Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 22/06/06 for Rosedale Nursing Home

Also see our care home review for Rosedale Nursing Home for more information

This inspection was carried out on 22nd June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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.

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

What the care home does well

Service users live within clean and comfortable buildings, one of which has been refurbished in part, to a high standard. Staff were seen to be attentive, kind and provided care to service users protecting their privacy and dignity. Service users were seen to be exercising control over their lives, by going out if they wished, rising and retiring as they wished and choosing what to wear and how to spend their day. The staff were provided with training to improve their knowledge and care skills, this ensures service users receive a quality service. Staff were recruited using thorough policies and procedures to ensure service users were protected.

What has improved since the last inspection?

Service users who suffered weight loss were monitored well by the care staff and referred to their general practitioner; this ensured that their health care needs were met. Service users who were prone to pressure sores were well monitored by the staff, their GP and tissue viability nurse, to ensure their health care needs were met. A good choice of food was available to service users, puree diets were well presented and looked appetizing; this ensures all service users receive a varied and nutritious diet. Fresh and dried foodstuffs were stored in airtight sealed containers, which were labelled when opened; this ensured that service users and staff were adequately protected by correct food handling procedures. All visitors sigh into and out of both buildings, this helps to ensure security and provides a record of visitors for health and safety purposes that could be used in the event of a fire at the home. Kitchen staff undertake the morning and afternoon tea round, this allows care staff to have more quality time with service users.

What the care home could do better:

Information relating to service users assessed needs prior to them coming into the home must be available for inspection on the working file to ensure all their original needs are still being met. Service users who self medicate must be assessed to ensure they are safe to do so. Staff should sign for and witness all medications returned or destroyed in The Lodge to ensure the safety of staff is maintained. Service users must be informed of the activities available within both buildings, so that they can make an informed decision and plan to attend if they so wish. The kitchen cleaning schedules required more information to be recorded upon them to ensure health; safety and food hygiene was adequately maintained to protect service users and staff. Staff must ensure food supplements are recorded when given, to ensure that adequate monitoring occurs to protect service users. The home must undertake an assessment of all windows to ensure that the Health and safety of service users is protected, in relation to security and the possible risk of falls out of windows. Laundry access must be restricted and cleaning chemicals must be stored securely in The Lodge to ensure health and safety is maintained for service users and staff.

CARE HOMES FOR OLDER PEOPLE Rosedale Nursing Home The Old Vicarage Catterick Road Catterick Garrison North Yorkshire DL9 4DD Lead Inspector Denise Rouse Key Unannounced Inspection 22nd June 2006 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 Rosedale Nursing Home DS0000064332.V301067.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 Nursing Home DS0000064332.V301067.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosedale Nursing Home Address The Old Vicarage Catterick Road Catterick Garrison North Yorkshire DL9 4DD 01748 833302/4948 01748 834468 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) Maria Malliband Care Homes Limited Mrs Muriel Gazzard Care Home 68 Category(ies) of Old age, not falling within any other category registration, with number (68), Physical disability (68), Physical disability of places over 65 years of age (68) Rosedale Nursing Home DS0000064332.V301067.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users in category PD to be aged 50 years and above and to require nursing care. 10th November 2005 Date of last inspection Brief Description of the Service: Rosedale is a care home providing nursing care and personal care only for up to 71 service users. It is located near the centre of the garrison town of Catterick. The home comprises of two buildings. It is set in extensive grounds with protected wooded areas to the north and west, and lawn to the south facing aspect of the home. The home is owned by Maria Mallaband Care Homes Limited. Main Building This building was previously a vicarage. There have been several additions to the original building since being opened in 1986; one on two floors as well as a twelve-bedded single storey unit. An additional 9 beds were provided in February 2004 in the main building with an extension and internal rearrangement of the internal spaces. The Lodge This is a separate 21-bedded unit within the curtilage of the grounds. It was opened in February 2004 and is being used for service users admitted for personal care only. Access to the upper floors in both buildings is facilitated by two vertical lifts. Fees range from £405 for residential care to £519 for private nursing care. Rosedale Nursing Home DS0000064332.V301067.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced site visit was carried out over two days, following three days preparation. The manager and senior carer in The Lodge were available to assist in the process. A tour of both buildings was undertaken; this included laundries, the treatment room, kitchen bathrooms, bedrooms and communal areas. Time was spent conversing with and directly observing service users, visitors and staff. Information was reviewed which was held on the homes file, at the Commission of Social Care Inspection, since the last inspection. Information was also submitted by the provider, in the Pre Inspection Questionnaire and this was also reviewed. Surveys were also received from service users and visitors. Records inspected included care profiles, medication administration records, personal allowance records, staff files and food preparation documentation. A feedback session was held with the manager at the end of the site visit. What the service does well: What has improved since the last inspection? Service users who suffered weight loss were monitored well by the care staff and referred to their general practitioner; this ensured that their health care needs were met. Service users who were prone to pressure sores were well monitored by the staff, their GP and tissue viability nurse, to ensure their health care needs were met. A good choice of food was available to service users, puree diets were well presented and looked appetizing; this ensures all service users receive a varied Rosedale Nursing Home DS0000064332.V301067.R01.S.doc Version 5.2 Page 6 and nutritious diet. Fresh and dried foodstuffs were stored in airtight sealed containers, which were labelled when opened; this ensured that service users and staff were adequately protected by correct food handling procedures. All visitors sigh into and out of both buildings, this helps to ensure security and provides a record of visitors for health and safety purposes that could be used in the event of a fire at the home. Kitchen staff undertake the morning and afternoon tea round, this allows care staff to have more quality time with service users. 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. Rosedale Nursing Home DS0000064332.V301067.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 Nursing Home DS0000064332.V301067.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 Quality in this outcome area was good. Service users needs were assessed prior to the service user being offered a placement within the home; this ensures that the service users needs are met. This judgment has been made using available evidence including a visit to this service. EVIDENCE: Six service users were case tracked, three from each building; this included a service user who had just been admitted to the home. Evidence inspected confirmed good practice. Service users had a full assessment of their needs undertaken prior to their admission to the home; this ensures their needs could be met. However two of the case tracked service users pre admission assessments were not available to be inspected as they had been archived. The pre admission assessment document must be kept upon the service users working file, to provide evidence that this process has been undertaken, and all relevant information from this document has been used to form the basis of care plans for the service user. Rosedale Nursing Home DS0000064332.V301067.R01.S.doc Version 5.2 Page 9 All service users had a copy of the service user guide, which was also available on audiotape, for service users with visual problems. Surveys received from six service users indicated four had received a contract, one stated, “ I don’t think I have”. Five service users indicated that they had received enough information about the home to make an informed choice, one comment stated, “ I visited the home and asked questions”. Intermediate care was not undertaken within the home. Rosedale Nursing Home DS0000064332.V301067.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7 8 9 10 Quality in this outcome area was good. Service users health care needs are well met but there are some shortfalls relating to medication, which could pose some risk. The judgment has been made using evidence including a visit to this service. EVIDENCE: Six service users were case tracked, three from each building. Service users had detailed care plans relating to their health and social care needs, which were signed by the service user or their chosen representative. The care plans and risk assessments had been reviewed at least monthly or as the service users needs changed. This ensured that the correct care was delivered to the service users. One service user stated, “ The carers are more helpful than I have the right to expect, I am more than satisfied”. Five surveys received from service users indicated that staff listed and acted upon what the service user says, one stated this happened “ Usually”. Five surveys indicated staff were available when service users needed them, one indicated “usually”. Rosedale Nursing Home DS0000064332.V301067.R01.S.doc Version 5.2 Page 11 The home had addressed the needs of service users with pressure sores, specialist equipment was provided, as well as regular GP reviews and input from the tissue viability nurse. This ensured that the service users condition was well monitored. Five service user surveys received indicated that service users received the medical support they required, one stated “ Usually”. All service users had their nutritional needs assessed, those who were prone to weight loss had a care plan in place, and weekly weights were recorded. They were also monitored by the GP, food supplements had been prescribed, however in the main building these were not always recorded on the medication administration chart when the service user had taken them. This must be recorded to ensure that service users who are still loosing weight with this intervention are reviewed again by the GP. Food charts for these service users required quantities of food taken, to be recorded in more detail as well as higher calorific foods to be offered at morning coffee, afternoon tea and supper time. Service users had access to a GP of their choice. During the site visit an optician and a care manager were seen visiting the home. An interview was held with the care manager who stated that “It’s a brilliant home, I’m glad to be involved with Rosedale, staff are always prepared to take time to accommodate appointment times. Staff always ask service users if they would like to meet with me on my own. The staff are knowledgeable about the service users, they go the extra mile to make service users happy”. Service users received visitors in private in their own bedrooms. Service users seen all looked well cared for, they spoke highly of the staff, which were seen to treat the service users with dignity and respect. Privacy was ensures whilst personal care was being given. Service users were addressed by their preferred name. One service user stated, “ over the years I have got to know the care staff, they have got to know me and I see them as my friends now.” The manager confirmed that the staff were not involved with legal of financial issues relating to service users. Medication systems within both buildings were inspected and found to be correct. All service users had a list of homely remedies that could be given, signed by their GP. In The Lodge returned medications were being recorded by one member of staff, two staff should witness the returns or disposals to ensure staff are protected. Service users who wished to self medicate, were assessed to ensure they were safe to do so, however one service user in The Lodge had not been re assessed to see if they remained capable of this, a reassessment must be undertaken. Rosedale Nursing Home DS0000064332.V301067.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 13 14 15 Quality outcome in this area was good. Service users had flexibility and control over how they wished to spend their day. Mealtimes were relaxed, food provided looked appetising and nutritious. This judgement has been made using available evidence including a visit to This service. EVIDENCE: Six service users were case tracked, Three from each building. All service users had their social and cultural needs recorded within a care plan. Two part time activities co-ordinators provided one to one and group activities for service users. Care staff were also seen assisting service users to read newspapers. Six service users completed surveys; two indicated that the home arranged activities that the service users could take part in, three indicated “sometimes” one indicated that they preferred to stay in their room. Service users confirmed that they could get up or go to bed when they liked. Service users stated that they could get up or go to bed when they wished. Rosedale Nursing Home DS0000064332.V301067.R01.S.doc Version 5.2 Page 13 Activities provided included in house bingo, quizzes, and gardening. Local clergy from different faiths visited the home several times each month. Outings to local tea dances, Richmond and Darlington theatre were undertaken. Service users were seen going out shopping with their families. In the Lodge a board indicated what activities were available in the afternoon, but this was not up to date on the first day of the site visit. The home must ensure a programme of activities is produced and circulated to all service users so that they are informed of activities and can decide if they wish to attend. Service users had access to an enclosed patio and garden area, which was accessible to wheelchair users. They could receive visitors at any time; within their own bedroom room or lounge areas. Service users could control their own finances, if they chose to do so, to maintain their financial independence. Service users personal allowance balances were checked and found to be correct. The manager did not act as an appointed person for any service user. This ensures that service users were correctly protected from financial abuse. The kitchen was inspected, it was clean and tidy. Food prepared looked appetizing, well presented and nutritious. Food was correctly stored and labelled to ensure food hygiene was maintained. The cleaning schedules were inspected, they had not been completed, and cleaning must be undertaken and recorded to ensure food hygiene was maintained. Menus were available. Mealtimes were unhurried, staff assisted service users who required feeding, or prompting with feeding with dignity and respect. The chef was aware of service users who required puree and special diets. The puree meals were well presented, however a higher calorific morning coffee, afternoon tea and supper menu must be offered, to these service users to ensure adequate nutrition was maintained. Six service user surveys indicated that two service users always liked the food, four stated “Usually”. Rosedale Nursing Home DS0000064332.V301067.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 16 18 Quality in this outcome area was good. Service users were protected by the homes complaints procedure and recruitment policies. This judgement has been made using available evidence including a visit to the home. EVIDENCE: There was a robust complaints procedure in operation; no complaints had been received since the last inspection. Information received included six service user surveys, which indicated, four people always knew who to speak to if they were not happy, two indicated “usually”. Five stated they knew how to make a complaint. Four surveys received from relatives and friends indicated three were not aware of the homes complaints procedure; none of the four had ever had to make a complaint. The home should ensure that friends and relatives are made aware of these policies and procedures. Staff files inspected indicated that staff were given training relating to the protection of vulnerable adults and the procedures, which must be undertaken if an allegation of neglect or abuse was received. Staff spoken with knew the procedures; a whistle blowing policy was in operation within the home. Six staff files were examined, all had evidence of a Criminal Records Bureau check and POVA first check completed, prior to staff commencing at the home. Rosedale Nursing Home DS0000064332.V301067.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 26 Quality in this outcome area was adequate. Service users live in buildings which were well maintained, however there were some shortfalls relating to windows restrictors, laundry access and storage of chemicals within the lodge, which compromised safety. This judgment has been made using available evidence including a visit to this service. EVIDENCE: Six service user surveys indicated five thought the home was fresh and clean. The main building had benefited from a refurbishment programme, new décor and carpeting had been fitted within the downstairs corridor, main lounge and dining area. A newly refurbished dining room on the ground floor of the main building was being used by service users who stated they liked the new décor The upstairs bedrooms and bathrooms within the main house had just Rosedale Nursing Home DS0000064332.V301067.R01.S.doc Version 5.2 Page 16 reopened following a major refurbishment programme which has enhanced the quality of the home. New service users who had been admitted upstairs were spoken with, they liked their bedrooms, and one was having pictures and shelves fitted by the handyman. There was an ongoing programme of redecoration, renewal and repair to all areas of the home. This ensures that it is well maintained and remains pleasant for service users. The gardens and patio areas were well kept and accessible to mobile and service users using wheelchairs, and their families. A door security entry system as well as signing in books for visitors, helped maintain security. Laundries within the main building and the lodge were inspected; all clothing as well as soiled articles were handled correctly. The laundry in the Lodge had two containers of washing products, these were removed to a secure cleaners cupboard, which was found to be unlocked. Access should be restricted to the cleaner’s cupboard and to the laundry when the staff are not in attendance, to protect service users. The domestic in the lodge had placed her cleaning equipment in the linen room, this held the fire door open, and the home manager spoke with the member of staff who moved the equipment so that the fire door could be closed, to maintain health and safety. Gloves and aprons were evident and available for staff to utilize throughout both buildings. This prevents service users being placed at risk from poor infection control One bedroom within the main building had a slightly musty smell, there had been a leak in a bathroom pipe, and the floor covering had been removed, and replaced. This bathroom should be monitored to ensure the musty smell is eliminated. Window restrictors within the main building and The Lodge must be reviewed in relation to maintaining adequate security as well as preventing the possibility of service users or staff falling out of the windows, which opened, by approximately two foot. The windows in the refurbished first floor were not affected as restrictors were already fitted appropriately. Rosedale Nursing Home DS0000064332.V301067.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 27 28 29 30 Quality in this outcome area was good. Service users were protected by the homes recruitment policies and staffing levels, relevant training was provided for staff to enhance the standard of care delivered to service users. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Service users were looked after by sufficient numbers of care staff who were adequately trained. Kitchen staff undertook the morning coffee and afternoon tea round, assisted in the morning by care staff once they have completed direct care to service users. This ensures care staff have more quality time to spend with service users. Staff stated this was an improvement. Domestic staff ensured the home was clean and tidy. This ensured that service users benefit from a homely environment. The chef stated that he felt it would be beneficial to have a head chef, who could monitor kitchen processes, cleaning schedules and monitor the ongoing quality of food services, to ensure that service users always received a good service from the department. Rosedale Nursing Home DS0000064332.V301067.R01.S.doc Version 5.2 Page 18 The home have tried to gain a 50 ratio of care staff who hold the National Vocational Qualification in Care at Level two or three. Due to Catterick being a garrison town care staff turnover occurs due to spouses being posted. The home continues to strive towards this. All the staff files which were case tracked, contained all the necessary pre employment checks and references. This ensured that service users were protected by the homes policies and procedures. Staff received all relevant training in order to perform their work safely; this ensured that service users received care from well-trained staff. Rosedale Nursing Home DS0000064332.V301067.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 31 33 35 38 Quality in this outcome area was adequate. Service users welfare was compromised by shortfalls in maintaining health and safety within the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was well run by an experienced manager, who was about to retire. Staff spoke about her management style and confirmed that she had run the home well and was supportive to staff and service users. Staff stated that they would miss her. Rosedale Nursing Home DS0000064332.V301067.R01.S.doc Version 5.2 Page 20 The home undertook a yearly survey of service users, relatives and visiting professionals; the results of the survey were documented and shared with all participants. Areas of concern that were identified were addressed. The personal allowance accounts for the case tracked service users were inspected, all receipts of transactions were recorded and receipts were kept on file. All balances were correct; this ensured that the systems in place protect service users from financial abuse. Health and safety was maintained relating to fire, staff had completed the relevant training, and weekly fire system tests were undertaken, to ensure the safety of service users and staff. However during a tour of The Lodge the chemical store cupboard was found to be unlocked and the linen room fire door had been propped open with cleaning materials and a Hoover. The manager immediately locked the store cupboard door and spoke with the cleaner who removed the items from the linen room doorway. This ensured that service users were not placed at risk from being able to access chemicals. Access to the laundry could be gained by service users when the area was not staffed, this must be addressed to prevent service users being placed at risk. In both buildings it was found that windows could be opened wide, with the exception of the first floor in the main building where window restrictors were fitted. An assessment must be carried out in relation to window restrictors in both buildings, to ensure that the health and safety of the staff and service users was maintained, in relation to ensuring adequate security and the prevention of possibility falls out of windows which open wide. Chlorination of the water tanks, to prevent the risk of Legionella, had never been carried out at the home. The home manager immediately arranged this to occur. This ensured that staff and service users health and safety was protected. The manager must fax evidence to The Commission of Social Care Inspection once this has been completed. Rosedale Nursing Home DS0000064332.V301067.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 17 18 1 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 1 3 X 3 Rosedale Nursing Home DS0000064332.V301067.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 (2) (a) Requirement Pre admission assessments for all service users must be held within the working file, so that it may be inspected and used by staff as a base line. Service users who self medicate must be regularly assessed to ensure that they continue to be safe to do so. Service users must be informed about the activities available within the home, using a format, which is suitable to them, so they can make a choice if they would wish to attend. The service users bathroom in the main building, which had a musty smell, must be re assessed and action taken as necessary to address this issue. The lodge Laundry chemicals in must be stored securely. The storage cupboard for chemicals must remain locked at all times. Access to the laundry must be restricted when it is unmanned. Laundry cupboard doors must DS0000064332.V301067.R01.S.doc Timescale for action 31/07/06 2 OP9 12 (a) 31/07/06 3 OP12 16 (m) 14/08/06 4 OP19 23 (b) 31/07/06 5 OP38 12 (1) (a) 31/07/06 Rosedale Nursing Home Version 5.2 Page 23 not be held open by cleaner’s equipment, this should remain locked shut. 6 OP38 23 (2) (p) The Lodge and Main building. 31/07/06 An assessment of all windows must be carried out to ensure that where necessary window restrictors are fitted to maintain safety. The registered person must 09/07/06 ensure that the water tanks within both buildings are assessed in relation to the risk of Legionella, and any necessary chlorination must be undertaken. All cleaning must be undertaken 31/07/06 and recorded within the kitchen. 7 OP38 12 (1) (a) 8 OP38 16 (2) (j) 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 3 4 Refer to Standard OP9 OP16 OP27 OP28 Good Practice Recommendations Medications returned or destroyed In The Lodge should be witnessed by two members of staff. Service users relatives and visitors should be made aware of the homes complaints procedure. Review should be undertaken in relation to how the kitchen operates, and cleaning recorded. 50 of care staff should be qualified to at least NVQ level 2 in Care by December 2005. Rosedale Nursing Home DS0000064332.V301067.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Rosedale Nursing Home DS0000064332.V301067.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. 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!