Inspection on 21/11/07 for Rosedale Court

This inspection was carried out on 21st November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Rosedale Court 23/11/06

Rosedale Court 24/11/05

Rosedale Court 20/04/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Rosedale Court Hockley Road Rayleigh Essex SS6 8EP Lead Inspector Sharon Lacey Unannounced Inspection 21st November 2007 09:45 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 Rosedale Court DS0000064180.V348795.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. Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosedale Court Address Hockley Road Rayleigh Essex SS6 8EP 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) 01268 773180 01268 774025 rosedale.court@runwoodhomes.co.uk www.runwoodhomecare.com Runwood Homes Plc Mrs Frances Mary Mallett Care Home 73 Category(ies) of Dementia - over 65 years of age (51), Old age, registration, with number not falling within any other category (22) of places Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. To provide personal care to 51 service users with dementia. (DE(E)). To provide personal care with nursing to 22 older people on the first floor. (OP). Total number not to exceed 73 service users. Date of last inspection 23rd November 2006 Brief Description of the Service: Rosedale Court is a large purpose built detached building set back from the main road. The home is approximately one mile from Rayleigh town centre. Residents are accommodated on the ground and first floor and there is lift. The home has good car parking facilities. There is a large patio area and small grassed area to the rear of the building. The home is divided into four areas; Jasmine, Primrose and Honeysuckle accommodate older people with dementia care needs, whilst Lavender accommodates older people who have nursing care needs. All bedrooms have en suite facilities and there are separate lounge, dining and bathroom areas on each floor. The home has a statement of purpose and service users guide available. Information about the home and most recent inspection report are available to residents/visitors in the lobby area of the home. It was confirmed that the current weekly fees at the home are: Rates funded by the Local Authority (non nursing beds) £359.80 to £416:29, depending on need. Funded nursing beds are £566.50 to 633.45, depending on need. For privately funded people the fees are: Residential 518.00 and nursing £673.00. There are additional charges for chiropody, hairdressing, personal items, newspapers/magazines and some outings. Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine Unannounced Inspection, which took place over seven hours. The ‘key’ standards were inspected, but also evidence was gained on some of the other National Minimum Standards. A tour of the home was completed and an inspection of relevant records and documentation took place. Areas looked at included information given to residents before being admitted to Rosedale Court; information gained when residents first come into the home; how information is given to staff on the care required; the facilities and environment of the home; and any complaints that may have been received since the last inspection. Also staffing and management of the home were inspected. A notice was displayed in the home advising all visitors that an inspection was taking place with an open invitation to speak with an inspector. During the tour of the home a number of residents were spoken to about their life and experiences at Rosedale Court. Some of the other residents approached were unable to express their thoughts and feelings, but were observed during the day interacting with staff. Most staff members were spoken with informally during the Inspection and any feedback has been included as part of the report. Completed questionnaires were received from relatives and residents and also some from other professionals. Staff questionnaires were also distributed and four were received back. At the end of the day the Inspection was discussed with the Manager and advice and guidance was given regarding the findings. What the service does well: The manager has produced a very informative Service Users Guide, which provides resident and relatives with information about the home and procedures in place. Information could be found in the foyer, which would assist new residents and relatives with any questions or queries they may have. New residents can be sure that an assessment of needs will be completed and a care plan produced which highlights their care needs, so staff are aware how to meet these. The atmosphere within the home was good and staff worked as a team. When staff required advice the Manager was always on hand to assist. Generally relatives and residents were happy with the care at the home and stated staff were approachable and friendly. Observations during the inspection confirmed that relationships between staff residents were good. Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 6 Medication is managed well at the home, providing a safe system that protects residents. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are well informed about the home and their needs are assessed prior to admission to ensure that this is the right home for them. EVIDENCE: There are detailed operational policies to help with the day-to-day running of the home. The Statement of Purpose and Service User Guide has recently been reviewed and this contains details of the home and the services provided. A copy of these documents could be found in the home’s foyer and new and prospective residents are given copies during the assessment process. Feedback from the resident questionnaires indicated that they had received sufficient information about the home before moving in. Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 9 There is a thorough admission process and all new residents are visited to ensure their care needs can be met. Three files were inspected and all contained a full assessment; this contained all the areas listed in Standard three of the National Minimum Standards (NMS). The Service User Guide clearly states that anyone coming into the home can come for a trial visit. If this does occur the manager stated this would be written on the pre-admission form. Rosedale Court has a written contract/terms and conditions of the home. Three files were inspected and all contained a signed and dated contract. Staff had the skills and knowledge for the present residents care needs. The Manager had clear training records, which showed that staff had attended training in moving and handling, Fire Awareness, First Aid, Health and Safety, Medication, Safeguarding Adults, Food Hygiene, and dementia. Some staff had also attended a course on Parkinson’s disease. Residents and relatives that responded to the questionnaires stated that they felt the care provided was appropriate to their needs. Intermediate care is not provided at Rosedale Court. However the home do provide a number of ‘interim placement beds’. These beds offer residents a temporary placement as an extended recovery period following illness or crises. Sometimes residents in interim beds go on to take up permanent residence at the home. Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans contain sufficient information for staff to ensure residents care needs are met. Referrals are made to appropriate professionals to ensure that the resident’s health care needs are being met. Medication practices at the home are very well managed and ensure that residents are kept safe. EVIDENCE: Three resident’s files were inspected and all contained a care plan, which had been completed around the care needs of the individual. Those viewed from the residential units were of a good standard and provided a good basis for staff to deliver care to residents. Care planning on the nursing unit had been reviewed and the manager had tried to bring this in line with the information recorded on the residential care side of the home. There was clear evidence that these had been reviewed regularly. Training records showed that eleven staff had attended training on care plans. Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 11 Residents and visitors spoken with were very happy with the care being offered by the home. The files contained clear evidence to indicate that Residents are supported and have access to a variety of healthcare resources (GP, District Nurse, Hospital appointments, mental health nurse etc). Appropriate referrals had been made to other health care professionals when required. Feedback from visiting professionals was positive, comments included: ‘Good standards of care’ and ‘the home staff are aware of the referral procedure….and on most occasions they are receptive to advice given and will act upon it’. The home was also using specialist equipment to help in the prevention pressure sores. Visits from the optician and dentist are arranged as required. Appropriate risk assessments were in place. On the nursing unit in particular there was a good format and process in place relating to the use of bed rails for individual residents. Nutrition records are maintained at the home. Regular Regulation 37 forms are submitted by the home to the CSCI advising of any falls, deaths or injuries to residents. The home tries to ensure Residents are able to stay at the home in familiar surroundings for as long as possible. There was little information on resident’s files regarding death and dying. The manager had recently attended a training course on this subject, and aims to develop this further within the home. There is a policy on the Administration of Medicines, but this was not viewed during this inspection. Medication at the home is mainly managed through a monitored dosage system. (Blister packs). As part of the Inspection process the Nurse in Charge was observed during the lunchtime medication round and there were no concerns. Bottles of medication had been dated when opened, records sampled were well maintained, storage was good and no anomalies were noted. Seven staff had completed medication training. Management at the home undertake weekly medication audits to make sure that good practice and systems are maintained. During the day it was noted that staff treated residents with dignity and respect. Those who were unable to converse or had ‘special needs’ were included in the day-to-day activities and appropriate care provided. Relatives spoken to were positive regarding the care the staff provided, but some felt the staffing levels may not be sufficient. Feedback from a Health Care professional stated ‘During my frequent visit to the home, which are normally unannounced, I have always observed residents to be appropriately dressed and spoken to courteously’. Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 12 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. Activities are available to residents at the home, but these need to be developed further to provide more stimulation for all residents. EVIDENCE: A new Activities Co-ordinator has now started at the home and has recently introduced a weekly activities plan. This includes bowls, ball games, music, arts and craft, videos and shopping trolley. Other activities that had been organised included a visit to Alton Garden Centre, a harvest festival and ballroom dancing. On the day of the inspection the PAT dog was visiting the home and residents were viewed actively taking part. The hairdresser was also present and most female residents were either having their hair set or having a perm. Due to the size of the home and also the number of people the Activities co-coordinator has to entertain, this is an area that still needs further development. On discussion with the manager she is aware that further activities need to be organised to ensure that all residents are having their needs and interests met. One health care profession reported ‘there appears to be a lack of activity based involvement’. Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 13 Feedback from relatives and residents included ‘Very bored, all I can do is sleep’, ‘more things for those residents who are capable of playing games or cards etc’ and ‘there has been nothing for the clients to do – his must be resolved’. Entertainers are brought into the home. Praise and worship is organised and there is regular provision for residents to meet their various spiritual needs. Routines within the home were fairly flexible and choice is provided in meals, times to get up and go to bed, clothes, bathing times, etc. Lounges were staffed during the inspection and one staff member added that now the home had activities it allowed them to spend more one to one time with those who did not take part. The home has an open visiting policy, although they would prefer that visitors not to call before 9am or after 9pm without advising the home. There is a separate visitors room available if privacy is required. There are also other areas around the home, which are quiet. There is a book in the foyer for visitors to sign when they arrive and leave. Visitors were noted to come and go throughout the day and those spoken to stated the home was very welcoming and one relative said ‘The home is always welcome to outsiders – I never feel that I should not be there’. Each unit has a menu board, which clearly advises residents what the menu is for the day. There is a four-week menu, which the inspector was advised had been produced by a Dietician, but residents had added some choices of their own. One the day of the inspection, residents had a choice of two hot meals at lunchtime and two choices at tea. Feed back on the food included ‘the food is on top of this world’, ‘I would like curry more – as it is a change’, ‘too much chicken’ and ‘the food is good’. On the day of the inspection the meal looked hot and well presented. Staff were observed feeding those residents who needed assistance and they did this with dignity and respect. Hot and cold drinks and snacks are available outside meal times if required. One lady who did not drink tea or coffee stated she would like ‘diet coke’ as an option instead of orange or lemon. The kitchen was inspected and noted to be clean and tidy. There was an excellent supply of fresh vegetables and fruit. Information provided about the home confirms that residents are able to bring in their own possessions. Many of the bedrooms at the home were very personalised. Information on advocacy services is available to residents and visitors. Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 14 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, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a established complaints procedure in place to enable residents and relatives to raise concerns or issues. Residents are protected due to staff having a good understanding of safeguarding adult procedures. EVIDENCE: There is clear written guidance in the Home’s Service Users Guide and Statement of Purpose on how relatives and residents can make complaints. On viewing the ‘Complaints Folder some complaints had been received since the last inspection, but all had been fully recorded, investigated and a satisfactory outcome reached. No complaints had been made to the CSCI. Staff spoken with had a good understanding of safeguarding adults and whistle blowing issues. Staff training records showed clearly that all staff had received training in this important area. One Safeguarding referral had been made since the last inspection and this was in the process being investigated. Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. Rosedale Court provides a generally clean and comfortable environment for residents. Residents live in a safe and well-maintained environment. EVIDENCE: Rosedale Court is a new purpose built home that provides residents with a spacious and comfortable environment. For operational purposes the home has four designated areas: ‘Jasmine’ and ‘Primrose’ on the ground floor and Honeysuckle’ on the 1st floor accommodate older people who have dementia, whilst ‘Lavender’ also on the 1st floor, accommodates older people who require nursing care. Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 16 During a general tour of the home it was noted that residents bedrooms were well decorated and personalised. All bedrooms had ensuite facilities and bedrooms doors were clearly marked with the residents name and a picture of their choice. The home had the use of hoists, handrails, pressure mattresses and the signage was good around the home to aid orientation. Feedback from health care professionals included ‘it has a homely environment’ and another added ‘I feel the home as a dementia home there is little room for dementia suffers to be allowed to wander as the corridors are small and restrictive’. A general hand is employed for 20 hours per week to undertake maintenance tasks and carry out safety checks. At a previous inspection it was noted that part of the homes grounds were no longer accessible to residents, thus not providing the space agreed at the homes registration. The garden consists of a large paved area at the back of the home, which is ideal for wheelchair users. Raised flowerbeds have been added. On the path leading to the back gate there is a large handrail, which is ideal for residents with some mobility to be able to use this to access the garden. The manager also stated that they were in the process of looking at ways to utilise a grassed area at the back of the home. One the day of the inspection one gentle man was sitting in the garden and enjoying the winter sun, he added that he chose to do this each morning. On the day of the site visit the home was generally clean and well presented. There were some areas where odour control needed to be improved. Bathrooms and toilets had evidence of paper towels and liquid soap. Staff were observed wearing disposable gloves and aprons. Eighteen staff had completed infection control training, but further training is yet to be organised for the remaining staff. Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels and routines need to be reviewed to make sure that they meet residents needs and expectations at all times. Staff at the home are recruited safely and given training to help them understand and meet resident’s needs. EVIDENCE: From rotas viewed and a discussion with the manager it was established what the staffing levels at Rosedale Court were being maintained at. Each unit has different staffing levels and these also differ from the morning to the afternoon shift. On Lavender (the nursing unit) - Four care staff and nurse were on duty during the morning and three care staff and one nurse during the afternoon/evening. They had increased the staffing by 6 hours to help with the lunch and teatime routines. On the three residential units, they shared six care staff and two care team managers (CTM’s) in the morning and five care staff and two CTM’s in the afternoon/evening. To cover the home at night four care staff, one CTM and one trained nurse. The registered managers hours are supernumerary to this. The home does have some vacancies for staff and agency staff are being used. Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 18 Residents spoken with made positive comments about the staff at the home, but on one unit the staff, relatives and residents raised concerns regarding the staffing levels. Feedback from questionnaires included, ‘sometimes I find he has not had a shave. I then do it myself, but I don’t mind as I know they are short staffed’, ‘The staff downstairs are always changing’, ‘I feel sad whenever I visit, it is truly a nice place, good staff but not enough for it to be a happy atmosphere. It was there once’, ‘I think the staff are overworked’, ‘Put on a bit more staff’ and ‘I can’t grumble, but occasionally I have to wait for help’. From observations on the day, the nursing unit with four staff and a nurse was running smoothly and residents had their needs catered for. On the residential units, two staff was observed working very hard and residents had to wait for care. The manager stated that staffing of the home had not been changed since registration. From evidence gathered it was felt that this is an area that needs to be looked at to ensure that residents dependency needs on the residential unit were being met as it can also have an impact on resident’s privacy, dignity, choice and independence. Since the last inspection further domestic staff have been employed. On speaking to the new members they stated they had been made welcome and the their cleaning routines were manageable. The registered manager reported that out of 40 staff 19 had completed NVQ at Level two and 4 had completed NVQ level three. This represents 50 of the current care workforce at the home. Further staff had also registered to start NVQ courses. The files of recently recruited staff show that recruitment practices that protect residents are in place and maintained. One area that was highlighted was that the present application form only requested details of the applicant’s employment for the past 7 years. On viewing files it was not possible to gain a full employment history or look for gaps. This was discussed with the manager. Files showed that staff receive an induction. They are provided with an induction of the home and then start to work towards the Skills for Care induction standards, which should equip staff to assist residents in a consistent and competent manner. The manager had produced a training matrix, which clearly showed all training that staff had completed. Those staff spoken to confirmed they had been offered regular training. Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 19 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, 32, 33, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and others are consulted to gain their views on the quality of the service provided by staff and management. Checks are completed to ensure the environment is safe for residents. EVIDENCE: Rosedale Court benefits from having an experienced and competent registered manager. She has considerable experience in managing residential care homes for older people. She holds a nursing qualification and also her NVQ 4. There are clear lines of accountability within the home. During the Inspection there was evidence of staff coming into the office to discuss care issues or Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 20 concerns with the Manager and appropriate advice and action being taken. The manager was also observed talking to staff on the units. Staff, residents and relatives at the home spoke well of the manager and felt that they were very approachable. Feedback from questionnaires stated included ‘They have an excellent caring, dedicated team – nothing is too much trouble’, ‘Any concerns are dealt with immediately – they have great team leaders’, ‘The staff are always friendly’, ‘They always do all they can to help’ and ‘The staff do the best they can in the circumstances – rushed off their feet and still manage a smile’. Evidence of regular residents meetings were seen and resident’s views had been sought on the service. The registered provider has strategies in place to monitor the quality of the service provided at Rosedale Court. An annual audit is normally undertaken and the manager had just received her report for 2007. The home’s Operations Manager also completes monthly visits. Other monitoring tools such as a catering survey and medication audits also take place. Resident’s monies were not sampled during this inspection, but systems and procedures for this was discussed with the manager. It also clearly describes the procedure in the Service Users Guide. There was clear written evidence that staff had received appropriate supervision. Staff meetings had been organised and also one to one sessions. Staff and resident files are kept secure and Runwood Home’s are registered with the Data Protection Act. Residents can have access to their files if requested. The accident book was viewed and in order. Regular checks on gas appliances, hoists, fire alarm system, lift, emergency lighting, water temperatures, nurse call system and electrics were seen and in order. Appropriate insurance certificates were seen and in order. Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 21 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 3 3 3 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 2 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 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP12 Regulation 16(2)(m) Requirement Having regard to the size of the home and the number and needs of your present residents, please speak to residents regarding the present programme of activities. The programme of activities should help to stimulate the environment of the home and meet the needs of all residents. There must be suitably qualified, competent and experienced persons on duty at all times in such numbers that are appropriate for the health and welfare of residents. This is with particular reference to: The need to review and address: Staffing levels in respect of the residential units to be reviewed to ensure present staffing numbers are meeting present residents dependency needs. Elements of this requirement with a compliance date of 31/12/05, 31/05/06 and 14/01/07 have not yet been met. Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 23 Timescale for action 28/02/08 2. OP27 18 28/02/08 3. OP26 13, 18 There must be suitable arrangements within the home to prevent the spread of infection. This refers to the need for need for staff to receive training/have a good awareness of infection control/universal precautions. 28/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP11 OP29 Good Practice Recommendations The resident’s wishes regarding care and arrangements after death should be discussed, recorded and carried out. Ensure that a full employment history is received from all new applicants and that any ‘gaps’ in employment are discussed and clearly recorded. Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Rosedale Court DS0000064180.V348795.R01.S.doc Version 5.2 Page 25 - 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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