Inspection on 25/04/06 for Rosecroft

This inspection was carried out on 25th April 2006.

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

Other inspections for this house

Rosecroft 12/08/08

Rosecroft 01/08/07

Rosecroft 27/11/06

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 Mr E McLeod Unannounced Inspection 25th April 2006 09:15 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.V293304.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. 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.V293304.R01.S.doc Version 5.1 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.V293304.R01.S.doc Version 5.1 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. 6th September 2005 Date of last inspection Brief Description of the Service: Rosecroft is registered as a care home for up to 19 residents in the category of old age, one of whom may be in the category of physical disability. The premises overlook the green at Southwick, and are close to local shops and bus and train services. The accommodation for residents is located on ground floor and first floor levels. The registered provider is Mr Dennis R. Clark, who is also the registered manager. Rosecroft DS0000014687.V293304.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was arranged to follow up requirements and recommendations made at the previous inspection, and to update our assessment of the home’s compliance with national minimum standards. The second inspector on the inspection visit was Mrs L. Riddle. The inspectors had met to plan the inspection with Mrs D. Peel, who is link inspector for the service. The inspectors made a partial tour of the premises and grounds, and spoke with residents, staff, two visiting relatives, and registered manager Mr D. Clark. Care plans and records were sampled, and staff recruitment and training records were also sampled. Documents and policies seen included the statement of purpose for the service, adult protection procedures, and health and safety records. Outcomes for residents in the home were assessed as adequate. The inspectors would like to thank all residents, relatives, staff and managers who contributed to the inspection. What the service does well: What has improved since the last inspection? Since the previous inspection, some new chairs have been provided in the sitting room. Mr Clark said he and his staff were now clearer about the need to make health care referrals in circumstances such as head injuries, and that he had met with district nurses in their office to improve understanding between them. Staff are now receiving training in adult protection, including local adult protection procedures. Bathrooms and toilets in the home which previously were found to be being kept locked, are no longer being locked and are therefore more accessible to residents. Rosecroft DS0000014687.V293304.R01.S.doc Version 5.1 Page 6 All staff employed now have CRB checks, which helps protect residents. Four members of care staff have now achieved NVQ level 2 in care. What they could do better: Pre-admission information for prospective residents needs to be improved, and all residents and prospective residents should receive a copy of the service user guide. Individual care plans need to include the action to be taken by staff to meet a resident’s care needs. Risk assessments need to list the action to be taken by staff to minimise the risks to residents identified. Clear medication procedures must be provided, and medicines must be securely stored at all times. Food menus need to be more varied and to show alternatives so that residents can know they have a choice. Residents’ interests should be encouraged more, and be included in care plans. The provider must ensure residents in need of medical treatment or monitoring are enabled to access this. An adult protection procedure for the home which is robust and is up to date with current legislation and protects residents must be developed. A formal system for recording complaints must be provided. A redecoration, refurbishment and repair programme needs to be undertaken. The large amount of unused equipment and appliances being stored in communal areas do not help provide a comfortable or homely environment for residents, and should be removed. Paint and decorating materials should be removed from the kitchen areas. Better disabled access to and from the premises needs to be provided. The garden and areas are in need of better upkeep. Staff rotas which identify which tasks staff are undertaking on each shift need to be provided. Staffing levels need to be reviewed to ensure there are enough staff on duty to meet the needs of residents. Not all staff have received refresher training in required topics such as health and safety and manual handling. There is a lack of proper sluicing facilities to ensure that incontinent laundry is being properly cleaned and good hygiene is maintained. The provider needs to diminish the risk to residents posed by uncovered radiators and unmarked steps. Fire doors need to be self closing, and should not be propped open. An annual development plan for the service should be provided. Rosecroft DS0000014687.V293304.R01.S.doc Version 5.1 Page 7 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. Rosecroft DS0000014687.V293304.R01.S.doc Version 5.1 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.V293304.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 6 Pre-admission information for prospective residents needs to be improved, and all residents and prospective residents should receive a copy of the service user guide. Good arrangements for pre-admission assessments and visits are in place. Outcomes for residents were assessed as adequate. EVIDENCE: A new resident interviewed said she had not received a copy of the service user guide, and this was confirmed by care staff. The service user guide seen by inspectors was in handwritten form, and it was suggested to Mr Clark in feedback at the end of the inspection that this would be easier for residents and relatives to read if it was typewritten. Rosecroft DS0000014687.V293304.R01.S.doc Version 5.1 Page 10 The Service User Guide and Statement of Purpose are contained in one document – however, this does not include all required information and some information in it needs updating, such as the staff team information. In discussion with Mr Clark he agreed that the staff team information in the service user guide and Statement of Purpose was not up to date. The information on the minimum age was missing in the Service User Guide/ Statement of Purpose with regard to the provision for one resident aged between 60 and 65 with a physical disability, and this therefore could be misleading for prospective residents. The inspectors sampled two sets of admission records, which were seen to include pre admission assessments, risk assessments, and care plans. Staff and residents interviewed said that visits to the home before admission was arranged had taken place, and that registered manager Mr Clark had visited them at home or in hospital to carry out an assessment of needs. The home does not provide facilities for intermediate care. Fees in the home range from £325 to £405 per week. Rosecroft DS0000014687.V293304.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Individual care plans need to include the action to be taken by staff to meet a resident’s care needs. Risk assessments need to list the action to be taken by staff to minimise the risks to residents identified. Clear medication procedures must be provided, and medicines must be securely stored at all times. Outcomes for residents were assessed as adequate. EVIDENCE: Accident records were sampled and discussed with Mr Clark. Mr Clark said he and his staff were now clearer about the need to make health care referrals in circumstances such as head injuries, and that he had met with district nurses in their office to improve understanding between them. He said the two adult protection investigations undertaken in the past year had been a difficult time for himself and his staff team, but that they had learned from the experience. The inspectors looked at a number of care plans. Care plans and risk assessments seen were found to not provide enough detail on care needs. There was also a lack of advice to staff in care plans and risk assessments on actions to be taken to meet the needs identified or minimise the risks identified. Rosecroft DS0000014687.V293304.R01.S.doc Version 5.1 Page 12 There was also a lack of information recorded on resident’s interests, which would be useful in planning for how a resident’s social and leisure needs might be met. Mr Clark said they used to record more on residents’ interests in the past than they do now. Care records and interviews with staff, residents and visitors indicated that residents’ health care needs such as chiropody, dental, optician and GP visits are being provided for. Mr Clark said that a recent adult protection investigation had suggested that there had been a delay in seeking medical assistance when a resident had received a head injury. Mr Clark said he and his staff were now clearer about when medical advice should be more quickly sought. District nurse records for one bed bound resident were sampled, which included records kept by the home of when the resident had been turned or had cream applied. A nimbus 3 pressure relieving bed is provided. Mr Clark said that the family had requested that the resident remain in the home rather than be transferred to nursing home care, and so the district nurses have been involved in monitoring the care provided once per week. The resident has soft food and is very frail and unable to communicate, but Mr Clark said she smiles at the staff when they are feeding her and she likes to listen to classical music. A radio chat show was playing in the resident’s room, but the station wasn’t tuned properly and the quality of reception was poor. This was drawn to Mr Clark’s attention by the inspectors, who suggested the radio be retuned to a station the resident preferred. Mr Clark said that no residents at present are suffering from pressure sores or pressure areas, and advised that pressure relieving mattresses are being provided from residents where needed. On the mid-morning of the inspection, a number of medicines were noted to be left on a kitchen shelf, including prescribed lactulose (liquid) and senokot, and some unlabelled tablets (later identified as belonging to Mr Clark). This was immediately drawn to Mr Clark’s attention, and he was advised that all medicines should be properly stored and locked away. During the mid-afternoon of the inspection, it was noted that the same medicines were still on the kitchen shelf, and again this was immediately drawn to Mr Clark’s attention. Staff advised the inspectors that a procedure for the administration of medicines policy hasn’t yet been written, and the inspectors advised that there need to be administration procedures in place, including on proper storage, and there needs to be a photograph of the resident attached to their medicine charts to better ensure safe administration. Rosecroft DS0000014687.V293304.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Food menus need to be more varied and to show alternatives available. Residents’ interests should be encouraged more. Residents are supported by staff to maintain contact with family and friends. Outcomes for residents were assessed as adequate. EVIDENCE: Residents interviewed said they liked the food provided. Two residents indicated that as it was Tuesday the lunch would be Shepherd’s pie. Menus seen confirmed that meals are not changing much from week to week. Alternatives being offered were not included on the menus seen. Mr Clark said his cook had left, and staff cooking were not experienced cooks. The shepherd’s pie served seemed to only consist of mince and potatoes, to which Mr Clark replied that the member of staff cooking was not an experienced cook and that she “didn’t make shepherd’s pie as you know it”. Mr Clark said he may consider employing a cook. On the day of the inspection, staff were noted to be engaging with residents, and friendly conversations were taking place. Inspectors asked residents what their interests were and if staff were assisting them to continue their interests in any way, but no examples were given of this happening. Rosecroft DS0000014687.V293304.R01.S.doc Version 5.1 Page 14 Two members of staff were interviewed. They described activities which were being provided for residents, and individual support that residents were receiving. Discussions with staff and Mr Clark indicated that staff were making efforts to take a few residents on short local outings, and to encourage residents to take part in a few games. However, one resident told inspectors that as there was nothing to do she spent most of her day just lying on her bed. Discussions with residents indicated that their families are made welcome when they visit. Inspectors observed that in the sitting room the TV was turned on throughout the day although residents did not all appear to be watching it. In the late afternoon, when children’s programmes were on, the inspectors asked Mr Clark if residents may like the channel changed. Mr Clark found that the residents did wish the channel changed, and this was done. Rosecroft DS0000014687.V293304.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Staff are receiving training in the protection of vulnerable adults, which includes training in local adult protection procedures. The provider must ensure residents in need of medical treatment or monitoring are enabled to access this. An adult protection procedure for the home which is robust, reflects current legislation and protects residents must be developed. A formal system for recording complaints must be provided. Outcomes for residents were assessed as adequate. EVIDENCE: Staff training records seen indicate that staff are now receiving training in adult protection, including local adult protection procedures. The home does not have an adult protection procedure, and Mr Clark said they adhered to the West Sussex County Council procedures – however, as these were written in 1987 they do not reflect changes to legislation such as Care Standards Act 2000, and the introduction of the Protection of Vulnerable Adults register in 2003. The inspectors said to Mr Clark that the home should provide an adult protection procedure which advises staff that the provider has a responsibility to report staff where appropriate to the Protection of Vulnerable Adults register, and clarifies that CSCI does not investigate adult protection incidents – this is done by the local authority or police service as appropriate. The procedure should also provide guidance for staff on the steps to be taken if an adult protection incident is suspected or known to have taken place. Rosecroft DS0000014687.V293304.R01.S.doc Version 5.1 Page 16 There have been two adult protection investigations in the home in the past year, which have highlighted the need to refer residents earlier for medical treatment on such conditions as head injury and pressure areas. A complaints policy was seen. However, a formal system for recording complaints is not in place. A book is used which contains various comments from relatives/visitors. No record of the more recent complaints/concerns had been made. Rosecroft DS0000014687.V293304.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 26 A redecoration, refurbishment and repair programme needs to be undertaken. The large amount of unused equipment and appliances being stored in communal areas do not help provide a comfortable or homely environment for residents, and should be removed. Better disabled access to and from the premises needs to be provided. The garden and areas are in need of better upkeep. Outcomes for residents were assessed as adequate. EVIDENCE: The bedrooms and communal areas visited were free of unpleasant odours. Further to the requirement made at the previous inspection, none of the bathrooms and toilets in the home were found to be being kept locked, and they are therefore now more accessible to residents. Rosecroft DS0000014687.V293304.R01.S.doc Version 5.1 Page 18 Mr Clark was not able to advise the inspectors of any improvements to the premises which have taken place since the previous inspection, but did write to the inspectors later to say that some new chairs had been bought for the sitting room. Mr Clark was not able to provide a schedule of improvements for the premises as required at the previous inspection. Residents interviewed said they liked their bedrooms, and had been able to bring with them furniture and possessions which they wished to, which had assisted them in personalising their bedrooms. Two steps on the ground floor of the home were identified at the previous inspection as needing hard warning strips to help prevent trips and falls. This has not been done, and one of the inspectors tripped over the steps concerned while walking around the premises. A resident advised the inspectors that the lack of a ramp at either the front or rear entrance made it difficult for her with her mobility problems to go out. This was discussed with Mr Clark, who said he would consider providing ramp access at the rear entrance. Two of the baths seen were not in good condition, and some of the bedroom and communal area furniture seen was in poor condition and in need of replacement. The inspectors noted other areas of repair or replacement needed, such as the area around a large window frame in an upstairs corridor, the hole in the wall with bare wires showing in the rear sitting room, the lack of a lamp shade in the rear sitting room, and the light in the dining room was reduced by most of the light bulbs not working. The home continues not to have a washing machine with a sluice cycle, which is needed for purposes of hygiene. As the dish washing machine has not been replaced, this was also thought to have possible hygiene implications. The front and rear gardens were a bit overgrown, and there was an amount of garden rubbish and other discarded items especially in the rear garden. The garden areas need better upkeep. There was a large amount of equipment no longer in use such as televisions, washing machines, a spin dryer, chairs in poor condition, a bed end, and old wheelchairs which had been left or were being stored in sitting rooms, bathrooms and the laundry area. This does not help provide a comfortable or homely environment for residents. Paint and painting materials were being stored in the kitchen, and Mr Clark was advised that these could present a fire risk and should be removed. It was noted that some radiator covers were plain sheets of plasterboard which had been attached to the front of radiators. This was preventing heat from coming through the front of the radiator, and looked unsightly Rosecroft DS0000014687.V293304.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Staff rotas which identify which tasks staff are undertaking on each shift need to be provided. Staffing levels need to be reviewed to ensure there are enough staff on duty to meet the needs of residents. There are some gaps in staff training. The recruitment procedures for the home are now better ensuring the safety of residents. Outcomes for residents were assessed as adequate. EVIDENCE: Three sets of staff records were sampled. Written references were not available for two of the employees – Mr Clark said these employees had worked for the home for a long number of years, and therefore he had not sought retrospective references for them. CRB check records were seen for all three staff. The inspectors asked Mr Clark about the staff he had employed at the time of the previous inspection without obtaining references or checks for them. Mr Clark said both those staff had left when they were told that CRB checks would be necessary. Mr Clark said that all staff employed now have CRB checks. No up to date staff rota was available. Mr Clark said that staff knew when they were working. As care staff were also noted to be doing cooking and cleaning, with no separate staff employed for those tasks, the inspectors advised Mr Clark that he should identify on his rotas which tasks staff were undertaking. Rosecroft DS0000014687.V293304.R01.S.doc Version 5.1 Page 20 It was noted that a number of residents have a high level of dependency needs – the provider needs to ensure that staffing levels are reviewed to ensure the needs of all residents are being met. Staff training records were seen, and training certificates were sampled. Training in adult protection is now being provided. Mr Clark said that four members of staff had now achieved NVQ level 2 in care. It was noted that some staff are overdue for refresher training in topics such as manual handling and food hygiene. Discussions with staff indicated that staff feel well supported by Mr Clark. Records for supervision with staff indicate that when supervision is taking place, it is not always being recorded. Rosecroft DS0000014687.V293304.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 The manager has ensured that some requirements made at the previous inspection have been met, while other previous requirements concerning the health and safety and good care of residents have not been met. Some new requirements have been made during this inspection concerning the health and safety and good care of residents. The provider must provide a plan for the improvement of the premises which will benefit residents living in the home. There is no annual development plan or clear system for reviewing the service provided, which if done would assist the provider in improving the service and environment for residents. Staff do not manage residents’ finances. Health and safety concerns noted at this inspection include uncovered radiators, the lack of a washing machine with a sluice capability, that fire doors should be properly self-closing, and the need for regular environmental risk assessments to be carried out by the provider. Outcomes for residents were assessed as adequate. Rosecroft DS0000014687.V293304.R01.S.doc Version 5.1 Page 22 EVIDENCE: Some radiators that could provide a risk to residents are not covered. No risk assessments for those radiators were presented to the inspectors. Sheets of plasterboard in some instances have been installed as radiator covers – this was preventing any heat from coming through the front of the radiator, and looked unsightly. Mr Clark said he was looking at options for radiator covers. The washing machine does not have a sluice capability, and as it is recorded in the care plans that a number of residents are incontinent or doubly incontinent, the inspectors asked Mr Clark how incontinence laundry was being cleaned. Mr Clark replied that in some cases stained underwear was being discarded, and new underwear purchased for the resident. It was the view of the inspectors that proper facilities are not being provided for the cleaning of incontinence laundry. The inspectors asked Mr Clark how dishwashing was carried out in the home. He said that the dishwashing machine had broken down, and was not going to be replaced as staff hadn’t been using it properly causing it to break down. The inspectors asked if the hot water at the kitchen sinks was sufficiently hot to ensure hygienic dishwashing. Mr Clark replied that sometimes staff have to supplement the hot water in the kitchen by boiling up kettles. Staff in the kitchen handling food were wearing aprons. Hard warning strips to identify steps which are seen as a trip hazards were required by inspectors at the last inspection, but have not been provided. The inspectors noted no instances where staff carrying out cleaning tasks were not changing protective clothing before entering areas where food is prepared, and this requirement was therefore assessed as met. Care plans were noted to be stored securely, and this requirement was therefore assessed as met. Mr Clark advised that staff do not take responsibility for the finances of residents, but where relatives were involved with finances the home would send invoices onto them on behalf of the resident. Mr Clark said he had been asking visitors to write down their views of the service. The inspectors sampled these comments, which were brief. No quality assurance programme, as recommended under standard 33, is in place. Requirements made by the fire service were seen to have been fulfilled, excepting the requirement for fire doors to be self-closing. Mr Clark agreed that some door springs needed further adjustment to meet the requirement. Two fire doors were noted to be propped open. Environmental risk assessments seen were not recorded in sufficient detail to ensure residents are being protected from hazards and risks. Rosecroft DS0000014687.V293304.R01.S.doc Version 5.1 Page 23 Certificates sampled included a certificate of liability insurance (expiring December 2006), fire equipment check 23.3.06, fire risk assessment 2.3.06, gas safety 12.5.05, lift repair 8.2.06. Fire tests were recorded for 24.4.06, 8.4.06 and 1.4.06. It was noted that PAT testing for electrical appliances was now overdue. The inspectors recommended that Mr Clark provide a sign next to the lift advising staff they should not use the lift in the event of a fire. Mr Clark said there was not a current annual development plan for the service. A certificate confirming that Mr Clark achieved the NVQ4 Registered Manager Award in December 2004 was seen. Rosecroft DS0000014687.V293304.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 1 3 X X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 2 X 2 Rosecroft DS0000014687.V293304.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13.2 Timescale for action Clear and comprehensive policies 30/06/06 and procedures for the receipt, recording, storage, safe handling, administration self administration and disposal of medicines, specific to the home, must be produced. (Previous timescale of 1/11/05 not met). The environment must be 30/06/06 improved to make sure that residents live in a safe and well maintained home (a schedule of improvements must be provided by the timescale date). (Previous timescale of 1.11.05 not met). Radiators must be guarded or 28/07/06 evidence of documented risk assessment must be provided to minimise risks. (Previous timescale of 1.11.05 not met). Radiators must be guarded or 28/07/06 evidence of documented risk assessment must be provided to minimise risks. (Previous timescale of 1.11.05 not met). Staff training must be developed 28/07/06 to provided staff with the skills to meet the needs of the DS0000014687.V293304.R01.S.doc Version 5.1 Page 26 Requirement 2 OP19 23.2 3 OP38 13.4(a), (c) 4 OP25 13.4(a), (c) 5 OP4 18.1 (a) (c) Rosecroft 6 OP30 18.1 (a) (c) 7 OP33 24.1 8 OP26 23.2 (k) 9 OP38 23.2 (k) 10 OP9 13.2 8 OP38 13.4 (a) 9 OP1 6 residents (safe handling of medicines, dealing with challenging behaviour, dementia care, infection control) in addition to mandatory training (Previous timescale of 1/12/05 not met) Staff training must be developed to provided staff with the skills to meet the needs of the residents (safe handling of medicines, dealing with challenging behaviour, dementia care, infection control) in addition to mandatory training (Previous timescale of 1/12/05 not met) A formal quality assurance system must be established. (Previous timescale of 1/11/05 not met). A washing machine must be provided which has a sluicing facility (Previous timescale of 1/11/05 not met). A washing machine must be provided which has a sluicing facility (Previous timescale of 1/11/05 not met). Medicines should be stored and transported around the home in a secure manner. Care should be taken medicines can be quickly and securely locked away in the event of an emergency. The carer administering the medicine should sign the administration record immediately after the medicine has been given. Hard warning strips should be put in place to identify the steps in the hallway and kitchen which present a possible trip hazard. The provider must update the statement of purpose and service user’s guide, which should be typewritten to be more DS0000014687.V293304.R01.S.doc 28/07/06 28/07/06 30/06/06 30/06/06 30/06/06 30/06/06 28/07/06 Rosecroft Version 5.1 Page 27 10 OP7 15.1 readable for residents, and should provide a service user guide to each resident and prospective resident. Individual care plans need to include the action to be taken by staff to meet a resident’s care needs. Individual risk assessments need to list the action to be taken by staff to minimise the risks to the resident identified. Food menus need to be more varied and to show alternatives available for residents. An adult protection procedure for the home which is robust, reflects current legislation and protects residents must be developed. A formal system for recording complaints must be provided. The provider must ensure residents in need of medical treatment or monitoring are enabled to access this. Better disabled access to and from the premises needs to be provided. Garden areas need to be appropriately maintained. Equipment and facilities to ensure good hygiene in the kitchen must be provided, consulting with the environmental health authority where appropriate Fire doors need to be self closing, and should not be DS0000014687.V293304.R01.S.doc 30/06/06 11 OP7 13.4 (c) 30/06/06 12 OP15 16.2 (i) 30/06/06 13 OP18 13.6 30/06/06 14 OP16 22.1 30/06/06 15 OP8 12.1 (a) (b) 23.2 (n) 23.2 (o) 30/06/06 16 17 OP19 OP19 28/07/06 28/07/06 18 OP38 16.2 (j) 28/07/06 19 Rosecroft OP38 23.4 (a) 30/06/06 Version 5.1 Page 28 propped open. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP26 Good Practice Recommendations Unused equipment and appliances being stored in communal areas do not help provide a comfortable or homely environment for residents, and should be removed. An annual development plan for the service should be provided. 2 OP33 Rosecroft DS0000014687.V293304.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 Rosecroft DS0000014687.V293304.R01.S.doc Version 5.1 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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