Inspection on 31/05/06 for Rosegarth

This inspection was carried out on 31st May 2006.

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

Rosegarth 18/02/09

Rosegarth 03/12/07

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 Kath Oldham Unannounced Inspection 31st May 2006 07:30 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.V293291.R01.S.doc Version 5.1 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.V293291.R01.S.doc Version 5.1 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.V293291.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 25 OP. Date of last inspection 11th October 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. The home has a statement of purpose and service user guide which were reported to be given to prospective service users or their families when they visit the home to look round. Copies of these are also on service users’ bedrooms. The fees for staying at the home were reported to be between £326 and £395 per week. Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit was unannounced and took place on 31st May 2006, commencing at 7:30am. Rosegarth residential care home is registered with the Commission for Social Care Inspection (CSCI) to provide personal care for up 25 people over 65 years of age. It is privately owned. The manager is registered with CSCI and was present during the site visit. Time was spent speaking with service users and staff, examining records and in discussion with the manager, deputy and senior. A partial inspection of the premises was also undertaken. As part of the inspection a newly admitted service user was spoken to; they described their experience of living at Rosegarth. They stated that they felt safe, particularly at night when they were aware that the carers would be available should they require them. A further service user spoke with the inspector and confirmed their satisfaction with the service. Comment cards were left at the home to give out to service users and their families, friends and visitors. In addition, some comment cards were sent directly to service users’ relatives and friends, doctors and district nurses. Comments received are included in this report. The last inspection of Rosegarth took place in October 2005 when the pharmacy inspector, who also attended the home, issued a number of requirements in relation to the administration, recording and storage of medication. The requirements of previous inspections were monitored on this visit and are reported on within this report. What the service does well: Many positive comments were made about the management and staff, and also about the atmosphere in the home. Visitors, relatives, friends and service users used the opportunity of the inspection to reflect on the service provided and said the home was a happy place. Rosegarth works hard to try to encourage the involvement of relatives, friends or representatives. Comments were made about being made to feel welcome and the feeling that the staff and service users were an extended family. The home was clean, tidy and free from odours. Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? Improvements have been made to the administration, recording and storage of medication. There are some medication requirements that are not yet fully complied with. These are being worked on by the home. A new television has been purchased for the conservatory and the three lounges have a DVD player so service users are able to watch films when they choose. The dining room has been redecorated. room seems a lot brighter and lighter. Service users commented that the Additional lounge chairs have been purchased to replace or add to the number in the home. They were reported to provide additional comfort to service users. One service user said they “are sat down all day so need a comfy chair”. Two newly appointed staff have undertaken induction training, which assists in their development. Service users’ care files include details of activities they have undertaken and provide an indication of how service users spend their day. Staff continue to receive NVQ training to further improve the service provided to service users. A new handyman has been appointed on a part-time basis and this allows repairs to be undertaken quickly. Previous inspections had described that there were problems with how long it took to carry out maintenance. A new boiler has been installed, which has regulated the heat in the home. The last inspection reported on the immense heat and the comments from service users and their visitors that it was unbearable. Previous comments have also been made that in particular parts of the building, bedrooms have been very cold. The new boiler has hopefully addressed these problems. What they could do better: The statement of purpose and service user guide need some further work undertaken and a review of the information provided to ensure service users are provided with the information they need before coming into the home. The medication records need some additional work to ensure it is clear what amount of medication service users are receiving. Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 Page 7 The care plans need additional development so that the detail from the assessment is accurately transferred to the care plan to ensure service users receive the care they need. The job application form needs to be developed and more thorough checks undertaken that the application is completed fully and accurately. All staff have not undertaken fire drill training and this needs to be addressed with immediate effect to safeguard service users and staff in an emergency situation. The blinds in the conservatory need replacing to ensure that service users do not become too hot in the warmer weather. Some of the blinds on the windows are missing and others do not work. The blinds on the roof eliminate some of the heat from the sun but service users are vulnerable to the heat from the windows. 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.V293291.R01.S.doc Version 5.1 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.V293291.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 ,2, 3 & 5 (standard 6 not applicable) Quality in this outcome area is good. Assessments of service users’ needs are obtained prior to their admission, to ensure the home is able to provide appropriate care. The information provided to service users needs to be developed to ensure it is up to date. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A statement of purpose and service user guide are in place and it was reported that these are given out to service users or their relatives when they visit the home to look round. Copies are also available in service users’ bedrooms. The information in these documents needs to be reviewed and amended to ensure they are up to date and detail all areas as required by the regulations. Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 Page 10 Four service users said they received enough information about the home before they moved in so they could decide if it was the right place for them and that they had received contracts. Prospective service users are provided with the opportunity to visit the home before making any decisions whether they want to live there. Admissions to the home take place if the home is confident that they are able to meet the service user’s needs. The manager undertakes an assessment of the service user in their own home or on the hospital ward if they are going into care from there. An assessment is recorded by the home, however the detail on occasions was minimal. For service users who are being funded by the local authority, social or health care workers undertake an assessment. All service users’ files examined contained a terms and conditions of residency with the home. Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. The care planning documentation was not consistently sufficient to meet personal and health care needs of service users. Medication administration needs further improvements. This judgement has been made using available evidence, including a visit to this service. 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. They are written by staff and do not involve the service users or relatives’ contribution or active involvement. There were a number of needs identified within the assessment process that had not been transferred onto the care plan. Four service users said they always receive the care and support they need Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 Page 12 Examination of service users’ records identified appointments with chiropodists, district nurses and other health care professionals. Service users said they received their medication regularly and staff took time with specific service users to assist them. Health professionals indicated that they work in partnership with the home and “on the whole, staff demonstrate a clear understanding of the care needs of service users and information from district nurses is well received”. Some service users have bed rails fitted to their beds. Since the last inspection, assessments have been undertaken and agreed by professionals and family involved in the service user’s care. The records did not always detail who the professional staff were but did detail when a review was to be undertaken, although it was not always recorded as having been done. A record was in place which detailed that the bed rails were maintained. Observations of care practice identified that the support and interventions of staff, in the main, promoted their privacy and dignity. The manner and discretion of one staff member when providing personal care to service users needs to be improved upon. Staff did not always speak to service users before assisting in transfers or spoke loudly when asking about personal care needs. One service user asked staff “Where are you taking me.” The manager acknowledged that some staff need to be more discreet when supporting service users and this would be developed with staff in supervision. One relative said “on the whole, we feel that our cared for relative is looked after very well, and they are most kind to her. We are quite satisfied at present.” A further relative said, “ Overall, I am very satisfied with the level of care provided for my cared for relative.” Five relatives said they are kept informed of important matters affecting their cared for relative. Examination of the medication records identified some improvements to the recordings. Photographs were on file to assist in the identification of service users, as is best practice. Senior staff have received basic training in the handling and administration of medication. A formal assessment of their competency is not currently undertaken. A service user self-administers their medication. A risk assessment had not been completed as a safeguard for the service user. A risk assessment had been undertaken for another service user who self-administers medication. The year of the assessment was not legible. There was no detail of how often this was to be reviewed. Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 Page 13 Medication that requires refrigeration is now stored in a medication fridge, which needs to have a lock fitted and the temperature taken daily, using a minimum/maximum thermometer. This is to ensure medication is stored at the correct temperature. The date of opening of some medication, which has a limited shelf life, was not undertaken. The deputy attended to this immediately. A number of service users have a variable dose of medication. The actual number of tablets administered was not included in the record. The dosage of medication for two service users with prescribed variable doses had been altered by the home. Examination of the controlled drugs record identified this to be completed in line with regulations. Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. Service users were satisfied with their lifestyles and are able to make their own decisions and choices. Service users receive a varied diet. This judgement has been made using available evidence, including a visit to this service.” EVIDENCE: Activities are recorded within service users’ care files that also include their views on the activity. Some service users have an organised routine where they spend the morning reading, then watch television and chat in the afternoon. One service user said they go out periodically and went out for some fresh air the day before the visit. Service users also commented that they go out on trips organised by the home and they went on four days out last summer, which they said they enjoyed. Service users said they were happy with what they do and don’t want very much more than warmth, meals, company and security. Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 Page 15 One relative said, “we also feel that some kind of activity, i.e., someone went in once a week to play old songs would be a good idea.” Service users said at the service user meetings they decide where they want to go. It was reported that the meetings are held every couple of months and they are told what is happening in the home and they can discuss any issues or queries they have with the manager. Service users said visitors come regularly and are made to feel welcome by the staff. Visitors are able to go to their cared for service user’s bedroom or sit in the lounge; service users said it was up to you where you see them. A number of clergy visit the home and a lay preacher comes into the home three times each week. Service users said there is a small quiet lounge where you can also sit if you want private conversations with your visitors. 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. The cook has resigned and the home continues to advertise for a replacement. Staff are currently cooking meals working on their days off. Service users said they had had some really good meals and commented on how nice the meal was on the visit. One service user said staff know what they like and how they like their food cooked. They had less favourable comments about the previous cook’s skills at cooking vegetables and meat. A record is maintained of the food served to service users so that, if necessary, an assessment can be made whether the diet is sufficient. Staff need to make sure that they always complete this. Service users are weighed monthly and an indication is made whether there is any weight gain or loss and what action is taken as a consequence. Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. Residents and relatives have access to the home’s complaint procedure. Staff have not had training in adult protection procedures. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Service users said they had few, if any, complaints regarding the care they receive at Rosegarth and when they did, they would let the manager know. Residents’ meetings were described as an opportunity to talk things over and forward ideas for change. A complaints book is in place and contained very few recordings. The home had a written complaints procedure. All service users spoken to expressed confidence that complaints would be appropriately dealt with. Staff felt confident that any concerns they had could be discussed with the manager and they would be listened to. Five relatives said they were not aware of the home’s complaints procedure. Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 Page 17 Staff said they dealt with any comments identified by relatives or service users as they were identified. The Commission for Social Care Inspection has not received a complaint since the last inspection. The home has a policy and procedure to respond to allegations of abuse. The manager was in the process of reviewing the document to ensure it remained current. Staff training in abuse had commenced in the home. Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 25 & 26 Quality in this outcome area is adequate. The home provides a comfortable, clean and homely environment. regulations were not adhered to. Fire This judgement has been made using available evidence, including a visit to this service. EVIDENCE: As reported on the previous inspection, 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. A number of service users bedroom doors did not close into the doorjamb when closed from particular positions. This practice compromises the health and safety of service users and staff. Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 Page 19 A door, clearly identified that it must be locked, as it contained equipment, was not, which again increases the risk to service users’ health and safety. The fire exit from the ground floor has a bolt fitted to the top of the door. The kitchen, laundry and dining room are situated on this floor. The fire officer should be consulted with regarding this and, in the interim, a fire risk assessment must be undertaken to ensure unrestricted access can be made from this area of the home in an emergency. There is a sounder on the first floor to alert staff if the fire door is activated. The staff could not hear the sounder. On the second floor the fire exit does not have a sounder on the door. Service users could leave the house undetected and use the iron staircase fire escape outside of the house. Another exit from the first 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. The manager stated that the registered person said he had the sounders fitted when there were service users in the home who wandered and, as there were no service users who have a tendency to wander, he would not be addressing this at the present time. The registered person has ultimate responsibility to safeguard service users accommodated at the home. On the visit the hairdresser was using the ground floor corridor to dry and style service users’ hair. If access was needed from the two downstairs bedrooms or the dining room fire exit, this would have restricted service users. The door leading from the dining room was very difficult for staff to manoeuvre service users with walking frames or wheelchairs. The door is, on occasions, wedged open. This was not the case on the visit. To promote service users’ independence and to assist staff when mobilising service users safely, an automatic closure linked to the fire alarm system could be fitted which would address the difficulties experienced. Advice should be taken from the Fire Authority regarding these matters. The home was clean throughout and free from unpleasant odours. A team of housekeepers work hard to maintain a good standard of cleanliness within the home. One relative said, “there is an issue with the smell in her room, the smell can be eye watering although staff say they do not notice.” A number of service users’ rooms were seen, these were furnished and equipped to a comfortable standard, some had been personalised by the occupants, with many of the service users being quite self contained in their own rooms. A number of bedrooms have been redecorated and have had new carpets fitted. Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 Page 20 A number of service users sit in the conservatory all day, using the room as the lounge. A recurring complaint identified by service users, staff and relatives is the temperature in the conservatory and the need to replace the blinds to counteract the heat from the sun. Some blinds were not working or were no longer up at the window. Ceiling blinds were in place, which deflect some of the heat. No action has been taken by the registered person to address this issue. Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 Page 21 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 Quality in this outcome area is good. Staff were employed in sufficient numbers and trained to meet the needs of service users. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: At the time of the inspection the home was staffed to meet the needs of service users. A staff rota showing, which staff were on duty and in what capacity, was kept at the home. One relative said, “staffing is only affected when someone goes off sick at the last minute or has to leave to escort a resident to hospital”. Since the last inspection two new members of staff have been appointed. Examination of the staff files identified all the checks had been undertaken in line with regulations. The application forms are not signed and dated. One application form had been amended, the changes being contradictory to information contained in the individual’s file. Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 Page 22 The home completes a format to record staff interviews. This needs to be extended to include all aspects of best practice when recruiting staff. References were on file, however they were pre-written references and there was no detail that these had been verified. Existing staff confirmed that they had undertaken further training to assist them in their role as carers, including moving and handling updates, health and safety, and the safe handling of medicines. Nine staff have obtained NVQ qualifications. Three staff are due to register to undertake NVQ level 2. The deputy continues with her studies for NVQ level 3 and envisages that this will be concluded in a couple of months. Staff do not routinely have meetings with the manager when they influence the running of the home and contribute to its developments. The manager said that staff routinely come to her to discuss any issues, problems or ideas they may have. Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 Page 23 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): 31, 33, 35 & 38 Quality in this outcome area is adequate. Health and safety procedures are not in place for all areas of risk. Staff are not regularly supervised. This judgement has been made using available evidence, including a visit to this service. 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. Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 Page 24 Not all staff had received regular supervision to support them in their work. The home did not have any involvement with service users’ finances; these remained the responsibility of service users or their relatives. Staff who have the responsibility of preparing and cooking meals, in the absence of the cook, need to make sure that the checks that should be in place are undertaken in line with environmental health guidelines. Hot probe checks and kitchen cleaning schedules were not in place. The home maintained up to date records on the checks undertaken to the emergency lighting and means of escape, in line with fire authority regulations. Not all staff had taken part in fire drills and practices and this must be arranged to make sure staff know what to do in an emergency. Staff had updated their training in safe handling and moving procedures and health and safety. A certificate confirming the maintenance of the lift was seen on inspection. However, a service report was not on file for the most recent hoist service. The manager said the service had been done and confirmation of this was now on file. Staff commented on the difficulty they have with the hoist, due to its age and service users commented that they didn’t feel comfortable using it. The home recorded information in respect of falls and accidents by service users. Examination of the policies and procedures file identified a number of procedures that had not been recorded as having been reviewed for a number of years. Arrangements need to be made by the home to ensure the content of the policies and procedures are up to date, relevant and reflective of best practice. Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 Page 25 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 2 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X X X X 3 3 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 1 X 1 Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 Page 26 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 OP1 Regulation 5 Requirement Timescale for action 31/07/06 2 OP7 15 3 OP7 13 4 OP7 15 The registered person must review and amend the statement of purpose and service user guide, ensuring they contain all areas defined in the regulations and are accurate. The registered person must 30/06/06 review care plans, risk assessments and all areas of a service user’s care monthly, or more frequently if the care plan states this, and record that the reviews have taken place. The registered person must 30/06/06 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. (Previous timescale of 31/11/05 not met). The registered person must 30/06/06 further develop the care plans, ensuring all areas of the service users’ needs and interventions are detailed. (Previous timescale of 31/11/05 not met). DS0000008584.V293291.R01.S.doc Version 5.1 Rosegarth Page 27 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 OP9 Regulation 13 &17 Requirement Timescale for action 30/06/06 6 OP9 13 &17 7 OP9 13 8 OP9 13 &18 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. (Previous timescale of 25/10/05 not met). The registered person must 30/06/06 ensure that the directions of medication prescribed as ‘as directed’ is clarified with the resident’s General Practitioner and the prescriptions altered accordingly. (Previous timescale of 22/11/05 not met). The registered person must 30/06/06 ensure that service users 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. (Previous timescale of 22/11/05 not met). The registered person must 30/06/06 ensure that the competency of carers with responsibility for medication administration is assessed regularly on a formal basis. (Previous timescale of 17/01/06 not met). DS0000008584.V293291.R01.S.doc Version 5.1 Rosegarth Page 28 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. 9 Standard OP18 Regulation 12, 13 Requirement The registered person must arrange for all staff to attend training on what constitutes abuse. (Previous timescale of 31/12/05 not met). The registered person must ensure that all fire doors fit into their rebate when closed from any angle. (Previous timescale of 11/10/05 not met). The registered person must ensure that all doors that display a 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. (Previous timescale of 11/10/05 not met). 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. (Previous timescale of 31/12/05 not met). The registered person must consult with the fire authority in relation to safe practice within the home, in particular relation to hairdressing arrangements Timescale for action 31/07/06 10 OP19 23(4) 30/06/06 11 OP19 12, 13, 31/07/06 12 OP19 23(4) 31/07/06 13 OP19 23 14/07/06 Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 Page 29 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 OP19 Regulation 23 Requirement Timescale for action 31/07/06 15 OP29 19 16 OP36 18(2) 17 OP38 16(2)(j) The registered person must replace the window blinds in the conservatory and ensure that the temperature in the room is net excessively hot or cold for service users. The registered person must 14/07/06 ensure that all recruitment and selection procedures are followed, and prospective employees complete comprehensive applications and two verifiable references are provided for all new staff. (Previous timescales of 30/06/05 and 31/12/05 not met). The registered person must 14/07/06 ensure that staff receive 1:1 supervision and appraisal at a minimum of six times each year and that this detail is recorded. (Timescale of 31/11/05 not met). The registered person must 14/07/06 ensure that a record is maintained of kitchen cleaning and hot probe temperatures in line with food safety regulations. Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 Page 30 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 OP38 Regulation 23(4) Requirement 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 of 11/10/05 not met). The registered person must arrange for a suitable hoist to be available to service users which can be operated by staff with ease. Timescale for action 12/06/06 19 OP38 23(2) 12/06/06 Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 Page 31 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 OP9 Good Practice Recommendations The registered person should ensure that if the prescriber amends the dosage of medication, 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 provide staff with direction, supervision and training in how to interact with service users, ensuring privacy and dignity are respected. The registered person should ensure that an individual list of possessions is made on a service user’s admission to the home, which is dated and updated as new items are purchased or provided. The registered person should review the policies and procedures taking into account changing legislation and good practice guidance. 2 3 OP10 OP12 4 OP33 Rosegarth DS0000008584.V293291.R01.S.doc Version 5.1 Page 32 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.V293291.R01.S.doc Version 5.1 Page 33 - 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!