Inspection on 30/04/07 for Rosedale Nursing Home

This inspection was carried out on 30th April 2007.

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

Rosedale Nursing Home 22/06/06

Rosedale Nursing Home 10/11/05

Rosedale Nursing Home 18/07/05

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

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 30th April 2007 10:20 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.V334994.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.V334994.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 Mallaband Care Group Limited Mrs Julia Wright 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.V334994.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. 22nd June 2006 Date of last inspection Brief Description of the Service: Rosedale is a care home providing nursing care and personal care only for up to 68 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 £445 per week for private residential care to £479 per week (plus free nursing care banding) for private nursing care. The home received residential and nursing service users funded by social services on their current rates. Rosedale Nursing Home DS0000064332.V334994.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The accumulated evidence used in this report has included: • A review of the information held on the homes file since its last inspection. • Information submitted by the registered provider in the pre inspection questionnaire. • Surveys received from five service users, four relative, and three General Practitioners. • An unannounced visit to the home, which lasted six hours and forty minutes. This included a full tour of all areas of the premises. • • Evidence gained by direct observation, talking with service users, management and staff. Inspection of records, including care profiles, medication administration records, and staff files. What the service does well: What has improved since the last inspection? What they could do better: Rosedale Nursing Home DS0000064332.V334994.R01.S.doc Version 5.2 Page 6 All service users care plans and risk assessments must reflect their full and current needs including nutritional needs, to ensure that their health care needs are fully met. Information relating to the activities available within the home must be available to all service users so that they are fully informed and can make a decision about if they would wish to attend. Service users health and safety must be protected, by ensuring shortfalls relating to cleaning chemicals, bed rails, nurse call system and window restrictors are addressed. Food must be in date, and all kitchen cleaning and freezer temperature checks must be undertaken and recorded, to maintain food hygiene and health and safety for service users and staff. Training and supervision for staff, must be up to date, to ensure staff and service users are not placed at unnecessary risk. 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 Nursing Home DS0000064332.V334994.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.V334994.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): Standard 3 (6 not applicable) People who use this service experience good quality outcome in this area. Service users are fully assessed prior to being admitted, to ensure their needs can be met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Potential service users were fully assessed by staff that were competent, prior to being admitted. This ensured their needs were known and could be met. Potential service users were able to visit the home and had access to the statement of purpose and service user guide. Comments received included “ I received enough info about the home and came and looked around before I moved in”. This ensured service users were fully informed about the services provided. Intermediate care was not undertaken in the residential or nursing unit. Rosedale Nursing Home DS0000064332.V334994.R01.S.doc Version 5.2 Page 9 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): Standards 7 8 9 10 People who use this service experience adequate quality outcome in this area. Service users health and care needs were known, however there were shortfalls, which placed some service users at risk. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Main House Service user surveys received indicated that they “received care and support”. Staff were seen assisting service users as required and treated them with dignity and respect. There was evidence that some service users and their families were involved in signing risk assessments and care plans, this ensured they were kept fully informed. Incidents of pressure sores were recorded and monitored, advice was sought from specialists and general practitioners to ensure service users were receiving the correct care. Two service users care documents were inspected, they contained detailed care plans and risk assessments. These had not been reviewed monthly. One service user receiving a liquidized diet, did not have this recorded in their care Rosedale Nursing Home DS0000064332.V334994.R01.S.doc Version 5.2 Page 10 plan. The care plan stated they required weighing weekly, however this had only been undertaken and recorded monthly. Their daily food and dietary input was monitored, however on some days very little food and fluid was recorded. There was no evidence that any action had been taken by the nursing staff to address this issue at the time. The general practitioner had prescribed nutritional supplements however there were only six entries signed for upon the medication chart to indicate these had been given. This must be addressed so that the service users condition was not allowed to deteriorate. These shortfalls place the service users health at risk. Fluid and food charts for other service users were inspected, these also had gaps, and the entries were not descriptive enough about the amount and type of food taken. This must be addressed to ensure all service users are receiving nutrition to maintain their health. The second service user was being nursed in bed. Bed rails were in situ to prevent the risk of falling out of bed. There was a risk assessment in place, but this was not signed by the service user or their representative to say that they agreed with the use of this equipment. The service user was on a new bed, which had been delivered; it did not have the relevant protective padded bed rail bumpers in situ to ensure the service user was protected from possible bruising or entrapment. This was discussed with the manager and bed rail bumpers were immediately applied. The care plan did not state that the service user was nursed on a pressure-relieving mattress to ensure that their skin integrity was maintained. This was discussed with the deputy who recorded this information immediately. The key worker record for this service user had nothing recorded upon it recently and the activities sheet had nothing recorded upon it since October 2006. Staff must ensure that care and key worker interaction undertaken, is recorded and reflect the full needs of the service user. The Lodge A comment received from surveys indicated “I always received care and support, sometimes I may need to wait a little while but am happy with staff when they came.” Staff were seen to be supportive of the service users who were following their own chosen routines, and were seen to come and go, as they liked. Staff interacted positively with service users to maintain their independence and individuality. Staff treated service users with dignity and respect. Another comment received was“ All aspects of care at Rosedale Lodge seem to be fine. I would like to be a resident there myself should the need arise”. “ Rosedale Lodge and Staff deserve full marks”. Care plans inspected were detailed, service users were having their weight and blood pressures taken and recorded monthly. This may not have been necessary for all service users. Those who had nutritional needs were monitored. If there was evidence of weight loss weekly weights and food and Rosedale Nursing Home DS0000064332.V334994.R01.S.doc Version 5.2 Page 11 fluid monitoring took place. However there appeared to be no consistent approach. One care plan was inspected, this service user liked small meals, and the care plan did not state how they would provide an adequate dietary intake, to maintain their weight. No fortifying foods, finger foods or high calorie snacks were on offer on the daily menu. Service users nutritional needs must be fully met. Surveys were sent to service users, visiting professionals and relatives, a variety of comments were received “Staff listen and act on what I say” and “ Staff are usually available” “ I always receive medical support, the doctor will come when I ask or staff request”. One comment referred to how the home could improve,“ A little more assistance with personal grooming”. The monitored dosage medication systems in both areas were inspected. Main Building The medication systems was inspected and found to be correct. Stock balances looked high, this might have been because the next month’s medications had arrived. This should be audited to ensure unnecessary stock was not being stored. The Lodge. One service user was nearly out of Gaviscon this had not been ordered timely. If stock balances are getting low action should be taken to ensure service users medication needs are being met. One-second signature was missing for a controlled medication, this must be recorded, to ensure that the medication record remain a true record of the checks undertaken to maintain service users safety. Service users who wished to self medicate had been assessed to ensure they competent to do so, this promoted their independence. Rosedale Nursing Home DS0000064332.V334994.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): Standard 12 13 14 15 People who use this service experience adequate quality outcome in this area. Service users preferred social needs were known, but this information required circulating, and there was a shortfall relating to nutrition. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Responses received from surveys stated “I always take part in activities if asked.” And “ I like to sit in own room, and listen to what goes on but don’t like to take part. I do go to the concerts when entertainers come in. I know activities are available”. And “ They organise good entertainment for the residents”. And “the home has a separate room with drink making facilities where you can have a meal or just be private with their relative”. Main Building Service users records inspected had their social preferences recorded. On the day of the site visit the activities coordinator was on holiday, there was no formal activities being undertaken other than the hairdresser being present. The television was on in one lounge and background music was playing in the lounge dining area. Service users were seen to be making decisions and choices upon how to spend their day, promoting their own independence and Rosedale Nursing Home DS0000064332.V334994.R01.S.doc Version 5.2 Page 13 choices supported by the staff. Visiting was open and this ensured contact with friends and family was maintained. Service users had personalized their own bedrooms and could choose where to sit and who to socialize with in the lounges. A board in reception had the activities programme displayed upon it, bingo and quizzes were the preferred activities requested by service users. Holy communion was provided at the home weekly. Service users social and religious needs were being met, however not all service users had access to the information about the activities available in reception. Those who did not come out of their bedrooms would benefit from receiving this information, so that they may be fully informed and arrange to attend planned activities if they so wished. Staff were seen helping service users to eat their lunch, this was carried out in an unhurried manner. One comment received was “ Every meal is good”. The Lodge Service users were relaxing in their own bedrooms or in the communal areas. They were going out with their families and friends, and sitting outside on garden furniture in the grounds. Newspapers of the day were available in the lounge areas; activities available were advertised on a board in reception. Service users had access to this, and this ensured that their social needs were being met. Kitchens in both units were inspected. The cleaning undertaken in the lodge kitchen had not been recorded daily. Cleaning chemicals were not stored securely and they could be accessed by service users should they access the kitchen. These were immediately removed to ensure service users health and safety was maintained. Some food items opened and stored in the fridge were not labelled with the date that the food needed to be thrown away. This must occur so that service users and staff are not placed at risk. Both dry foods stores were inspected; in the main house two items were found to be best by the end of November 2006. These were discarded. All food items in both dry food stores must be checked to ensure that they remain in date. In both units, the menus inspected did not contain relevant choices on a daily basis for service users who required a liquidized diet. The teatime meal for Sunday week one was soup and cold sandwiches. This could not be liquidized. The menu must contain all relevant choices available to service users as well as high calorie option or finger foods for service users who required nutritional support, to encourage service users to eat and maintain the correct level of nutrition and weight to remain healthy. Foods eaten by these service users must be recorded clearly to state the amount consumed. High calorie options and finger foods should be offered between meals to help encourage service users to maintain their weight. Rosedale Nursing Home DS0000064332.V334994.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): Standards 16 18 People who use this service experience adequate quality outcome in this area. Service users complaints are dealt with, however some service users and relatives did not know the complaints procedure. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Complaints received were investigated and dealt with correctly by the provider. Policies and procedures were in place relating to complaints and for safeguarding vulnerable service users. Upon the site visit two service users stated to the inspector they had complaints, the manager spoke with both service users and dealt with their issues raised, thoroughly and immediately. Surveys received stated some service users and relatives were not sure how to make a complaint, others were aware a comment received was “Yes I know how to complain, I have seen the complaints policy, I would contact the manager” and another was “I Don’t know how to make a complaint”. This information must be made known to all service users and relatives to ensure that they are fully informed of the process and can raise any concerns they may have. There had been two issues at the home relating to safeguarding vulnerable adults, since the last inspection. The company had dealt these with correctly. Following one of these investigations a member of staff was meant to have received monthly supervision, this had been undertaken but not recorded. Rosedale Nursing Home DS0000064332.V334994.R01.S.doc Version 5.2 Page 15 Supervision must be recorded and undertaken to ensure that service users continue to be protected. Some staff spoken with were not sure what the correct action was for dealing with an allegation of abuse, however other staff were aware. Further training was planned and was being provided to ensure all staff were fully aware of the correct action to be undertaken to safeguard vulnerable service users if an allegation of abuse was to be received. Rosedale Nursing Home DS0000064332.V334994.R01.S.doc Version 5.2 Page 16 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): Standards 19 26 People who use this service experience adequate quality outcome in this area. Service users live in a clean home, however there were issues relating to health and safety, which may have placed service users at risk. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The grounds were well kept and garden furniture was available. An inspection of both buildings was undertaken. General refurbishment and maintenance was routinely undertaken. Communal areas in both buildings were clean, tidy and well decorated. Comments received included “One of the things that is particularly noticeable, the home is always fresh and clean”. And “ My family appreciate the environment, my room is cleaned daily”. Both laundries were inspected and were found to be operating safely. Soiled linen was handled correctly, and hand washing facilities were available throughout both units. This ensured infection control measures were effective. Rosedale Nursing Home DS0000064332.V334994.R01.S.doc Version 5.2 Page 17 The Lodge Cleaning chemicals were found in the kitchen and sluice, and an unattended cleaners hand held basket was found on the first floor. The linen room door was held a jar by a Hoover flex. These areas of concern were immediately addressed, to ensure that service users health and safety was maintained. There was no protective aprons available when entering the kitchen, these had to be gained by walking into the dry store through part of the kitchen. Aprons must be made available at the entrance of the kitchen to maintain food hygiene. The freezers temperatures had not been recorded since February as the display units had stopped working; manual thermometers were placed on order. Temperatures must be recorded to ensure that food is stored at the correct temperature to maintain food hygiene. These shortfalls must be addressed to ensure service users and staff’s health and safety is maintained. Window restrictors in the lodge were not stopping the windows from opening wide; therefore this may place service users and staff at potential risk of falls. Immediate action was requested and undertaken to address this health and safety issue. Main unit On the first floor, cleaning items were found in the sluice, which was unlocked with the key in the door. The cleaner’s cupboard had the key in the lock and contained Milton and other chemicals. These doors were locked and the keys removed and given to the manager. The sluice by the manager’s office was also unlocked and there was an open container of Sterison tablets available, Bed rails inspected were not safe, and posed a risk to the service users health and safety. Immediate action was requested and was undertaken. The boiler room was found to be unlocked, the inspector gained access, and waited for the manager to find the appropriate key to lock the door. The store cupboard next to the boiler room could not be locked as the key was missing. There were chemicals present, which were removed; the handyman fitted a lock whilst the inspector was on site. The back lounge had service users present who could not get up and activate the nurse call system, which was a pull cord in the corner of the lounge where no service user was sitting. The manager stated that normally care staff walk by regularly or an ambulant service user would pull the cord to gain help for other service users. The manager was sent to gain two mobile nurse call units for the service users to use. This ensured that they were able to activate the nurse call system should they require assistance and maintained the service users health and safety. Rosedale Nursing Home DS0000064332.V334994.R01.S.doc Version 5.2 Page 18 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): Standards 27 28 29 30 People who use this service experience adequate quality outcome in this area. Service users are looked after by adequate numbers of staff, however there were some shortfalls relating to staff training, which may place service users at risk. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Comments from surveys included “ I always receive the care and support I need”. And staff listen and act on what I say, staff are always available”. But others stated “I Sometimes receive the support needed, staff are usually available when needed”. Also people using the service are generally satisfied but may have to wait a short time for staff to attend. One survey indicated to the question do staff listen and act upon what you say “ Not all of them”. However service users stated staff working with them knew what they were meant to be doing and met their needs. Other feedback included “ As far as I can see on my visits the staff at Rosedale treat everyone equally”. And “ staff are always helpful”. The home currently have less than a 50 ratio of staff who hold the National Vocational Qualification in Care at Level two or three. They are working towards achieving the 50 ratio, by encouraging staff to undertake this qualification. This would help to ensure that care is provided by staff that have relevant underpinning knowledge. Rosedale Nursing Home DS0000064332.V334994.R01.S.doc Version 5.2 Page 19 New staff were undertaking the foundation In Care Induction and foundation standards. New staff were interviewed using set questions to ensure equal opportunities was respected. The answer to these questions was recorded. Application forms and two written references were gained. However for one of the staff case tracked the second reference was missing and this should be addressed. All relevant checks were undertaken to ensure that the service users were protected from new staff that may not be suitable to work within the care industry. Training relating to Abuse awareness, Fire and Moving and Handling was updated regularly. Training was also provided for some staff in cancer care dementia, Health and safety, food Hygiene, basic first aid, catheter care, infection control and care planning. This clarifies that the service recognises the importance of training and tried to deliver a programme that delivers the statutory requirements, as well as training relating to other issues, which would benefit the service users. However upon further inspection there were some gaps in mandatory training for staff, relating to moving and handling, fire and food hygiene. This must be addressed to ensure that service users and staffs health and safety is maintained. The maintenance man was undertaking bed rail checks, however had not received formal training. This must be undertaken. Care staff must also receive training in this area so that any health and safety issues relating to bed rails can be quickly and appropriately addressed. Rosedale Nursing Home DS0000064332.V334994.R01.S.doc Version 5.2 Page 20 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): Standards 31 33 35 38 People who use this service experience adequate quality outcome in this area. Service users live in a home that is run appropriately, however there were shortfalls relating to health and safety, which placed service users at risk. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager has experience and has had a number of issues to address since commencing her post within the home. Staff stated that the manager was approachable and she was seen on the day to be helpful and approachable to service users and staff. Managerial support was gained from the company who offer help and support to the manager and staff as needed. Quality assurances processes and procedures were in place. The operations manager undertook a regular monthly visits to the home and compiled a report, which was sent to the Commission for Social Care Inspection. Rosedale Nursing Home DS0000064332.V334994.R01.S.doc Version 5.2 Page 21 Management undertook monthly and six monthly audits of different departments to ensure that the quality of the services was being monitored and corrective action could be implemented when issues were found. Quality assurance systems were in place and the outcome of staff and resident meetings were recorded and this information was available to staff and service users. The manager had completed appraisals for all the staff, however staff supervision had not been undertaken and was not up to date for most of the staff. This must be addressed so that staff performance and training needs are monitored. And any issues raised must be addressed, to maintain the quality of the service. The home places its service users at the forefront and tries to ensure that the service users needs were met, however there were shortfalls found during the site visit, which did not protect the service users and staff’s health and safety. On the site visit the window restrictors fitted in the lodge were found to be ineffective and could place staff and service users at risk of falls from these windows. An Immediate requirement was made. Also bed rails were found to be unsafe and this was pointed out to the manager, care staff and the maintenance man. The issues were taken on board and were to be addressed to prevent the possible risk to service users of entrapment. An Immediate requirement was issued. In both buildings cleaning chemicals and Milton solution had been accessible due to inadequate storage and staff leaving these items unattended. Staff were spoken to and these issues were resolved wherever possible on the site visit, they acted proactively and took on board the issues, which must be fully rectified. Service users personal finances were kept individually and a record of all transactions was correct. This ensured that service users were protected from financial abuse. Rosedale Nursing Home DS0000064332.V334994.R01.S.doc Version 5.2 Page 22 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 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Rosedale Nursing Home DS0000064332.V334994.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 12 15 (1) (2) Requirement Main building Service users care plans, risk assessments and other care documentation must be reviewed at least monthly or as the service users needs change. Service users or their chosen representatives must be asked to sign these documents where possible. 2 OP7 15 (2) (b) Main building Service users requiring a liquidized diet must have this information recorded. Food and fluid charts must be kept up to date and action must be taken to record all quantities of food, and fluids given. Where input is inadequate action must be taken by the nursing staff to ensure that the service user does not become malnourished. 3 OP8 14 (2) Main Building DS0000064332.V334994.R01.S.doc Timescale for action 30/05/07 30/05/07 30/05/07 Version 5.2 Page 24 Rosedale Nursing Home 15 (2) Weights must be recorded as stated in service users care plans. Prescribed nutritional drinks must be given as prescribed and recorded upon the medication administration record. 4 OP8 12 (10 (a) 13 (4) (c) Main Building Service users, who require bed rails, must sign to say they agree to this intervention. (Or their chosen representative) Bed rails must be safe and cot bumpers must be provided to decrease the risk of injury or entrapment. 30/05/07 5 OP9 13 (2) The Lodge Gaviscon must be ordered timely, to ensure it is available for the service user. The missing signature for the witnessed controlled medication administered, must be recorded. 30/05/07 6 OP12 16 (m) 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. Requirement from the last Inspection. Service users who participate in activities must have this interaction recorded. 30/05/07 7 OP15 16 (2) (i) The Main Building & Lodge 30/05/07 Rosedale Nursing Home DS0000064332.V334994.R01.S.doc Version 5.2 Page 25 The menu must reflect all foods available including what is on offer to service users who require a liquidized diet. Foods should be on offer to encourage service users who are nutritionally challenged to eat. Provision of high calorie snacks in between meals and finger foods must be provided. 8 OP18 12 (10 (a) 18 (1) (i) Main building The supervision must be undertaken and recorded as agreed, following the protection of vulnerable adults investigation. Main building and Lodge All staff must receive training relating to the protection of vulnerable adults. 9 OP19 13 (4) (c) Main building The nurse call system must be available, to non-ambulant service users in the lounge. The boiler room door must remain locked to prevent service users gaining access. 10 OP19 12 (1) (a) The Main building & Lodge Cleaning Chemicals must be stored securely, and must not be left unattended in communal areas by cleaning staff. The Lodge The Laundry cupboard door, must not be held open by the Hoover flex, this should remain locked shut. Plastic aprons must be available in the entrance of the kitchen. Freezer temperatures must be Rosedale Nursing Home DS0000064332.V334994.R01.S.doc Version 5.2 Page 26 30/05/07 30/05/07 30/05/07 recorded daily. Cleaning must be undertaken and recorded within the kitchen. 11 OP19 13 (4) (a) (c) 23 (2) (p) The Lodge A risk assessment of all windows must be carried out to ensure that window restrictors are maintaining service users and staff’s safety, and repairs must be made as necessary. 02/05/07 11 OP28 18 (1) (i) 13 (4) (a) (c) Main building & Lodge 14/06/07 Training must be given to the handyman and all care staff in relation to maintaining the safety of bed rails. Fire training must be delivered in line with North Yorkshire Fire services Requirements. Food hygiene training must be undertaken for all staff working with food. Statutory training for all staff must be up to date. 12 OP38 16 (2) (j) Immediate requirements must be undertaken. Issues relating to bed rails and window restrictors, must continue to be monitored, by management, to ensure staff and service users health and safety is maintained. 30/05/07 Rosedale Nursing Home DS0000064332.V334994.R01.S.doc Version 5.2 Page 27 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 OP16 OP28 Good Practice Recommendations Service users relatives and visitors should be made aware of the homes complaints procedure. 50 of care staff should be qualified to at least NVQ level 2 in Care. Rosedale Nursing Home DS0000064332.V334994.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Nursing Home DS0000064332.V334994.R01.S.doc Version 5.2 Page 29 - 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. 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