Inspection on 14/03/07 for Rosehill (Robins` Hill)

This inspection was carried out on 14th March 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Rosehill (Robins` Hill) 24/01/06

Rosehill (Robins` Hill) 12/05/05

Rosehill (Robins` Hill) 09/02/05

Rosehill (Robins` Hill) 28/10/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Rosehill (Robins` Hill) Raleigh Hill Northam Bideford Devon EX39 3PA Lead Inspector Adele Adams Unannounced Inspection 11:00 14 March 2007 th 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 Rosehill (Robins` Hill) DS0000022177.V316145.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. Rosehill (Robins` Hill) DS0000022177.V316145.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosehill (Robins` Hill) Address Raleigh Hill Northam Bideford Devon EX39 3PA 01237 477625 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) Mrs Beryl May Jago Care Home 10 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (10) of places Rosehill (Robins` Hill) DS0000022177.V316145.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2006 Brief Description of the Service: Rosehill provides 24-hour residential care for 10 older people some of who may have dementia. The service is run in a large detached Victorian house standing in its own grounds and is a short drive away from the centre of Bideford. Access into the home is up a number of shallow steps from the car park. There is also wheelchair access from the car via a side entrance. The majority of bedrooms are located on the first and second floors, two bedrooms are on the ground floor, all vary in size and outlook and one bedroom is shared. A chairlift operates from the ground floor providing assistance with access for those that need it. There is a small section between the first and second floor that is not covered by the stair lift, therefore residents living on the second floor need to be mobile. The home has the ‘Investor In People’ award. Fees charged range from £306.00 to £364.00 per week; additional charges are made for some things such as hairdressing, chiropody, toiletries, magazines and newspapers and disposal of incontinence items. A copy of previous inspection report is available in the entrance of the home. Rosehill (Robins` Hill) DS0000022177.V316145.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has introduced “Key Standards “ to be inspected over each inspection year. Therefore, unless it is felt necessary by the inspector, some standards will not be inspected. This inspection was unannounced starting at 10:50 and ended at 16:40. During this inspection the inspector saw areas of the home including the dining room, the two lounges, the conservatory, laundry and kitchen and was shown a residents room by a resident and also viewed the bathrooms and toilets. The inspector sat and spoke with 7 residents as a group and observed staff and residents throughout the inspection. In addition, the inspector read residents care records, staff records, maintenance and health and safety records, policies and procedures for the service and spoke with the owner and briefly with care staff. There were no visitors to the home during the inspection. Information was also received before the inspection from the homeowner who had completed a pre inspection questionnaire and from surveys that had been returned from residents and families, doctors, district nurses and a visiting health care worker. All of this useful information has been used as part of the inspection process. What the service does well: All people wishing to move into Rosehill are assessed and can have the opportunity to visit the home beforehand, this makes sure that the service can be certain they can meet the needs of the person wanting to move there and provides people with an opportunity to make sure for themselves that Rosehill is where they want to live and be cared for. The residents at Rosehill feel as they did at the last inspection, that is; ‘everything at the home is done well’; and said, ‘you don’t have to worry about us, we’re well looked after’. The residents told the inspector how much they enjoy the home cooked food and like the way their likes and dislikes are catered for and the amount of choice and variety they have. Rosehill (Robins` Hill) DS0000022177.V316145.R01.S.doc Version 5.2 Page 6 The residents praised the staff that ‘work hard to look after them well’ and that the home is ‘kept spotless’. The residents place great importance on this. Several residents told the inspector that Rosehill is ‘their home’ and that they are treated with respect and spoken to politely and not only do they feel well looked after but feel they are ‘ spoilt’ – appreciation was made by residents in particular about the owners and staff efforts at Christmas and also how it was like being on holiday in the summer. Residents also like the welcome that is extended to their families and told the inspector that when families visit they are able to enjoy their company in the way they would if they were still living in their own home. Residents enjoy the varied activities that are available and value that they are respected as individuals and are not ‘expected ‘ to ‘join in’. The residents at Rosehill enjoy the homely, relaxed and comfortable surroundings and are proud of the way the staff look after them and the home – one resident said’ I like the way the home is kept spotless – they really look after us and are always making sure it’ clean’. Residents also find it reassuring that they know the staff well and that they are always on hand to assist them. What has improved since the last inspection? What they could do better: Although people wishing to move to Rosehill are assessed and can visit before moving to the home this can be further improved by ensuring that assessments made by the home owner and any visits to the home before admission are kept on record to show that very good practice takes place. The medicines policy and procedure now needs updating to make sure risk to residents is minimised and that staff have up to date guidance to follow which will ensure they are aware of how and where to record for example, medicines received in to the home and how handwritten prescriptions must be recorded. Rosehill (Robins` Hill) DS0000022177.V316145.R01.S.doc Version 5.2 Page 7 In order to reduce risk and promote safety staff must also receive suitable regular updates in relation to giving medicines to residents and staff should be regularly assessed in practice to make sure they are up to date and following the home guidelines. This was discussed with the homeowner who is to address this. Rosehill follows the guidance set out in the Alerter’s Guide (Devon County Council guidance) in relation to protecting vulnerable adults from every type of abuse and some staff have done some training in this area when doing their care qualifications, this could be improved upon by introducing regular updates for all staff and by making sure that new staff have read and understood the guidance and have access to training as soon as possible after beginning to work as a carer. It was found that a new member of staff had not had 2 references supplied before starting to work at Rosehill. Although risk to residents is minimised, as new staff do not work unsupervised at Rosehill until they have completed a period of induction and all checks have been undertaken, it would be better practice to ensure that 2 references and all other essential recruitment checks have been received for staff before they are employed to work at the home. Residents and staff would benefit from the reintroduction of residents quality assurance questionnaires – these had lapsed as it was thought that the C.S.C.I resident questionnaires had replaced these. Residents’ financial records should be kept up to date to provide an accurate account of what transactions have taken place, to provide an accurate audit trail ain the event of any query and to protect service users financial interests. 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. Rosehill (Robins` Hill) DS0000022177.V316145.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 Rosehill (Robins` Hill) DS0000022177.V316145.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): Quality in this outcome area is good. The service’s performance was assessed against Key standard 3. Standard 6 was not assessed, as intermediate care is not provided at Rosehill. Resident’s needs are assessed before they move into Rosehill this helps to show that Rosehill was the right choice of home for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One resident was able say that they had chosen Rosehill as the home they wished to move to, they could remember that a member of their family had helped with the decision making process and that they had visited the home before moving there. Other residents either chose not to comment or could not remember events before moving to Rosehill. The two newest residents appeared well settled and content, one told the inspector that they had settled well and liked living at Rosehill. Rosehill (Robins` Hill) DS0000022177.V316145.R01.S.doc Version 5.2 Page 10 The owner confirmed that she usually visits people herself to meet and assess them and whenever possible a pre admission visit is made to Rosehill by the person wishing to move to the home. The care records and care assessments of the 2 residents that had most recently moved into Rosehill were read. These show that before moving to Rosehill people have their needs fully assessed usually by social services or by a joint health and social services team, this information is provided to the owner and is kept on record and used as a baseline when people first move in. Unfortunately records of the owner’s visit to assess prospective new residents are not kept and neither is a record of a person’s pre admission visit to the home. This was discussed with the owner who agreed she could see the value of doing this and would do this in future. In addition, the inspector read the returned residents surveys, the pre inspection questionnaire, the doctors’ surveys, the district nurses surveys and a health care professionals survey. Rosehill (Robins` Hill) DS0000022177.V316145.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): Quality in this outcome area is adequate. The service’s performance was assessed against key standards 7, 8, 9 and 10 Each resident is treated with respect and is supported to be as independent as they are able. Each resident has a record detailing their individual needs this helps to make sure that each resident’s needs are met communicated well and regularly reviewed. Medication policy and training must be improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: When sitting and chatting with a group of 7 residents, 2 of the residents confirmed they were aware that there are records that the home keeps in relation to their care. Two residents said they are not particularly bothered about knowing what is in their record as the staff are ‘efficient and caring ‘and deal with anything that arises. Other residents either chose not to comment. Rosehill (Robins` Hill) DS0000022177.V316145.R01.S.doc Version 5.2 Page 12 Residents talked about how they are cared for, for example what assistance they need and receive with washing and dressing and said they are never hurried or rushed by staff. Residents spoke with the inspector about going to visit family and family and friends coming to the home to visit them. Residents have 2 lounges one is used less than the other and told the inspector they can take their visitors to the other lounge or to their room or in the summer sometimes sit outside. Residents told the inspector that staff give them their ‘tablets’ and there are only certain staff that are allowed to do that. Residents told the inspector that they are either taken to the doctors as needed but if someone is too poorly that a doctor’s visit to the home is arranged, district nurses also visit the home when needed. The residents told the inspector that a chiropodist visits regularly and sees them in a private area and that they can see an optician and dentist as well. The residents that spoke with the inspector all said that staff knock on their bedroom doors before entering and that staff are always polite and respectful to them. A resident explained that post is taken to residents unopened at breakfast time and that telephone calls can be made and received in private if they wish to have privacy. A resident confirmed that a district nurse had come to the home to give the residents their flu jabs and that this had been done in the privacy of another room. The care records and care assessments of the 2 residents that had most recently moved into Rosehill were read. These are held on computer and show that residents are involved in the writing and reviewing of care records. The 2 records read show that care needs and health needs are well documented and regularly reviewed. In addition, the inspector read the returned residents surveys which showed that residents are aware that they have care records, that residents are content and pleased with the way their care needs are met and the doctors’ and district nurses surveys have confidence in the service’s abilities. The inspector read the medication administration records (MAR) of 4 residents these showed that there was good recording in respect of residents taking or refusing their medication but there were gaps in relation to the amount of medication received by the home. Handwritten prescriptions were not written in capital letters and when handwriting prescriptions these need to be signed and dated by 2 staff and ideally a doctor should sign the prescription. The service has medication policies and procedures that follow guidance that is now out of date – this was pointed out to the provider who assured the inspector that a review would be carried out. One resident self medicates and keeps their medicine in a locked facility – this is monitored by the staff. The guidance for resident’ s self-medication and homely remedies was read and this is out of date. Rosehill (Robins` Hill) DS0000022177.V316145.R01.S.doc Version 5.2 Page 13 Staff training records demonstrate that care staff have received medication training and that staff with medication responsibilities are named as such, however the training was over 3 years ago and no updates have been undertaken – this was discussed with the home owner who is to address this. Rosehill (Robins` Hill) DS0000022177.V316145.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): Quality in this outcome area is good. The service’s performance was assessed against key standards 12, 13, 14 and 15. Residents at Rosehill are able to have a full and varied life depending on their wishes and preferences and enjoy a varied and nourishing diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Time was spent sitting chatting with a group of 7 residents in the lounge with the conservatory area to the rear – the radio was playing and the residents at different times were observed to be tapping their feet or moving their hands to the music and told the inspector they enjoyed having the radio on. During this time we discussed daily life at Rosehill. The residents told how they spend their days and that this is built around them as individuals, for example residents choose when they like to get up and go to bed and their breakfast is arranged to fit in with the time they like to get up. Residents told the inspector about the meals they have, the choice and quality of food, how their likes and dislikes are taken into consideration and how extra special effort is taken at times of celebration such as Christmas and birthdays Rosehill (Robins` Hill) DS0000022177.V316145.R01.S.doc Version 5.2 Page 15 – the residents really value that a birthday cake is made especially for them on their birthday and all can join in and mark the occasion. On the day of inspection the inspector observed the residents enjoying a cooked midday meal and dessert in the comfortable dining room – the meal was eaten at a relaxed pace with drinks also being offered to residents. The residents also feel that Rosehill is even more like home because they s prefer a lighter evening meal and they can choose what they want to eat and gave examples of this. Staff have undertaken food hygiene courses and these are due to be done again this year. The residents told of the activities that they take part in at Rosehill and also talked of the value they place on being respected as individuals and that are not ‘expected ‘ to ‘join in’ and ‘can come and go to their rooms as they please’. The activities discussed included; skittles, ball games, movement to music, quizzes, T.V. DVD’S and CD’s, cards and board games – the residents also said how much they enjoy entertainers that come into the home and sing-alongs. One resident explained how they like to go to their room to read or watch their television, another told the inspector how they like to knit and was observed being assisted by a member of staff with their knitting later in the day in the second lounge. Several residents told the inspector that Rosehill is ‘their home’ and that not only do they feel well looked after but are ‘ spoilt’ – appreciation was made by residents in particular about the owners and staff efforts at Christmas and also how it was like being on holiday in the summer. Residents said they like the welcome that is extended to their families and told the inspector that when families visit it, they are able to enjoy their company in the way they would if they were still living in their own home. The pre inspection questionnaire, discussion with staff and the owner, the residents and health professionals surveys, reading of and general observation throughout the inspection confirmed what had been discussed with residents. Rosehill (Robins` Hill) DS0000022177.V316145.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): Quality in this outcome area is adequate. The agency’s performance was assessed against key standards 16 and 18. Rosehill has a formal complaints procedure and residents can be confidant their views are taken seriously and will be acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: When talking in the lounge with a group of 7 residents, 3 of the residents said if there was something wrong or they had a concern they would go to the owner and that she would ‘sort things out’, part of the conversation included what is and what is not acceptable behaviour from staff and residents. The residents felt that they should be and are spoken to respectfully and politely and be able to openly express their views. The residents that commented told the inspector they would find it unacceptable to be spoken down to or told off, as Rosehill is their home. One resident explained how they are not told off but is ‘reminded’ about a certain behaviour / habit they have and understands and agrees to being reminded as they do not want to offend or upset anyone. The owner told the inspector that the home had not directly received any complaints. The inspector advised the homeowner of one issue that had been raised with the Commission for Social Care Inspection that was being looked into. Rosehill (Robins` Hill) DS0000022177.V316145.R01.S.doc Version 5.2 Page 17 The inspector read Rosehill’s compliments and complaints policy and procedure, which also contained information about the timescale in which complaints made to the home will be dealt with. Rosehill has a copy of Devon County Council’s Alerter’s Guide, which also acts as the service’s adult protection policy. The inspector saw in the records of 2 staff that Ault Protection training had been undertaken in 2004 as part of an NVQ course – no further training or updates has been undertaken. The two newest members of staff have not received any adult protection training to date. The homeowner is aware of the training that has to be addressed and is planning training events for this year for staff. The pre inspection questionnaire, discussion with the owner, the residents and reading of health professionals surveys, reading of policies and general observation throughout the inspection confirmed what had been discussed with residents. Rosehill (Robins` Hill) DS0000022177.V316145.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): Quality in this outcome area is good. The agency’s performance was assessed against key standards 19 and 26 and standards 20, 23, 24 and 25. The residents living at Rosehill live in a safe, comfortable, clean and homely environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During time spent sitting chatting with a group of 7 residents the inspector was told that the home ‘is really well looked after’, ‘is spotless’, ‘ they really look after us, they are always making sure it’s clean’. The residents all like their rooms and the other areas of the home and said it feels ‘homely’. One of the residents took the inspector to show them their room, which was appropriately furnished with a bed, dressing table, bedside table, a television, an armchair, a second chair, there was a main ceiling light, a table light on the Rosehill (Robins` Hill) DS0000022177.V316145.R01.S.doc Version 5.2 Page 19 dressing table and a light over the mirror above the hand basin. The room had an ensuite toilet, hand basin and toiletry cupboard. The room was centrally heated with a covered radiator and had natural light from a window overlooking the left of the grounds – the window openings were restricted and privacy provided by lace curtains. The door to the room was fitted with an automatic door closer, which meant the resident could have their door open or closed and the door was a fire door. The room was homely with photographs, ornaments and paintings on display. A call bell is located both next to the bed and in the ensuite toilet. The inspector made observational checks on the rest of the home and visited the ground, middle and upper floors, saw 2 bathrooms, the laundry and the kitchen, the stairs and landings and entrance hall, dining room and 2 lounges. The outside of the home is tidy and well kept; the residents enjoy the outside areas in the Summer months, access into the home is up a number of shallow steps from the car park. There is also wheelchair / stretcher access from the car via a side entrance. The owner provided the inspector with a list of the purchases made for Rosehill in 2006. This included; a replacement hallway carpet, a DVD and video player, a new bed and an extra mattress, a tumble dryer, 2 small vases, new bedlinen, 2 sets of new towels per resident, a bread maker, replacement carpets in Room 4, 7 and on the first floor bathroom, a slow cooker, kettle, large skittles, garden plants for the summer and 5 automatic door closers. The pre inspection questionnaire, discussion with the owner, reading of health professionals’ surveys, and general observation throughout the inspection confirmed what had been discussed with residents. Rosehill (Robins` Hill) DS0000022177.V316145.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): Quality in this outcome area is good. The agency’s performance was assessed against key standards 27, 28, 29 and 30. Residents at Rosehill are cared for by a suitable number of skilled staff that only work unsupervised once all recruitment checks have been undertaken and are known to be satisfactory. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During time spent sitting chatting with a group of 7 residents the inspector was told by 3 of the residents that there are always staff available to assist them with whatever is needed and that staff are always to hand and residents are never kept waiting. The residents said they feel that they are well cared for and that staff know what they are doing and are ‘experienced’. The residents feel they know the staff well and are happy with the new staff that have been employed and told the inspector that staff changes do not take place very often. The inspector observed that there were enough staff to support residents in a timely calm manner and that residents did not appear to feel the need to rush even though the staff were having to manage a situation with a resident that Rosehill (Robins` Hill) DS0000022177.V316145.R01.S.doc Version 5.2 Page 21 was particularly unwell. The staff duty rota confirmed staff numbers were as found during the inspection and showed that the staffing rota is planned in advance. The inspector read 4 staff files and training records and saw that essential training undertaken each year such as moving and handling and fire training had been undertaken in August 2006 and that further training is due this summer in areas such as First Aid and Food Hygiene to ensure that staff are kept up to date. Staff undertook a dementia awareness course in 2005 and this is an area that is important for staff to maintain their skills in and for new staff to receive training in. Staff also need to update or receive medication training – as mentioned in Standard 9. Staff training needs were discussed with the homeowner. The staff records of 2 new members of staff were read – these showed that when employed the appropriate checks are carried out and 2 references are sought – one new member of staff was on their period of induction and supervised work but the 2 references had been requested but had not been received by the home – this was discussed with the homeowner. New staff have a POVA First (Protection of Vulnerable Adults) check before starting work and also have a CRB check (police check) carried out – evidence of this was seen. Rosehill (Robins` Hill) DS0000022177.V316145.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): Quality in this outcome area is good. The agency’s performance was assessed against key standards 31,33,35 and 38. Rosehill runs smoothly with the residents and staff’s health and safety being well managed. Quality assurance checks take place, which are to be improved upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents spoken with both in a group and on a one to one basis told the inspector that the homeowner makes sure everything runs smoothly. Residents said ‘ The home runs like clockwork and all is very well organised’, residents told the inspector this made them feel secure and confidant. The residents spoken with told the inspector about the different roles and responsibilities the Rosehill (Robins` Hill) DS0000022177.V316145.R01.S.doc Version 5.2 Page 23 staff have. A resident that had recently moved to Rosehill told the inspector that the home is relaxed and runs smoothly and that this has made it easier to settle there. Residents could not remember filling out any questionnaires about quality (this included the residents recently completed C.S.C.I questionnaires.) The owner Mrs Jago has now completed the NVQ Level 4 and the Registered Managers Award and lives on site and oversees the day-to-day running of the home. The service had routinely undertaken resident questionnaires to find out their views – this had lapsed recently but the owner gave assurances that this is to start again. Any general household quality issues are dealt with as and when they occur the owner feels this is a real benefit as they do not have to wait for permission from anyone before undertaking repairs or making any type of replacement. The inspector did a random check of residents ‘pocket money’ records. The inspector was told how finances are managed within the home for residents, however the resident records seen on the day of inspection were out of date – this was discussed with the owner and is to be addressed. When chatting with the residents, the inspector was told of the fire drills that take place and told the inspector they feel these are important, as they know that everyone knows what has to happen – they also told the inspector that they can recognise the fire alarm. The inspector also read the homes fire logbook and fire risk assessment, which is all up to date. The home was last inspected by a fire officer on 06/07/06 and all findings and recommendations have been acted upon. The homes maintenance records were read and evidence of routine testing of equipment was seen – this included the testing of the emergency lighting system and the alarm engineers report dated 09/02/07. Health and safety risk assessments were read – each residents room is also risk assessed. The inspector was advised of the storage arrangements for all hazardous liquids, detergents and oxygen. Health and safety training and food hygiene training is due to be repeated later this year. Evidence was seen that a Legionella risk assessment has been undertaken and a Legionella bacteria testing was undertaken on 14/09/06. Rosehill (Robins` Hill) DS0000022177.V316145.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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 3 Rosehill (Robins` Hill) DS0000022177.V316145.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Timescale for action The registered person shall make 31/05/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. This refers to: • The recording of medicines received in to the home. The method of recording handwritten prescriptions. The out of date medication policy and procedure. (including self medication and homely remedies) Staff training / updates. Requirement • • • Rosehill (Robins` Hill) DS0000022177.V316145.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP18 OP29 OP33 OP35 Good Practice Recommendations New staff have access to, read and understand the Adult Protection guidance and all staff have regular updates in this area. Two references should be sought for all staff. Quality assurance systems seeking the views of service users should be in place. Service users’ financial records should be accurate and up to date. Rosehill (Robins` Hill) DS0000022177.V316145.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Rosehill (Robins` Hill) DS0000022177.V316145.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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