluid and nutrition charts with the help of the nurse for someone who needs to have their fluid and food intake monitored. The staff who administer medication have all attended training so that they are competent. The recording system and storage facilities were seen. There is no storage facility for controlled medication however no controlled drugs have been prescribed at present. If this situation changes the home must ensure that a controlled drug cupboard that complies with the current legislation is supplied and fitted. People spoken with said that staff treat them with respect and the two people who returned surveys said that this is the case. Staff were observed being sensitive and patient in the way they were providing care. Rosecroft DS0000014687.V369295.R02.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): 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. People find the lifestyle experience in the home sometimes matches their expectations. People are supported to maintain contact with relatives and friends. People exercise some choice and control over their lives. People are provided with a balanced and nutritious diet. EVIDENCE: There is no activities programme in the home and during the visit one person had gone out for a walk, another was attending a hospital appointment and the other people were watching television in the lounge or in their rooms. The manager said that some entertainment had been arranged in the home including a poetry evening and people had told him they did not like it. The assistant manager said that it is difficult to motivate people to take part in activities and that when she asks them they seem content with their lives. Sometimes people have the opportunity to go out for a drive in the country. There was little information on the case records that were seen about people’s life history and interests. It is recommended that a more person centred Rosecroft DS0000014687.V369295.R02.S.doc Version 5.2 Page 14 approach should be taken to providing stimulation for people during the day to avoid a deterioration in mental health. The assistant manager agreed to spend time finding out more about people’s interests and provide staffing for some one to one time with people. The daily activity programme should be recorded and monitored to make sure people do not become isolated. Two of the people spoken with enjoyed having someone to talk to in their rooms. It was evident that people are supported to maintain contact with relatives and friends. One person said that her visitors are always made welcome and could have a meal with her if they wish to. The manager said that he tries to create an informal atmosphere and people are welcome to have visitors at any time. People are supported to make some choices in their daily lives. They can get up and go to bed at times they choose; one care plan said ‘ X likes to watch television until 9 o’clock’. The assistant manager said that meal times are more flexible so that people can eat when they choose although there is a set time for lunch. There is an emphasis on encouraging people to maintain their independence and there was evidence of this in the care plans. A sample menu was seen and showed that a range of meals is provided. There is a choice of meal available although this is not advertised. New menu cards are being planned so that staff speak to each person in the evening and show them the meal choices for the next day. The assistant manager said that the menus would be displayed in the dining room so that people are reminded of the main meal and a choice of meal. Some people choose to eat in their rooms and others eat in the dining room that is part of the lounge. The assistant manager said that at the moment it is difficult to make sure people are weighed each month to monitor their wellbeing; it is advised that the home purchase scales that are suitable for people who have mobility problems. The care staff provide meals and clear away afterwards. During the morning one of the two staff on duty was cooking the lunch. Rosecroft DS0000014687.V369295.R02.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. People can be confident that their concerns and complaints will be listened to and acted upon. There are measures in place to protect people from harm. EVIDENCE: There is a complaints book that has been provided following a requirement made at the previous inspection. Four complaints had been recorded and followed up. The assistant manager said she is introducing a better system for recording concerns and complaints so that the progress of each investigation can be charted and the outcome clearly recorded. People spoken with and those who returned surveys said they know who to speak to if they have a concern and they feel they would be listened to. There is a copy of the West Sussex multi disciplinary policy and procedure for safeguarding vulnerable adults. All staff have attended training in adult abuse and those spoken with understood their responsibilities to report any concerns that abuse may have occurred. West Sussex Caring and Social Services carried out an investigation in March following a referral from hospital when someone was admitted from the home. One of the recommendations was that the home should be clear about the level of care that they are able to provide through the assessment process. Rosecroft DS0000014687.V369295.R02.S.doc Version 5.2 Page 16 The assistant manager said in the AQAA that senior staff are trained and understand how to support people who on occasions display disruptive behaviour. Rosecroft DS0000014687.V369295.R02.S.doc Version 5.2 Page 17 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some areas of the home are not safe and well maintained. The laundry facilities do not fully protect people from the risk of cross infection. EVIDENCE: The outside of the building and some areas of the home have been redecorated. Some of the bedrooms have been fitted with new carpets. A patio area has been built in the garden so that people can sit outside in good weather. The fire officer has been to the premises recently and the report states that the home has complied with fire regulations. The passenger lift was not working and the manager and other people spoken with said that this is an intermittent problem. This means that people who have rooms upstairs are not able to access any other part of the building or the garden. A requirement has been made regarding this matter. Rosecroft DS0000014687.V369295.R02.S.doc Version 5.2 Page 18 There is one communal lounge in use at the moment and some people also use this as a dining room. Part of the lounge is being used as an office. The manager must make sure that confidential documents are stored in a lockable facility and that disruption to people living in the home is kept to a minimum. People said that they are happy with their rooms and those seen had personal items. There is a call bell system. Only one of the three bathrooms has an assisted bath seat for people who have mobility problems. It is on the ground floor and not accessible to people who have rooms on the first floor when the lift is out of order. This bathroom was being used for drying laundry and there was no soap or any paper towels available. The laundry room is in need of refurbishment to make sure that it meets the standard so that: ‘floor finishes are impermeable and these and the wall finishes are readily cleanable’ (Standard 26.4). Laundry was spread over the laundry room and clean laundry spread over a small lounge that is currently not in use by people living in the home. The laundry room floor had not been cleaned. The hand washing facilities for staff are not accessible because a washing machine has been fitted in front of it. Arrangements must be made to ensure that the risk of cross infection is minimised and that clean laundry is either returned to the person it belongs to or stored in a clean and dry facility. A requirement has been made regarding the laundry facilities. The care staff are responsible for laundry and cleaning as well as care and kitchen duties. The laundry room floor was not clean and a table in one person’s room had not been cleaned recently. The kitchen is in need of a deep clean. The manager should ensure that there are sufficient numbers of staff on duty for cleaning and other duties as well as care. A requirement has been made regarding this matter. Bleach and other hazardous material had not been locked away and the cupboard for storage of these materials was not lockable. A requirement has been made regarding this matter. Radiator covers have been fitted to radiators in people’s rooms to prevent the risk of burns. Several radiators in the hallways, communal areas and bathrooms were not protected to ensure that the surface temperature is kept at a safe level as recommended by the Health and Safety Executive. The surface temperature of radiators that are used in cold weather should be at a safe temperature that protects people from the risk of burns. A requirement has been made regarding this matter. Rosecroft DS0000014687.V369295.R02.S.doc Version 5.2 Page 19 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s care needs are met by the numbers of staff on duty. The home’s recruitment policy and procedure does not fully protect people. Staff have received some training so that they have the knowledge and skills to do their job, however there is no clear induction or training programme in place. EVIDENCE: The duty rota for the week was seen and showed that three care staff are on duty in the morning and two in the afternoon. At night there is one waking night staff and one person sleeping in. The assistant manager is on duty during the day in the week and at the moment is staying in the home so is available on call at other times. The manager said that he is in the home every day. On the morning of the visit one person was off sick, one person was providing care and another was preparing lunch. The assistant manager said that there had been additional staff to help people get up and have breakfast in the morning. Care needs were being taken care of however staff did not have time for cleaning and laundry duties. Staff are supported and encouraged to study for the National Vocational qualification (NVQ) at level two or above. Seven of the thirteen staff have achieved the NVQ at level two or above and one person is enrolled on the level three course. Rosecroft DS0000014687.V369295.R02.S.doc Version 5.2 Page 20 One person has been recruited since the previous inspection and the recruitment records were seen. There were two written references, however there was no application form or evidence to show that the persons employment history had been checked. The assistant manager said in the AQAA that she is supporting and encouraging staff to attend training courses. Several staff have studied for a dementia care course that has given them in depth knowledge about caring for people who have a dementia. Staff who returned surveys and who were spoken with said that they are provided with the training they need to do their jobs. There were copies of training certificates on file however there was no clear training programme and it was not clear that all staff have attended the mandatory training and updates as required. The manager must ensure that an induction programme that meets the Skills for Care guidance is put in place for all newly appointed staff, there was no evidence to show that this is the case. Rosecroft DS0000014687.V369295.R02.S.doc Version 5.2 Page 21 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. The home is run by people with the qualifications and experience to do so. People’s views about the service are sought. People’s finances are not fully protected. The health, safety and welfare of people living in the home and staff are not fully protected and promoted. EVIDENCE: The owner and manager have obtained the NVQ level four in care and the Registered Manager’s Award. He runs the home with the assistant manager who has also achieved the Registered Manager’s Award. The manager and assistant manager have many years of experience in providing care for older people. The assistant manager said that the home would be purchasing a Rosecroft DS0000014687.V369295.R02.S.doc Version 5.2 Page 22 computer to make the running of the service more efficient. She is also intending to register for a computer course. Surveys have been circulated to people living in the home, their relatives and health care professionals; some of these had been returned and were seen on file. They had not yet been collated and published so that people could not yet see that their views are taken seriously and acted on. The assistant manager said that more flexible meal times had been introduced following requests from residents. The Commission sent surveys to gain people’s views about the home; the assistant manager arranged for an independent person to explain the purpose of the surveys and to help people fill them in. Unfortunately only two were received in time for people’s views to be included in this report. The assistant manager said that it had been a useful exercise and people had felt included. The assistant manager was advised to devise a quality monitoring system so that a regular audit could be carried out of all aspects of the service to ensure that standards are being met. The home does not take responsibility for anyone’s finances; family members or solicitors carry out this task. Staff or volunteers do assist people in buying small items and other financial transactions. There was no clear policy or guidance for staff and no system for ensuring that these transactions are recorded and receipts obtained and kept on file in order to protect people. A requirement has been made regarding this matter. The AQAA showed that equipment is maintained and serviced as required. The manager must ensure that the lift is in working order at all times so that people have safe access to all communal areas of the home. The fire officer has stated that the home meets the requirements of the fire service. Staff said they had been provided with training, however there was no evidence to show that all staff have attended the required health and safety training including moving and handling, infection control, fire training and food hygiene. A requirement has been made regarding this matter. The requirement that was made at the previous inspection regarding incident reporting has now been resolved and the home has been informing the Commission of key events in the home. A record is kept of accidents and incidents in the home and these are monitored by the assistant manager. Rosecroft DS0000014687.V369295.R02.S.doc Version 5.2 Page 23 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 2 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X X X 1 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 Rosecroft DS0000014687.V369295.R02.S.doc Version 5.2 Page 24 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. OP3 Reg 14 Standard Regulation Requirement The registered manager should be able to show how a decision has been made about whether or not the home could meet the needs of someone interested in moving to the home, through an assessment process that the person and their relatives have been involved in. Policies and procedures should be put in place to make sure that people’s finances are protected and that guidance to staff is clear. An induction and training programme should be devised and records kept to make sure that staff have the ongoing training that they need including mandatory training and updates in order to protect the safety and welfare of people living in the home and staff. There should be safe access to all areas communal areas of the home including an operational lift. The guidance of the environmental health officer should be sought regarding this DS0000014687.V369295.R02.S.doc Timescale for action 31/10/08 2. OP35 Reg 13 31/10/08 3. OP30 Reg 18 31/10/08 4. OP19 Reg 23 31/10/08 Rosecroft Version 5.2 Page 25 5. OP26 Reg 23 6. OP26 7. OP38 8. OP38 Reg 13 Reg 13 Reg 16 matter. The registered provider should ensure that the laundry facilities are suitable for the purpose with cleanable flooring and wall covering. Staff hand washing facilities should be accessible to staff to prevent the risk of cross infection. The registered provider should ensure that the home is kept clean to prevent the risk of cross infection. Materials hazardous to health should be stored in a lockable facility in order to keep people safe from harm. The surface temperatures of all radiators that are used in cold weather should be kept at a temperature that protects people from the risk of burns. 31/10/08 31/10/08 31/10/08 31/10/08 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.V369295.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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.V369295.R02.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!