Inspection on 11/10/05 for Rosegarth

This inspection was carried out on 11th October 2005.

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

Other inspections for this house

Rosegarth 18/02/09

Rosegarth 03/12/07

Rosegarth 31/05/06

Rosegarth 27/04/05

Rosegarth 13/10/04

Rosegarth 13/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Rosegarth 40 Moseley Road Cheadle Stockport Cheshire SK8 4HJ Lead Inspector Kath Oldham Unannounced Inspection 11th October 2005 08:15 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 Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 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. Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Rosegarth Address 40 Moseley Road Cheadle Stockport Cheshire SK8 4HJ 0161-485 3349 0161 485 8466 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) Rosegarth Limited Mrs. Elaine Reid Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 25 OP. Date of last inspection 27th April 2005 Brief Description of the Service: Rosegarth is a Victorian building situated at the end of a quiet cul-de-sac in an area between Cheadle and Cheadle Heath. The home is set in gardens, surrounded by mature trees. Rosegarth provides care and support for up to 25 service users who are older people. Single bedroom accommodation is provided for all service users on the ground and upper floors. Service users are able to bring small items of furniture and personal possessions with them. A call system is installed in all rooms to enable service users to summon support or assistance from staff. Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the day on 11th October 2005. Time was spent during the inspection examining a sample of records and observing staff practice and routine. Time was also spent in conversation with the deputy managers and staff employed at the home. Parts of the building were seen during this inspection. The inspector had the opportunity to speak to service users at the home. The pharmacy inspector looked at medication storage, administration and the records in relation to medication. Comment cards were left at the home for distribution to service users, relatives and visitors. Their comments are included in this report. What the service does well: What has improved since the last inspection? Two staff are to commence induction training organised by an external facilitator in the week after the inspection to help them to deliver care to service users. The newly appointed cook and a member of the senior team, who undertakes cooking periodically, are to undertake food hygiene training. Service users’ care files include details of activities they have undertaken and provide an indication of how service users spend their day. An individual record of service users’ weights was maintained in service users’ files examined, indicating any weight gain or loss. The reports of the visits undertaken by the registered person are now recorded and these reports are forwarded to the commission in line with regulations. Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 Page 6 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. Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 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 Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 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): 2, 3 & 5 The lack of terms and conditions of residency for all service users means they do not have all the information they should have to make an informed choice. EVIDENCE: Examination of service users’ files identified a contract in place from the local authority funding their care. An assessment undertaken by the placing local authority was also in place in the sample of files examined. There was evidence of the home undertaking its own assessment prior to agreeing to accommodate service users on a trial basis. There were no contracts or terms and conditions of residency between the home and the service user on the files examined. Service users said their friends and relatives visit at their convenience, some visit many times during the week. One service user said she goes out with her relatives when they visit. Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 9 The care plans are not sufficiently detailed. The administration, storage and re-ordering of medication is not wholly satisfactory, however there was a commitment to ensuring good health for service users. EVIDENCE: Examination of the care files identified that there was minimal information recorded in relation to service users’ care needs and how they are to be met. The care files did not contain photographs of service users, which would assist the home in identification, as stipulated within the standards. One service user had recently had cot sides fitted to their bed, this detail was not recorded as having been assessed and agreed by all professionals and family involved in the service user’s care. Examination of the medication records found the receipt and disposal of medication were not completed appropriately, nor were records of administration completed satisfactorily. Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 Page 10 The home has a list of staff members authorised to administer medication, which includes a record of their signature and approved initials as is required by regulations. The list has not been updated in line with staff changes. The home does not have a system in place to identify service users prior to medication administration, as is best practice. Medication administration was observed, medication was inappropriately handled and the administration records were signed before medication had been given. Medication was observed to be prepared into a medicine pot and left for later administration along with medication for other service users. This contravenes regulations and can result in errors being made. A service user self-administers her medication. A risk assessment had not been completed as a safeguard for the service user. Storage and the temperatures of medication must to be improved to safeguard service users and staff. Examination of medication storage areas identified a large amount of excess stock. The home had an oxygen cylinder in storage. The oxygen did not belong to a current service user and the room in which it was stored was not labelled with the appropriate warning signs. Senior staff have received basic training in the handling and administration of medication. A formal assessment of their competency is not currently undertaken. District nursing services are involved in the health care needs of service users when necessary. Service users said they were able to see their doctor whenever they are unwell and the home will telephone through their request. Service users said they see their doctor in private and a staff member will come in with them if they feel this is needed. One service user said they had the same doctor’s practice from being young and had every confidence in the surgery. A relative/visitor said, “We are told of any medical attention and would be telephoned about serious problems”. Staff were observed to be using a wheelchair for a service user without the use of footrests; this practice can compromise the safety of the service user. The service user’s instruction not to have footrests is recorded on their care file. A risk assessment was not in place which detailed the potential risks and that the service user had made an informed decision. Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Residents were, in the main, able to make their own day-to-day decisions and choices; their independence was promoted. EVIDENCE: Service users’ care files identified the activities they undertake; these include ball exercise, old time music, video afternoons, manicures and visits to the hairdresser. Some service users said they are told when activities are arranged and could take part if they wished. A couple of service users said that the activities weren’t for them and they preferred to occupy themselves. One service user said they would like to go out more often. Others said they were happy with what was provided by the home. A number of service users have recently been on a trip to Blackpool, which they said they had enjoyed. A record was not always maintained of service users’ clothes and possessions brought with them on admission to the home and added to during their stay. This could lead to losses, which are not accounted for. In one service user’s file a record was in place but this hadn’t been updated as new items were purchased. Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The complaints procedure ensured that all interested parties were aware of how to complain and the process that would be undertaken. All staff were not trained in adult protection. EVIDENCE: The record of complaints identified comments and concerns identified by service users, staff or visitors to the home in relation to the care they receive. The record details the action to be taken to address the complaint or comment. Although the complaints recorded were few, this evidences that the home takes comments seriously, in an attempt to improve the quality of service provided at the home. Service users said they would let the manager know when they have any complaints or queries. A comment card indicated that when a complaint had been made to the home, it had been resolved. Staff spoken to on the inspection had not received training in what constitutes abuse; this should be arranged to highlight areas of potential abuse and to identify the action that must be taken on any suspicions. Staff were aware of what constitutes physical and sexual abuse. Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, The home provides a comfortable, clean and homely environment, but control of the central heating was not satisfactory. Fire regulations were not adhered to. EVIDENCE: A number of fire doors were wedged open by the placement of articles or were retained in the open position. The wedging of the kitchen door when food was cooking on the hob, the placement of the washers and dryers in the laundry means that the fire doors cannot be closed. The kitchen and laundry are high risk areas. The door leading from the ground floor kitchen/laundry and dining areas to access the stairs did not close sufficiently into the doorframe which, in an emergency situation, may increase the possibility of the spread of fire. This practice compromises the health and safety of service users and staff. Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 Page 14 A number of doors, clearly identified that they must be locked as they contain equipment or cleaning materials, were not, which again increases the risk to service users’ health and safety. There is a sounder on the first floor to alert staff if the fire door is activated. The staff could not hear the sounder. Service users could leave the house undetected and use the iron staircase fire escape outside of the house. Another exit from the same floor is also freely available for service users to leave the building without the knowledge of staff. These areas of the home should be risk assessed in the interim in consultation with the fire authority. A number of bedrooms have been redecorated and have had new carpets fitted. The manager has previously stated that the home is redecorated on a rolling programme and replacement carpets purchased routinely. Service users said they were happy with their accommodation and had comfortable bedrooms. One service user said their bedroom served its purpose and they used the bedroom to sleep. A further service user said she has her room just how she likes and entertains her visitors in her bedroom. The home was clean throughout and free from unpleasant odours. Examination of safety records did not detail whether work to the passenger lift and hoist recommended by contractors to be undertaken had been. The deputy manager was to research this with the lift contractor and with the registered person and confirm this work in writing to the commission. At the time of writing this report the commission had not received this confirmation. The house was unbearably hot, visitors to the home were commenting on the fact that the heat “hit you” as soon as you came into the home. The inspector has been previously informed that specific bedrooms were cold and supplementary heating has been used. Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Staff were employed in sufficient numbers and trained to meet the needs of residents. Safeguards were not always in place in the recruitment procedures. EVIDENCE: Examination of a sample of care staff files identified that the necessary paperwork, which must be in place, was not. This is a matter that has been identified previously. Criminal Record Bureau checks were not always undertaken by the home, previous checks being accepted. The job application form used by the home does not provide enough information and was, on occasions, not completed fully by the applicant. The home had not received two references for new employees as required by regulations. Newly appointed staff are scheduled to undertake induction training by an external facilitator. Newly appointed staff have yet to attend moving and handling training. One staff file indicated that they had obtained NVQ 2 training at a previous employment. Certification of this fact was not held on file. The deputy said she had seen the certificate and must have omitted to copy for the file. Two staff are due to register to undertake NVQ 2 and one of the deputies has been successful in obtaining NVQ 3, the other deputy continues with her studies and envisages that this will be concluded in a couple of months. Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 Page 16 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): 36, 37 & 38 Health and safety procedures are not in place for all areas of risk. Staff are not regularly supervised. EVIDENCE: The records maintained to record the fridge and freezer temperatures were not all completed for the month of October 2005. This detail is required to be kept in line with food safety regulations. Examination of the fire safety records identified that not all staff had received fire drill training and practice at the regularity prescribed by the fire authority. This has the potential to put service users and staff at risk in an emergency situation. The fire detection and alarm systems report identified that this equipment was serviced in June 2004. Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 Page 17 A record is maintained of accidents, incidents and falls experienced by service users. The records examined were completed in line with requirements. Examination of the service records for the lift identified worked that needed to be carried out. There was no detail available to confirm whether this work had been undertaken. The most recent record of the service to the hoist was recorded as being done in April 2004, these services must be undertaken six monthly, the records available did not confirm this fact. The supervision notes examined did not include new staff appointed in the months prior to this inspection. Supervision is an integral part of staff’s development and progression and should be undertaken regularly. Records containing personal information in relation to service users were not stored securely to promote service users’ privacy and confidentiality. Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 Page 18 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 2 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X X X X X X X STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 1 2 1 Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 Page 19 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 OP2 Regulation Schedule 4(8) 13(4)(c) Requirement The registered person must arrange for all service users to receive a copy of terms and conditions of residency. The registered person must ensure that a thorough risk assessment has been undertaken when service users elect not to have footrests in place on the wheelchair, clearly documenting the risk to the service user and how the risk will be minimised. The registered person must further develop the care plans, ensuring all areas of the service users’ needs and interventions are detailed. The registered person must arrange for risk assessments to be recorded for the use of bed rails for any resident in the home. The registered person must ensure that an accurate dated record is maintained of all medication received or disposed of by the home in order to maintain a complete audit trail of medication. DS0000008584.V254584.R01.S.doc Timescale for action 31/12/05 2 OP7 30/11/05 3 OP7 15 30/11/05 4 OP7 13 30/11/05 5 OP9 13(2) 17(1)(a) 22/11/05 Rosegarth Version 5.0 Page 20 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. 6 Standard OP9 Regulation 13(2) 17(1)(a) Requirement The registered person must ensure that on occasions where a variable dose of medication is prescribed, for example, one or two tablets to be taken, an accurate record is made of the actual dosage of each medication administered. The registered person must ensure that the directions of medication prescribed as ‘as directed’ is clarified with the resident’s General Practitioner and the prescriptions altered accordingly. The registered person must ensure that care home staff administer medication as per a recommended medication administration procedure which must include when records are completed, how medicines must be handled and who can receive prescribed medicines. The registered person must ensure that homely remedies are only administered in line with a policy which covers the storage, administration and recording of such items. Homely remedies must not be administered by carers without first consulting an appropriate healthcare professional. DS0000008584.V254584.R01.S.doc Timescale for action 25/10/05 7 OP9 13(2) 17(1)(a) 22/11/05 8 OP9 13(2) 13(4)(c) 25/10/05 9 OP9 13(2) 13(4)(c) 22/11/05 Rosegarth Version 5.0 Page 21 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. 10 Standard OP9 Regulation 13(2) 13(4)(c) Requirement The registered person must ensure that residents who wish to manage their own medication are assessed as to their ability to do so, before medication is provided to them. Assessments must then be repeated on a regular basis. The registered person must ensure that medication in the custody of the home is stored securely and is not accessible to unauthorised persons. The registered person must ensure that medicines are stored at appropriate temperatures (max temperature 25oC). The registered person must ensure that all items of medication which have exceeded their expiry dates, do not belong to current residents or are not labelled with prescribed directions are returned to the supplying pharmacy at the first opportunity. The registered person must ensure that that the expiry dates of medicines stored within the home are checked on a regular basis. Timescale for action 22/11/05 11 OP9 13(2) 13(4)(c) 25/10/05 12 OP9 13 (2) 20/12/05 13 OP9 13(2) 13(4)(c) 25/10/05 Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 Page 22 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. 14 Standard OP9 Regulation 13(2) 17(1)(a) Requirement The registered person must ensure that the receipt, administration and disposal of controlled drugs are recorded accurately and contemporaneously in a Controlled Drugs register and that any corrections are made by dated marginal note or footnote. The registered person must investigate the detailed discrepancy in the controlled drugs register and record the outcome on the appropriate page in the register. The Commission for Social Care Inspection must be informed in writing of the outcome of this investigation. The registered person must ensure that the competency of carers with responsibility for medication administration is assessed regularly on a formal basis. The registered person must arrange for all staff to attend training on what constitutes abuse. The registered person must cease the practice of wedging open fire doors. Timescale for action 28/10/05 15 OP9 13(2) 18(1)(c)(i) 17/01/06 16 OP18 12, 13(6) 31/12/05 17 OP19 23(4) 11/10/05 Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 Page 23 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. 18 Standard OP19 Regulation 23(4) Requirement The registered person must ensure that all fire doors fit into their rebate when closed from any angle The registered person must ensure that all doors that are display notice of the fact that the door is to be kept locked for health and safety reasons are such and that keys are removed from the door. The registered person must arrange for sounders to be fitted to the two doors which access iron staircases outside the home. These sounders must be audible to staff wherever they are in the home. The registered person must ensure that all recruitment and selection procedures are followed, including receipt of CRB checks and prospective employees complete comprehensive applications and two references are provided for all new staff. (Previous timescale of 30/06/05 not met). The registered person must ensure that staff receive 1:1 supervision and appraisal at a minimum of six times each year and that this detail is recorded. Timescale for action 11/10/05 19 OP19 12, 13, 23(4) 11/10/05 20 OP19 23(4) 31/12/05 21 OP29 19 31/12/05 22 OP36 18(2) 30/11/05 Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 Page 24 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. 23 Standard OP37 Regulation 17(1)(b) Requirement The registered person must ensure that all records are maintained securely and confidentially. The registered person must ensure that a record is maintained of daily temperatures of the fridges and freezers in the home in line with food safety regulations. The registered person must arrange for all staff on their next duty to attend fire drill practice/ training and ongoing training is provided at a minimum of every six months. Timescale for action 30/11/05 24 OP38 16(2)(j) 30/11/05 25 OP38 23(4)(d) 11/10/05 Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 Page 25 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 OP7 OP9 Good Practice Recommendations The registered person should obtain a photograph of service users and include on the care plan to assist in the identification of the individual. The registered person should ensure that if the dosage of medication is amended by the prescriber, the current record is discontinued and a new record is commenced. If a record is handwritten it must be signed and dated and the details validated by an additional member of staff. The registered person should ensure that the list of staff members authorised to administer medicines which includes a record of their signature and approved initials is updated in line with staff changes. The registered person should ensure that a formal system is in place to identify residents prior to medication administration. The registered person should ensure that oxygen cylinders which are either empty or not in use are returned to the supplying pharmacy. If oxygen cylinders are to be stored within the home warning notices specifying: Compressed Gas, Oxygen; No Smoking, No Naked Lights must be posted clearly. The registered person should ensure that an individual list of possessions is made on service users admission to the home, which is dated and updated as new items are purchased or provided. The registered person should ensure that a minimum of 50 of care staff are trained to NVQ 2. 3 OP9 4 5 OP9 OP9 6 OP12 7 OP27 Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Rosegarth DS0000008584.V254584.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!