Inspection on 03/12/07 for Rosegarth

This inspection was carried out on 3rd December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Rosegarth 18/02/09

Rosegarth 31/05/06

Rosegarth 11/10/05

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 Steve O`Connor Unannounced Inspection 3rd December 2007 10:30 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.V353658.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. Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 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.V353658.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 25 OP. Date of last inspection 31st May 2006 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. People are able to bring small items of furniture and personal possessions with them. A call system is installed in all rooms to summon support or assistance from staff. The home has a Statement of Purpose and Service User Guide which were reported to be given to prospective people or their families when they visit the home to look round. Copies of these are also in bedrooms. Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection report is based on information and evidence gathered by the Commission for Social Care Inspection (CSCI) since the home last had a key inspection in May 2006. This information included a Random Inspection, carried out in December 2006, to find out how the requirements made at the key inspection were being addressed. The home completed a self-assessment form called an Annual Quality Assurance Assessment (AQAA) describing how they feel they have supported people in meeting the National Minimum Standards. Additional information that was taken into account included incidents notified to the CSCI and information provided through other people and agencies, including any concerns and complaints. Surveys were sent to people living at the home and to members of staff to find out their views of the service. Two people and three relatives returned surveys. During the inspection site visit, time was spent observing how staff work with people and talking to management and staff on duty. Documents and files relating to people and how the home is run were also seen and a tour of the building was made. The inspection was an opportunity to look at all the core standards of the National Minimum Standards (NMS) and was used to make a judgement on the quality of the service provided by the home and to decide how much work the CSCI needs to do in the future. What the service does well: People, their relatives and other visitors to the home have all made positive comments about the quality, values and attitude of the staff and management. One regular visitor stated that, ‘the residents are clean and well-cared for, and the staff are courteous toward them.’ The work that staff do to improve people’s situation was commented on with one relative stating that, ‘The staff look after her very well and she is eating now.’ Whilst another relative highlighted that, ‘Encouragement with eating is done well and calmly and consistently.’ Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 6 The staff team welcomes friends and relatives regardless of the time of day and make an effort to keep in touch with families about people’s wellbeing and will spend time giving people reassurance and the chance to express their worries and concerns. The environment was bright and clean that looked and felt comfortable. A comment made by a relative said that, ‘Rosegarth provides a warm, welcoming homelike environment’. With a number of communal areas, people had the flexibility and choice of where and with who they spend their time with or could have the privacy of their own bedrooms. What has improved since the last inspection? What they could do better: Previous inspection reports had highlighted to the owner and manager of the home that good recruitment practices and checks were not being followed when employing new staff. The current site visit also found problems with the references for the latest member of staff and no evidence that they had been checked to see if they were on the Protection of Vulnerable Adults (POVA) list before they began employment. The importance and seriousness of not following the correct recruitment practices were again raised with the manager. People are supported to take the correct medication so that they stay well. To make sure that medication is given correctly, a medication administration system is used to record all aspects of managing medication. Staff are still making some errors in recording and there was no clear guidance for when staff should administer medication prescribed ‘as required’. Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 7 The home was seen to be very clean in all bedrooms, communal areas, bathrooms and toilets. However, it was noticed that items such as bars of soap, cloth towels, shared toiletries and nail brush were being used in the bathrooms that increase the risk of cross-infection and is not seen as current good practice. Although individual care plans are written that record the support that people need, this and previous inspection reports have highlighted that they lack detail and description and do not really focus on the person themselves in terms of how they want to be supported. Also, there is no evidence that people and/or their families were involved in developing or agreeing these plans. To find out how people and other relevant people feel about the quality of the service means that a system of quality assurance be used to gather these views and other relevant information that will help to find out the quality of service being provided and where the service may need to be improved. 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. Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 not applicable) Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. People’s needs were assessed and known prior to them coming to live at the home. EVIDENCE: If people were to be funded through a local authority, a Care Management/ Single Assessment was obtained prior to people being offered a place at the home. An example of a Care Management assessment was seen and it set out a person’s primary health and care needs. Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 10 The manager stated that they would undertake their own information gathering assessment through visiting the person/family and/or through visits to the see the home. However, none of this information gathering was recorded and so could not evidence the practice described. It is recommended that all information gathered and assessed prior to a person’s admission be clearly recorded and used in the decision making process when offering a person a place at the home. Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. People’s needs were not fully recorded but staff gave care and support in a positive and respectful way. The medication administration system did not fully ensure that medication would be administered as required. EVIDENCE: Previous inspection visits and a requirement from the previous random inspection report had highlighted that people’s care plans were not sufficiently detailed in recording their needs nor the support staff provided. The care plan of a recently arrived person was sampled and found that it contained the minimum amount of information and mostly reflected what was in the local authority care management assessment. There was no evidence that the person and/or their family had been involved or agreed with the care plan. Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 12 Staff spoken to at the time of the site visit were able to describe in greater detail how the person was supported but none of this person centred information had been recorded or reflected in the care plan. Examples of care plan reviews were seen and risk assessments in relation to areas such as medication and the use of bed rails. Care plans must fully reflect people’s needs in all aspects of their life and it is recommended that the support provided is based on a more person centred approach to how the person themselves wants to be supported. It is also recommended that people, and/or their representative, be fully involved in the care planning process and that this was clearly evidenced. Information about people’s health needs was recorded in people’s care plans and was not very detailed or comprehensive. For example, there was little reference to people’s dental care or nutritional needs. The manager acknowledged that the staff knew this information but it was not fully recorded. It is recommended that people’s general and specific health needs, such as dental, nutritional and emotional, and interventions were fully recorded. Support from specific health providers such as District Nurses and other health professionals were recorded in their files. People with specific health needs, such as diabetes, had been referred and received input from health providers such as chiropodists and opticians. A separate room was made available for health professions to use in privacy, if required. Staff were observed talking with and supporting people in different settings within the home. They were seen to be supportive and respectful in the way that they spoke to, encouraged and helped people. The medication administration system was checked and found that all deliveries of medication were recorded on the Medication Administration Record (MAR). Returned medication was signed for correctly. Staff who had responsibility for administering medication had received training from the supplying pharmacy and a number had completed a more in-depth medication training event. A sample of MAR sheets were checked for accuracy of recording. All the appropriate medication administering had been signed for. It was noticed that if staff used the coding to explain why a medication had not been given, there was no further recorded explanation as to why, for example, a person had refused medication. It was also found that errors in recording had been covered over hiding the error made. It is recommended that when coding is used on the MAR sheets that the reasons for not administering the medication be clearly recorded. It is also recommended that errors in recording were corrected using a single line and initialled by the person making the correction. Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 13 An example was found where a person’s medication dosage had been reduced and staff had recorded this on the MAR sheet. However, there was no evidence that a prescribing GP had made that decision. It is recommended that, as far as is possible, written evidence of GP’s decisions to alter people’s medication be gained. Several people had medication prescribed ‘as required’ (PRN) including for pain relief, constipation and anxiety. There was no recorded administering instructions setting out guidance on when and how much medication should be given. To make sure that people were being given the medication that they need to maintain their health and wellbeing, all medication prescribed ‘as required’ (PRN) must have accompanying written administration details and guidance. Controlled medication was kept secure and the recording was accurate and in line with regulation. It is recommended that staff who administer controlled medication only need to sign the Controlled medication book. A weekly audit and count of the controlled drugs was undertaken. Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People were satisfied with the opportunities offered regarding their lifestyles and are able to make their own decisions and choices. People were generally satisfied with the quality and quality of meals offered. EVIDENCE: Several people were able to access the community themselves and to follow their own routines and preferences without relying on support from staff. People were offered the opportunity to take part in a range of activities arranged by staff, including in-door games and exercises, films, music and visiting entertainers. People can also pay for the services of a visiting hairdresser. When people took part in an activity, then this is recorded on a daily basis. At the time of the inspection visit, preparations were being made for a fundraising ‘Winter Fair’ and the Christmas decorations were being put up with people’s views and opinions being sought. Photographs from the fundraising ‘Summer Fair’ were displayed in the hallway and several people and relatives had commented on how enjoyable this had been. However, it was confirmed by the manager that very few social trips had been made during the summer months. Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 15 Several people were supported to attend local places of worship and members of local churches also visited people to say prayers, mass and give communion. At the time of the site visit a number of visitors came to see family and friends living at the home. Comments from visitors found that they were welcome at any reasonable time and found that staff were friendly and supportive. People could receive visitors in either communal lounges or in the privacy of their bedrooms. Comments on the quality and range of meals offered at the home were positive. A three-week menu was developed in consultation with people and was based on traditional homemade meals. The main meal was taken at lunchtime with a lighter evening meal and supper available. The choices offered to people were recorded by the chef. Staff were observed supporting people with their meals where needed and offering people a choice rather than just placing food in front of them. Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The systems and policies were in place to allow staff and management to respond to people’s concerns and keep them safe. EVIDENCE: Comments from people and visitors confirmed that they were aware that they could raise concerns and make a complaint to the manager. The written complaint policy and procedure was available to people through the Service User’s Guide and Statement of Purpose. A complaint log was available but there had been no formal complaints since the last key inspection in May 2006. The issue of how people can raise their worries and concerns was raised with the manager. The manager confirmed that people would come to her or other staff if they had any problems and these would be dealt with as they arose. No records were kept of these concerns. It is recommended that a record of people’s concerns and worries be maintained that resulted in some action being taken to rectify or put right the concern. Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 17 A policy and procedure was in place for responding to incidents/allegations of abuse. The manager was asked to describe the process they would follow in the event of an allegation and they were able to go through the stages they would follow. A random inspection, carried out in December 2006, stated that staff had undertaken specific training in adult protection but the training records could not clarify this. It is recommended that all staff have the understanding and awareness of their role and responsibility in protecting and responding to incidents and allegations of abuse. Some people living at the home experience dementia and a result of this is that people’s behaviour may, at times, be difficult for the staff to manage safely. It is recommended that a policy and procedure be developed that covers the use of non-physical and physical intervention to keep people, staff and others safe. Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People live in a clean and homely environment that meets their needs. EVIDENCE: The premises were very clean throughout and well maintained. There were three lounge areas where people could choose to spend their time and a dining room in the basement area that had direct access out to the extensive grounds. Previous inspection reports had highlighted some areas where the environment needed improvement. New blinds had been installed in the conservatory to help maintain a comfortable temperature. The requirement to install sounders on fire doors had been carried out and a number of doors were now fitted with magnetic door closers. Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 19 The ground floor areas had been redecorated in the summer and the areas looked bright and fresh. The other communal areas were comfortable with a homely feel to the environment. Several bedrooms were seen and these were very clean and well maintained. All had been personalised with people’s belongings. At the time of the site visit one of the vacant bedrooms was being redecorated. It was found that some of the bathroom and toilet facilities contained cloth towels and bars of soap that people were sharing. In one bathroom there was a nailbrush that was being shared by people. To minimise the risk of crossinfection, people and staff must not use shared bathroom items such as towels, soap, toiletries and nail brushes. It was also found that infection control equipment, such as disposable gloves and aprons, was kept in the bathrooms and toilets. It is recommended that infection control practices were reviewed to ensure that they meet the relevant infection control guidance for care homes as provided by the Department of Health. Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. People were being supported by sufficient staff who had the knowledge to meet their needs. The practices and systems in place for recruitment do not make sure that staff are safe to work with vulnerable people. EVIDENCE: At the time of the site visit the staff rota showed that between 8:00am and 10:00pm there were four care staff supporting people’s needs. In addition, a deputy manager was available through the day. Between 10:00pm and 8:00am, two night staff were on duty. The staff and management supported a number of people with high levels of personal care and mobility needs and so the numbers of staff on duty were sufficient to meet people’s needs. Staff were observed spending time talking with people and the support they gave was unhurried and suitable for their needs. Comments from people and relatives were positive about the staff team in terms of their work, attitude and values in supporting vulnerable people. Information provided by the manager showed that the majority of staff had attained a NVQ level 2 vocational qualification and that the remaining staff were undertaking the qualification. Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 21 The most recently employed member of staff’s records were assessed. The application form was seen and found that only one reference had been provided with no clear contact details. The references seen were not from the person’s previous employer and there was no clear record of where these references actually came from and were not completed on the reference proforma sent by the home. The Criminal Record Bureau certificate was dated 5th October 2007, although the staff member had started employment in March 2007. There was no evidence that a POVA first check had been made. It was also noted that the person had not filled in the previous conviction section of the application form accurately. This issue of employing staff without the correct checks and documentation had been raised in three previous inspection reports. This issue was again raised with the manager at the time of the site visit to clarify the seriousness of not following the correct recruitment procedures. The requirement was reiterated again. New staff would undertake an Induction Programme that would be supervised by a deputy manager and they would sign the Induction Record when they believe that the staff member is competent in that task/skill. It was noticed that the induction modules had not been updated to reflect the mandatory Skills for Care Induction Modules. A recommendation was made. It was also recommended that a system for assessing staff competence be developed to show that the skills and knowledge they developed through training had been translated to their working practices. Each member of staff had an individual record of training that they had undertaken. It was found that these records were not being kept up-to-date with the training that staff had participated in. There was also uncertainty as to whether staff had attended Adult Protection training in the last year. This issue was addressed in the Protection section of the report. It is recommended that staff training records were kept up-to-date and that each member of staff had a training plan setting out their needs for ongoing and refresher training. Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The management and practices of the home provided a safe environment for people to live but there was no system in place to monitor the quality of the service people received. EVIDENCE: The registered manager has a number of years’ experience in working in the residential care sector, she has been the manager at Rosegarth for about six years. She has completed the NVQ Level 4 in Care Management and the Registered Manager’s award. The manager and deputy managers were now providing regular supervision for the staff team. Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 23 People have the opportunity to come together in a formal residents’ meeting every three months. These meetings looked at issues such as leisure and social activities, meals and any other issue that people wanted to raise about the home. There was no evidence that the views of individual people, their family/visitors or other relevant professionals were sought to try to find out about the quality of the service they received. Information provided by the home confirmed the range of policies and procedures they have but there was no evidence that these had been reviewed or updated to reflect changes in guidance, regulation and/or legislation. To find out how people feel about the quality of the service they receive and to ensure that the staff and management working practices are in line with current guidance, regulation and legislation, a quality assurance system must be developed and implemented. People’s were helped and supported with managing their personal monies through either relatives or the relevant local authority being the appointee and looking after people’s financial affairs. The Local Authority Environmental Health and Health and Safety department had made visits to the home since the previous inspection. They had highlighted improvements that needed to be made in the kitchen area and other parts of the premises. These issues had been addressed. Information provided by the home stated that all servicing of gas and electrical items and other equipment, such as hoists and the lift, had been carried out. Checks for fire equipment were being carried out on a weekly basis. Cleaning schedules for the kitchen were in place. Temperatures for refrigeration and hot water were being recorded on a weekly basis. Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 (1) Requirement Timescale for action 30/01/08 2 OP9 13(2) 3 OP26 13(4) 4 OP29 19(1)(4) (5) Individual care plans must fully reflect people’s holistic needs and set out clearly the support and interventions used to help people to meet those needs. To make sure that people were 30/12/07 being given the medication that they need to maintain their health and wellbeing all medication prescribed ‘as required’ (PRN) must have accompanying written administration details and guidance. To minimise the risk of cross 30/12/07 infection people and staff must not use shared bathroom items such as towels, soap, toiletries and nail brushes To make sure that new staff are 30/12/07 safe to work with vulnerable people all the checks and documentation required in the recruitment and selection of staff must be followed correctly before they begin working with people. (Previous timescales of 30/06/05, 31/12/05, 14/07/06 and 18/01/07 were not met). DS0000008584.V353658.R01.S.doc Version 5.2 Rosegarth Page 26 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. 5 Standard OP33 Regulation 24(1) Requirement To find out how people feel about the quality of the service they receive and to ensure that the staff and management working practices are in line with current guidance, regulation and legislation, a quality assurance system must be developed and implemented. Timescale for action 30/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations It is recommended that all information gathered and assessed prior to a person’s admission be clearly recorded and used in the decision making process when offering a person a place at the home. It is recommended that care plans fully reflect a more person centred approach to how the person themselves wants to be supported. It is recommended that people, and/or their representative, be fully involved in the care planning process and that this was clearly evidenced. 2 OP7 Rosegarth DS0000008584.V353658.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. 3 4 Refer to Standard OP8 OP9 Good Practice Recommendations It is recommended that people’s general and specific health needs and interventions were fully recorded. It is recommended that when coding is used on the MAR sheets that the reasons for not administering the medication be clearly recorded. It is recommended that errors in recording were corrected using a single line and initialled by the person making the correction. It is recommended that staff who administer controlled medication only need to sign the Controlled medication book. It is recommended that as far as is possible written evidence of GP’s decisions to alter people’s medication be gained. It is recommended that a record of people’s concerns and worries be maintained that resulted in some action being taken to rectify or put right the concern. It is recommended that all staff have the understanding and awareness of their role and responsibility in protecting and responding to incidents and allegations of abuse. It is recommended that a policy and procedure be developed that covers the use of non-physical and physical intervention to keep people, staff and others safe. It is recommended that infection control practices were reviewed to ensure that they meet the relevant infection control guidance for care homes as provided by the Department of Health. 5 6 OP16 OP18 7 OP26 Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 8 Refer to Standard OP30 Good Practice Recommendations It is recommended that the Induction Programme be reviewed and updated to ensure that it reflects the mandatory Skills for Care Induction Modules. It is recommended that staff training records were kept up-to-date and that each member of staff had a training plan setting out their needs for ongoing and refresher training. It was also recommended that a system for assessing staff competence be developed to show that the skills and knowledge they developed through training had been translated to their working practices. Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Manchester Local Office 11th Floor, West Point 501 Chester Road Old Trafford Manchester M16 9HU 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 Rosegarth DS0000008584.V353658.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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