Inspection on 19/10/06 for Roselands Residential Home

This inspection was carried out on 19th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Roselands Residential Home 08/11/05

Roselands Residential Home 18/07/05

Roselands Residential Home 24/01/05

Roselands Residential Home 10/08/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Roselands Cackle Street Main Street Brede Rye East Sussex TN31 6EB Lead Inspector Jason Denny Key Unannounced Inspection 19th October 2006 10:25 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 Roselands DS0000021197.V313533.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. Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Roselands Address Cackle Street Main Street Brede Rye East Sussex TN31 6EB 01424 882338 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) Pleasantly Limited Miss Sylvia Wells Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The number of service users to be accommodated must not exceed 20 (twenty) The care home can provide personal care to older people aged 65 (sixty five) years or over on admission 8th November 2005 Date of last inspection Brief Description of the Service: Roselands is a converted Guest House that has been adapted to its present use as a care home. It has extensive grounds and off road parking. Roselands is located in an isolated rural, and quiet situation outside of the village of Brede near to the town of Rye in East Sussex. Residents are able to safely walk around its grounds with the long driveway a popular and safe walking route. Roseland’s is registered for 20 people who are over the age of 65. The home is suitable for people over 65 years who are in need of 24-hour care and support. The home has level access throughout with the provision of a shaft lift and ramping. The home also has its own passenger lift. There are 19 rooms one of which can be used as a shared facility. Five bedrooms have en-suite shower or bath facilities. An extension is currently being built due for completion in late 2007, which will provide en-suite rooms and additional supported bathrooms to complement the existing number of working and supported bathrooms. In the meantime the home are looking to improve another bathroom to convert this into a purpose built shower room. The home is not currently taking more than 15 Residents during the current building programme. Information on the range of fees charged is intended to be within the home’s current statement of purpose/service user guide and currently ranges from £337 to £405 per week, although this is yet to be published. The higher rate of fees is for those who are self-funded and is based on room size and facilities. Charges for extras include personal items beyond the basics and activities provided by the home. Such items include newspapers, personal toiletries, chiropody, and hairdressing. Inspection reports are not routinely sent out to families and advocates after each publication although a copy is kept on display in the reception area of the home and can be obtained via the manager. A service user guide containing the most recent inspection report is sent to any interested person [or their representatives] looking to move into the home. The brochure enclosed in this pack indicates the current fee levels. Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced key Inspection, which included a visit to the home which took place between 10.25am and 4pm on October 19, 2006. This inspection focused on the key major areas such as how needs are being met. Activities, lifestyles, environment staffing of the home, along with how the home is managed, and how concerns are dealt with, was looked at. During this inspection process, which covers the period since the last inspection November 8, 2005 a number of relatives, visitors, and social services have been spoken with. One [1] questionnaire was received from relatives, and 3 from Residents prior to the inspection, with all comments mainly positive, especially from relatives and visitors, about the manager, and the staff. Some visitors and ten [10] of the current fifteen residents were spoken with, along with others observed during the inspection, which also included discussion with some staff and observation of care-practices. The focus of the inspection was looking at the four newest Residents which included talking with them and looking at their care records. Some diversity and equality areas were explored in relation to lifestyles. Discussions with management looked at progress since the last inspection. The inspector toured all communal areas of the home along with some bedrooms. Meal arrangements were examined. A record of complaints was inspected. Staffing was looked at in detail along with the home’s management of quality. One [1] outcome area is Excellent, Five [5] areas are Good, and one [1] area is Adequate [ok] and in need of some improvement. What the service does well: One resident informed the Inspector in keeping with comments from all Residents that the home was “Excellent, food alright, like the views from my room, staff are kind and helpful”. The home was again found to provide excellent personal care. The management of the home was found to be especially good at responding to the changing needs of Residents and received special praise from relatives and Residents. A range of ways was seen of how well residents are supported to exercise their rights and choices. Resident’s benefit from a staff and management team, who have worked in the home for a long time. The manager is highly attentive to the needs of the home and now has the full qualification. There is a continued absence of complaints or concerns about the home. The home continues to provide enough staff to promptly meet needs with an exceptional number now having the national care qualification. Staff induction is also thorough along with recruitment checks. Meals were found to be tasty, healthy, and popular with residents. Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 6 The home continues to provide a good level of activities. The home ensures that it only provides services to those people whose needs they can safely and fully meet. Resident’s benefit from spacious communal space, which has a homely feel. The atmosphere of the home was again found to be calm and friendly. Medication arrangements were found to be excellent and safe. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, & 5. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home now provides both prospective and existing Residents, with a good level of information. Moreover, the way in which the home assesses prospective or existing residents ensures, that it currently meets needs. Contractual terms and conditions are fair, transparent and agreed and signed by residents and their representatives at the point of entry into the home, with only some minor additional information now needed. EVIDENCE: The home’s service user [residents] guidebook, which also contains the statement of purpose, was found in the hallway, which leads off from the reception area. The folder was found to be more clearly labelled and the manager explained how visitors are offered the opportunity to read the guide on their visits. Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 9 The statement of purpose corresponded to all the areas identified in the National Minimum Standards. The guide was now found to contain the two most recent inspection reports. The Managers qualifications were now found to be listed and along with useful information about the staff. Views of service users [Residents] were found in the guide. The home’s leaflet on the service had a range of photographs and information. A sample contract was seen in the guide although again this did not include the range of fees charged. Brochures were also on display, which are sent out to prospective new Residents and their families. The fee section on these was blank although the manager explained it was easier to write this on rather than re-print due to periodical changes in fees. The inspector explained that the overall range needs to be written down in the home’s guide/statement of purpose and then updated each year. This minor exception was not found to be affecting outcomes as new Residents explained how the actual fee was explained to them prior to admittance. The manager confirmed the current range of fees for new Residents are at between £337 to £405 with the higher rate for those who are self funded and depending on what facilities are afforded such as size of room and en-suite. This information is not published inside the home. Following the inspection the owner of the home explained in correspondence how complete visibility in the home about the range of fees might cause friction although is aware of the need for transparency and having to disclose this information to individual Resident’s if asked. The inspector looked at contracts for the 4 newest Residents and positively found that all contracts/terms and conditions were signed on admission and contained good information. The home was advised that although no one has moved in since September 2006 that they had to update future contacts by including additional information covered in the new regulations [5] to state for example where the fee would be different if the person was self-funded and who is responsible for paying the fee. The home was advised that for existing Residents that an additional letter to supplement their contracts could be sufficient. It was positively noted that fee charges were very competitive when compared with other similar homes, and in additional Residents enjoy a popular rural setting. The 4 Residents files looked at, showed that the home writes to prospective new residents to confirm that they could meet assessed needs prior to admittance. Pre-assessments carried out by the manager were found to be thorough with additional information from social services also obtained by the home either prior to or on admittance. These assessments accurately described the needs of the residents concerned who the inspector met with. The manager also indicates in the useful assessment pro-forma information why the Individual is being accommodated in the home to assist staff when the reason is less obvious. Such as when the Resident is very able and is in the home because it would be unsafe for the person to live without 24-hour care. Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 10 Residents spoken with confirmed that they had opportunities to have trial visits before moving in although in the main they relied on their relatives to make a decision. Evidence was also seen of the home sending out its guide and small leaflet style brochure to prospective new Residents all of whom confirmed that they had opportunity to read the information before moving in. Roselands DS0000021197.V313533.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 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 Good. This judgement has been made using available evidence including a visit to this service. An exceptional level of attention is given to the care-needs of residents. Residents are treated with dignity and respect with their wishes respected. Medication arrangements are safe. EVIDENCE: Individual plans of care were inspected of four [4] new residents and were found to be sufficiently detailed, up to date, and contained clear information to support staff to meet the needs of residents. The plans were found to be userfriendly and covered the full range of health needs, which the inspector observed during the inspection. All residents interviewed indicated the way in which there health needs were being met by the home. Staff and management are fully involved in plans of care and were found to be actively involved in their regular review. The home was found to be particularly mindful of how to prevent the risk of falls or pressure sores with a high level of ongoing risk-assessment and clear guidance to staff. Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 12 Plans benefit from good pre-assessments, which are carried out before someone moves in and which form the basis of the care-plan. All Residents and relatives spoken with including those who also completed comment cards indicated the excellent and attentive support given to Residents. Residents also confirmed how personal care is delivered to them by staff in an unhurried way which also respects their level of independence and preferences. The inspector looked at medication stocks, record keeping, training records and observed trained staff dispensing medication all of which was found to be in order. The manager discussed the range of checks carried out in relation to medication arrangements. There was no evidence of any Residents being over sedated with Residents found to be lively and sociable. Medication arrangements were found to be exceptional due to the provision of medication security safes in each bedroom, which reduces the risk of mistakes. The home was advised to record in care-plans the reasons for and effects of each medication listed so that staff are aware of why they are giving medication and what side effects to monitor for. Only trained staff as observed during the inspection dispense medication. Medication information sheets are also available in the home. Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 13 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. This judgement has been made using available evidence including a visit to this service. Residents are able to make a range of choices about their lives with significant consideration given to their views and feelings. The level of resident involvement in the home is good with them kept well informed by management. Food is popular with plenty of choice. The home was found to provide a good range of activities based on choice. EVIDENCE: Staff, management, and residents indicated that activities are organised depending on the preferences and needs of individuals. Staff who have worked in the home over 5 years explained that the level of activities in the home depend on what Residents live there. In previous years summer mini but trips have been organised when there has been a demand. All Residents spoken with indicated that they are regularly taking out by relatives and friends whilst others indicated no interest in outings. Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 14 It was explained that the current group of 15 residents are not demanding a lot of activity although some activity is taking place regularly. A music man visits quarterly, and 3 of the residents go out on mini-bus outing on weekly basis with another organisation. Several churches visit on a monthly basis and organise communal services. The home was found to have a range of activity aids such as bingo cards and board games, such as chess. Records and discussions showed that Residents preferences for activities and interests and hobbies are recorded when people move into the home. Some residents were observed to be listening to Wartime music in a lounge. One resident indicated that he liked the fact that the home was located some distance from the road and had large grounds. This fact encouraged him to go for daily walks with no risk to his safety. He also indicated that it was unsafe to walk at present due to the mud in the car park but explained that this was a temporarily situation. Residents were observed to come and go as they pleased with some choosing to take meals in their rooms or read their own ordered newspaper in the conservatory. The inspector observed 10 of the Residents having conservations amongst themselves in the Main lounge before lunch. During part of the morning some Residents read the various morning newspapers they have ordered. Residents benefit form the provision of regular informal meetings which most attend along with the manager. Residents were found to be well informed about the running of the home such as the current building work and future plans, and forthcoming events. Resident’s benefit from regular visits from one of the home’s owners that meets with everyone at least once a month. Residents were spoken with in relation to the food and when and where it is served. Breakfast was identified as usually starting around 8am either in rooms or in the dining room with others having this earlier if they prefer. A meal was observed being prepared by the manager and was sampled by the inspector and find to be good, tasty and wholesome. Menu sheets are completed on a daily basis where residents are consulted with in relation to their choices of at least two alternative Main meals along with popular vegetarian options, and the choice of hot or cold supper. These menu sheets were seen during the inspection and are based on the advertised menus in the home. All residents spoken with indicated satisfaction with meals and relatives commented that Residents received good portions and support in this important area. A recently appointed cook has now left the home with the management team sharing the responsibility between them whilst they recruit a new cook. Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 15 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. This judgement has been made using available evidence including a visit to this service. The home operates in an open, pro-active, and helpful manner. All residents and visitors are made fully aware of how to complain or raise concerns. The home has not received any complaints or concerns for many years. EVIDENCE: All residents spoken too confirmed the sensitive care they receive from an established staff team who were observed by the inspector to operate in an appropriately caring and patient manner. The home has a comprehensive complaint policy and form for reporting concerns. The homes complaints files showed no entries for many years. The inspector contacted the social services contracts department and was informed that there were no concerns logged by visiting professionals to the home such as district nurses or social workers. Residents indicated that they have regular and instant access to staff and the manager and are encouraged to air their views. All relatives spoken with indicated complete satisfaction with the home. Staff interviewed indicated a full awareness of how to both identify and report potential abuse. All staff are made aware of the home’s policy on this area and most staff have covered this in detail during completion of their National Vocational Qualification in care. All new staff cover this area during their induction as seen in records. Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 25, & 26. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Roselands has a warm and homely feel and benefits from a rural location. Bedrooms are spacious and well equipped with many enjoying sweeping countryside views. Resident’s benefit from extensive grounds and a off road quiet location. The front entrance area to the home has been improved. The home is positively working towards creating more suitable bathrooms with work starting on an extension which will lead to improved facilities overall. Some shortfalls such as communal carpets, car parking and access around the grounds, are temporary and will be resolved within the next year. EVIDENCE: The inspector toured both the interior and exterior of the home. The front entrance to the home, which includes a ramped access, was found to have been modernised with one of the two windows double-glazed along with the entrance door since the last inspection. Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 17 The remaining window was due for minor repainting. All communal areas were toured including a dining room, a lounge, and conservatory area. The manager indicated that carpets in all communal areas which are now due for replacement will be done once the building work finishes, as new carpets before then would quickly become stained and worn due to the risk of mud being walked into the home as the car park is on the route of the building work. Some Residents and relatives\visitors spoken with commented that the parking area has become more difficult to use and opportunities to walk around the grounds have been affected by the mud caused by the building works. It was confirmed that this is only a temporary situation with plans to improve the drive way before the building work is completed. The inspector also observed the recent mud being swept from the car park during the afternoon of the inspection. A possible shower room referred to in the last two reports was still in the discussion stage with reference to being made being made fit and safe for possible use by Residents in order to complement the one existing bathroom used by Residents. The possibility of a portable hoist was considered too expensive particularly as the extension will create at least two supported bathrooms and will complete by the end of 2007. Five of the bedrooms have either showers or baths although these are not used in practice. Residents prefer or require support with bathing, which usually means that 2 care staff are needed, meaning one bath at a time. The home again stated that at the present time the one supported bathing facility was meeting the needs of 15 people. The home has also recently spent £1200 on replacing the current hoist for the supported bathroom. No Residents were found to be affected by this situation. The home will consider an occupational therapy assessment of the premises once the extension is complete and Resident’s numbers increase. The home was found to be reasonably clean in the circumstances of mud being walked in from the car park, and free from offensive odours. Resident’s bedrooms were especially clean and well maintained. It was evident how well informed Residents are in relation to the extension and all indicate how they had been afforded flexibility to move rooms to be away from the noise of building work. It was evident how well the complex building works was being managed by the home, in the best interests of Residents. Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected 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 Excellent. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of experienced staff on duty who are well supervised, and trained. Tight recruitment and disciplinary procedures are followed to protect the interests of Residents. All Residents and visitors praised the quality of the staff. EVIDENCE: Staffing levels are matched to the needs of the 15 Residents as evidenced during the inspection. According to records and discussions with the management, two care staff cover the morning and two care staff cover the afternoon and evening shift. This is complemented by both the manager and deputy who worked 9-5pm and assist on the care-side where required. In addition the home has a cleaner, and usually a cook and kitchen assistant 7 days of the week. The cook’s role is to prepare all meals including suppers. On the day of the inspection due to a vacancy, the manager was doing the cooking. Staff, relatives and Residents confirmed that staffing levels were suitable to promptly meet their needs. Staffing levels were found to be unchanged since the last inspection despite a fall in resident numbers. Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 19 The manager was advised to resume the previous practice of recording on the rota the capacity of each person and also show the management hours as at present the manager and deputy are sharing cooking duties for a few hours per day whilst a new cook is recruited. When suppers are served there are two staff on shift although these levels are complemented by a manager being on care side at this time with any toileting support carried out beforehand. It was also noted that no current residents have high needs and most are quite independent and spend the supper period in their rooms. The current percentage of those who have passed National Vocational Qualification in Care at basic level 2 has risen to 66 which is over the required level of 50 with other care staff still on the course or due to start All staff were found to have compulsory training such as Moving and Handling, First Aid, food hygiene and Fire. The manager more closely monitors staff training and development as seen in records and training plans. One staff person who has just achieved a National Vocational Qualification in care indicated that they are booked to do refresher first aid training and along with other staff is working through a fire training course followed by an exam. Since the last inspection the manager has purchased a nationally recognised training package, which is being delivered to staff. Those staff who are approaching retirement and have declined National Vocational Qualification where found to have completed the 6 month foundation training course. The recruitment records of the two most recently employed staff where found to contain all necessary information including ID checks and Police CRB’s. All staff work under full supervision after passing their Protection of Vulnerable Persons Register check and before the Police CRB comes back clear. These staff were also found to have started or finished their TOPSS and foundation training induction under the supervision of the manager, as seen in records. Supervision records showed the progress being made, along with close monitoring of performance and development needs. Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, & 38. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home continues to benefit from a well-established, skilled, motivated, and highly attentive management team. The home has improved how it shows residents involvement in the running of the home and how it measures and improves quality. Residents are protected with safe practices with the exception of electricity certification, which is currently being actioned. EVIDENCE: The registered manager has now completed and achieved her National Vocational Qualification Level 4 in care and management. The manager stated that this has assisted her in professionalizing the home and awareness of recording activity in writing such as supervisions and quality assurance. Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 21 All staff spoken with praised the manager who they find very supportive and fair as well as showing strong leadership. Relatives and Residents were similarly praiseworthy. The deputy/assistant manager has a National vocational qualification at both Level 2 and 3. The staff team were observed to have easy access to management. The manager stated that she is looking at developing an effective office area, although records are well organised and secure with a locked vacant bedroom being used as a temporary office. The home has developed its own quality assurance system for measuring the views of Residents and their representatives. Since the last Inspection a survey has been carried out on all Residents with the results published in the homes service user guide in a user friendly way. Results were highly positive with two Residents suggesting improvements. The manager stated that any necessary improvements have been made although there were no records to show this. The manager was again advised to produce a short report to show any action plan. This action plan will in turn inform the overall yearly plan for the home showing written evidence of resident involvement and improving information to prospective new residents. The manager also stated that a new annual survey was about to commence. Staff indicated that policies and procedures are updated periodically with them informed of new polices such as recent one on the use of camera style mobile phones. The Commission receives monthly visit reports by the managing organisation’s representative/owner, with this now making clear reference to the views of residents in these reports. It was evident from these reports and talking with Residents how much interest the representative/owner, takes in the welfare of Residents. Residents were particularly pleased about how well informed they have been about the building works and how they had option to move rooms which some have positively taken. The home does not manage any Resident’s monies and invoices relatives and Resident’s representatives for any extras. Some Residents were found to fully manage their own financial affairs. Staff indicated that they received regular and helpful supervisory support from the manager. Although written records showed detailed supervisions/appraisals taking place every 6 months this was found to be meeting needs. The manager is currently devising a shorter less detailed form to record shorter discussions with the intention of holding these discussions at least every two months for full time staff. The homes health and safety certification was inspected with the only exception being Portable Appliance Testing information and Mains electricity, which was requested at the last inspection. The manager stated that the work is currently being carried out, with PAT testing already organised by the owner and completed, and within 3 months and will send the commission the evidence so that the requirements can be taken off the report. Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 4 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 2 X 2 2 X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 3 X 2 Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP21 Regulation 23[J] Requirement Timescale for action 15/11/07 2. OP38 13[4] That the bathing facilities within the home must be improved to provide service users [Residents] with sufficient and suitable facilities. [Requirement made at the last 4 Inspections]. Requirement first made January 2005. Timescale Extension 15/11/07. That the Registered Person must 15/01/07 by the date shown send the Commission a copy of a safety certificate in relation to both Portable Appliance Testing and Mains Electricity. Electricity at Work Regulations 1989 [Requirement made at the last 2-inspections. requirement first made November 8, 2005. Timescale extension 15/01/07. Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP1 OP2 Good Practice Recommendations That the home’s service user guide\statement of purpose includes specific information on the current scale of charges That the home ensures that all future service users from September 2006 have Statement of Terms and Conditions [Contract] which shows who is responsible for paying the fee. That the contract shows whether the fee would be different if the person was self-funding. [Amendment to regulation 5 effective from September 1, 2006] That an assessment of the premises and facilities should be undertaken by a suitably qualified person, or qualified Occupational Therapist, to advise on the suitability of disability equipment and environmental adaptations. That an action plan following the outcome of service user [Resident] surveys is also published in the home’s guide to show actions to be taken. 3. OP22 4. OP33 Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Roselands DS0000021197.V313533.R01.S.doc Version 5.2 Page 26 - 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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