Inspection on 12/02/07 for Rosemary Lodge

This inspection was carried out on 12th February 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

Rosemary Lodge 10/12/08

Rosemary Lodge 21/02/06

Rosemary Lodge 23/08/05

Rosemary Lodge 25/10/04

Rosemary Lodge 05/05/04

Rosemary Lodge 27/11/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Rosemary Lodge 191 Walsall Road Lichfield Staffordshire WS13 8AQ Lead Inspector Mr Keith Jones Key Unannounced Inspection 12 February 2007 08:45 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 Rosemary Lodge DS0000004996.V328837.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. Rosemary Lodge DS0000004996.V328837.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosemary Lodge Address 191 Walsall Road Lichfield Staffordshire WS13 8AQ 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) 01543 415223 F/P 01543 415012 Roselodgehome@aol.com Abivue Limited T/A Rosemary Lodge Residential Home *** Post Vacant *** Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (31), Physical disability over 65 years of age (1) of places Rosemary Lodge DS0000004996.V328837.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21/02/2006 Brief Description of the Service: Rosemary Lodge is a 32-bedded care home providing care for older people over sixty-five years of age. The home is operated by Abivue Limited and can accommodate people with varying dependency needs. Located in Lichfield, the home is a two-storey property providing twenty-eight single bedrooms and two double bedrooms. There are Three separate living areas, each having a loungedining room, with adjacent bedrooms, bathroom and toilets. First floor accommodation is accessed by a passenger shaft lift. Externally there is a car park and the rear garden offers an enclosed area for residents. The location of this home ensures that there is a wide range of community facilities nearby that can be readily accessed. The home is also on a public transport route and a short taxi/bus ride from Lichfield’s two railway stations. Rosemary Lodge DS0000004996.V328837.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of Rosemary Lodge was undertaken within a day, by one inspector; the Care Manager (designate) and senior care staff, in a professional, frank and open manner. The last inspection report was discussed, and it was noted that requirements and recommendations were being addressed satisfactorily. On the day of inspection there were 28 service users in residence. A tour of the Home allowed free and open access to all areas for inspection. The opportunity was taken to speak with a number of service users, relatives and members of staff. Service users and staff took an active role in the inspection process and contributed to the subsequent report. A full case tracking of Three Service Users yielded a valuable insight of policies in action. Records had been correctly filed and stored, with a sample review of the administrative arrangements confirmed effective management. Weekly fees range from £385 to £425. The Care Manager (designate) and staff were thanked for their cooperation and open willingness to contribute to the inspection process. A full verbal report was offered at the end of the inspection. The inspector thanked all concerned for their contribution to a pleasing and constructive inspection of an improving service. What the service does well: There is a friendliness and general ambience in the interactions observed throughout the inspection. There was evidence of a much improved infrastructural support, led by a Care Manager (designate) who has the necessary freedom to manage directly, with a deputy manager in assistance. The standards of personal care were observed to be of a good quality, reinforced by discussion with residents, staff and relatives. The housekeeping and support services all contribute to the team approach, and are recognised by the management for their efforts. Rosemary Lodge DS0000004996.V328837.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Rosemary Lodge DS0000004996.V328837.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 Rosemary Lodge DS0000004996.V328837.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,and 5 The quality in this outcome area is adequate. The Statement of Purpose has been reviewed, and has addressed the major issues. The Home ensures that the admission process is a reflection of a joint understanding that residents are aware, and that staff are able to meet expectations, to realise a comfortable transition. The Home ensures that prospective residents have the necessary information to enable an informed choice to be made. All residents have contracts of terms and conditions of residence at the home a copy of which is on resident’s files. EVIDENCE: The revised draft Statement of Purpose, and Service User’s guide represent a much-improved description of the home’s aims and objectives, philosophy of care and terms and conditions. It offers service users and their relatives the opportunity to make an informed choice about where to live. A continuing Rosemary Lodge DS0000004996.V328837.R01.S.doc Version 5.2 Page 9 attention to the issues raised in Schedule 1 of the Care Standards Regulations would improve the depth of information the prospective residents and their family require. It is stated in the Statement of Purpose that independence, privacy and dignity are encouraged, with the full involvement of family in all matters concerning the well being of service users. The Statement of Purpose also indicates the terms and conditions, which are discussed with service users and relatives prior to admission. A pre-admission assessment, carried out by the Care Manager (designate), or deputy, appreciated any special needs of the individual including cultural, social or personal needs, which are fully discussed and documented. This assessment initiates the process of care, each individual having a plan of care based on personal needs and a daily living process. The Home demonstrated through case tracking, that the assessor explained this information in respect of each individual to ensure a clear understanding is established. The assessor also makes a judgement as to the suitability of each prospective service user using the same criteria. At all times the family is kept fully informed of the situation, offering service users and their relatives the opportunity to make an informed choice about where to live. Rosemary Lodge DS0000004996.V328837.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 The quality in this outcome area is good. The service users’ assessment provides the base, from which care planning is formulated. It is recognised that this reflects an individual profile of needs, discussed fully with family. The home has access to a number of GPs that visits the Home frequently, and the majority of service users are registered within 48 hours. The Statement of Purpose, admission assessment and care plans are geared to engender a sense of individuality and privacy. The inspector observed the free, courteous interaction between service users and staff based on a level of confidence of essential mutual trust and respect. The provision of a secure and safe medicines administration is managed effectively. EVIDENCE: There was evidence to show that a review of the care process has produced a satisfactory standard of meeting care needs. The pre-admission assessment Rosemary Lodge DS0000004996.V328837.R01.S.doc Version 5.2 Page 11 represents the foundation for an informative care planning process. Three residents’ care files were tracked and demonstrated a system of detailed information on the individual, their life style and needs, events and contacts, procedures and actions measured on a daily basis and reviewed monthly. The policy of the home is to maintain service users own GP support wherever practical; otherwise residents are registered with the local surgery. District nursing services are also received, and the home has an established and positive professional rapport. Paramedical support is openly obtained when necessary. Discussions with service users confirmed their acceptance and confidence in the overall standard of care and service given. “ I feel safe and comfortable here”, ”I saw the nurse and doctor last week, it was really nice” were some of the comments offered by residents. There was evidence that suitable equipment was deployed effectively. Carers were seen to interact with residents with purpose and compassion. The facilities and bedrooms were presented to facilitate privacy for the individual, which included medical examinations and personal care procedures, being performed in private. The administration of medicines adhered to procedures to maximise protection to service users. The storage was secure, with satisfactory added security for controlled drugs. A controlled drug register was examined and found to be in order. The Care Manager (designate) was advised to close off records of CDA when a resident leaves or discontinues the drug. The MAR sheets would be more presentable with a front divider with resident’s photograph and relevant information on it. Staff training has been extensive over the past 12 months, and continues to be pursued actively by the Care Manager (designate), and her deputy. There were no residents self-medicating at the time of inspection. Each service user has the opportunity of their own lockable facility in their bedrooms on request. The procedure for handling accidents and incidents was inspected and found to hold a policy of referral for medical/paramedical opinion if in doubt. Reports were informative, detailed and meaningful. However the recording and archiving of reports needs a review, to ensure protection of information. The Care Manager (designate) was advised to analyse accidents on a 3 monthly basis. Family and friends have relative freedom of visiting, those spoken to remarking on the importance of maintaining social contact. There was also an observed knowledgeable, and positive attitude by staff towards residents, and feedback from the residents: “I feel well looked after here, and “ nice home, comfy and friendly” “good staff, very helpful” Rosemary Lodge DS0000004996.V328837.R01.S.doc Version 5.2 Page 12 The Statement of Purpose clearly and openly states that the wishes concerning arrangements after death would be discussed and respectfully carried out. The spiritual needs of service users were recorded and observed by the staff, with due respect. Rosemary Lodge DS0000004996.V328837.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 The quality in this outcome area is good. This judgement is based on discussions with service users, staff and examination of records in relation to social activities undertaken and general observations during to course of the inspection. The home had a relaxed and welcoming atmosphere where people were encouraged to continue with their individualised lifestyle. Those who wish to bring in personal possessions are encouraged to do so. During the course of the inspection staff were observed to interact with the service users in a positive and polite manner. The home operated a four-week menu providing a varied, nutritional and well balanced diet; service users had a choice of meals and were also offered alternative choice. Special diets were accommodated with the cook making every effort to engage with service users to discuss personal preferences. Staff were seen to offer discreet assistance to those who required it at lunchtime when a very attractive and delicious luncheon was presented. Rosemary Lodge DS0000004996.V328837.R01.S.doc Version 5.2 Page 14 EVIDENCE: Discussions with service users and staff clearly identified a relaxed atmosphere in which the service user’s needs were respected. A routine exists to establish a framework for managing the home, not as a yardstick for service users to comply with, but for a point of familiarity. Several residents expressed their appreciation for the freedom they enjoyed, with the security that there are routine events to the day they could relate to. Those service users’ rooms inspected showed a significant influence of personalisation in the inclusion of belongings, some furniture and general décor. During the course of the inspection staff were observed to interact with the service users in a positive and polite manner. The good standards of catering offered a satisfactory service, to which service users spoken to were complimentary of all aspects of quality. A menu on a four weekly cycle offered a wholesome, varied and suitable choice. A very pleasant lunch of braising steak was served during inspection, with choices available, served in a well-furnished and clean dining room. Three meals were provided daily, with hot and cold beverages and snacks available throughout the day. Service users that were interviewed confirmed that that the quantity and quality food provided was good. Individual preferences were recorded in assessment and conveyed to cook, who met with, and discussed their requirements. It was confirmed that the cook knew each service user, and some of the relatives. Diversity was discussed with the cook, who indicated his awareness in meeting individual needs. Staff were seen to offer discreet assistance to those who required it. The choice of dining room, lounge or bedroom was at the discretion of service users. The kitchen was inspected with the cook, and found to present a well equipped and organised area. All fridges and freezers were well maintained and checked daily by the kitchen staff. A cleaning schedule was in place and seen to be up to date and accurate. Rosemary Lodge DS0000004996.V328837.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 The quality in this outcome area is good. The home had a meaningful complaints policy in place to ensure the protection of resident’s legal rights, identifying the CSCI as a resource to approach with a complaint or grievance. On discussions it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned. The home has systems and procedures and to protect residents from abuse. EVIDENCE: Residents’ legal rights are protected by the systems in place in the home to safeguard them, including their contract, the continual assessment of care planning and policies in place i.e. the complaints procedure. The complaints policy was seen and records examined. There were few recent complaints, which would be better dealt with through a formal ‘record of concerns’, to record residents and families concerns in a meaningful and effective manner. On discussions it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned. The overall policy of openness and transparency was acknowledged. CSCI had dealt with two complaints since the last inspection, with the full cooperation of the management to effect a satisfactory outcome in each case. There is presently a concern over resident’s relationships, which is being satisfactorily addressed by the Care Manager (designate). Rosemary Lodge DS0000004996.V328837.R01.S.doc Version 5.2 Page 16 Discussion confirmed that there is satisfactory evidence of a protocol and response, to anyone reporting any form of abuse, to ensure effective handling of such an incident. The policy and procedure for handling issues of abuse was examined, and found to be generally accurate, but would benefit from an update and reappraisal. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users. Rosemary Lodge DS0000004996.V328837.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25,26 The quality in this outcome area is good. This judgement was based on discussions with service users, staff and a tour of the premises. The home is well appointed to meet the needs of an elderly population of service users in providing a safe and comfortable environment. On inspection, bedrooms were highly personalised with most displaying service user’s own furniture, and with personal belongings. All communal areas are of a good standard, offering social as well as private reflection, as the mood takes. The overall environment was found to be safe for service user’s comfort within risk assessed limits. The domestic services in the home were seen to be of a very high standard, with no evidence of unpleasant smells or unsightly debris anywhere throughout the inspection. Rosemary Lodge DS0000004996.V328837.R01.S.doc Version 5.2 Page 18 EVIDENCE: A tour of the Home, service departments, and a check on the maintenance documentation, verified that the premises were fit for purpose, clean warm and tidy, and were being well maintained. The surrounding garden areas were well maintained providing a pleasant area for relaxation within warmer months. Internal access was facilitated with suitable fittings of hand and grab rails, in adequate, well-lit and airy corridors. Recent rain damage on the landing corridor, from a leaking roof is being addressed. Wheelchair access was satisfactory throughout all areas of the home. On admission the provider or care manager assesses each individual service users’ needs for equipment and necessary adaptations. Efforts had been made to provide a homely atmosphere and the décor in most areas of home was found to be pleasant. The home provided two lounge areas that were pleasantly decorated providing essential furnishings and items to provide a comfortable area where service users were able to interact with fellow service users, or to entertain their guests. The conservatory leading to the garden provided a tranquil area where service users could experience the views of the surrounding grounds. However on the day it was unheated, and uncomfortable for general use. Consideration should be given to install central heating, and remove freestanding heaters. There was a spacious dining area where service users were able to dine in comfort. Toilets and bathrooms were located on both floors and were in close proximity to bedrooms and communal areas. One bath hoist is unused, and needs replacement to meet minimum assisted bathroom provisions. The lift in the new extension is consistently malfunctioning, being unreliable, and requiring a thorough appraisal to meet needs. Bedrooms were well maintained to meet service user’s personal preferences. On inspection, most bedrooms were highly personalised, with some displaying service user’s own furniture, and most with personal belongings. It is the policy that on bedrooms becoming vacant that each room is reappraised for redecoration, as confirmed during the Inspection. There is throughout a satisfactory standard of furnishing complemented, with the exception to original ‘Regency’ type furniture, which is in need of replacement. Several wardrobes were seen unattached to security mountings. Nevertheless service users spoken to expressed a sense of belonging and satisfaction in the quality and presentation of their living areas. An effective call system is installed; care staff reacted speedily to tests. The care manager expressed a willingness to meet any reasonable demand for special needs. A locked facility and lockable bedroom doors are made available on request, following suitable risk assessment. The evidence seen on inspection of service user’s rooms, and on discussion with the individual service users and family, assured that this standard was well met. Rosemary Lodge DS0000004996.V328837.R01.S.doc Version 5.2 Page 19 Kitchen presentation showed good standards of cleanliness and evidence of sound food hygiene practices. The laundry was well organised and equipped to a good standard. Consideration to the flow of laundry through the process would enhance cross infection control. Red Alginate linen bags are available and widely used. Notices regarding chemical handling in the areas that store chemicals are displayed. The process would benefit from COSHH poster displays in all areas dealing with chemicals. It was advised that items should not be stored on toilet cistern lids. The external and internal environment was well maintained and secure. The Care Manager (designate) is to provide the Inspector with a development plan for 2007/08. Heating and ventilation were found to be satisfactory and lighting was domestic in style. Aids, adaptations and equipment were available throughout the Home. Fire equipment was inspected and seen to be serviced and up to date. The home presented a clean and pleasant, odour-free atmosphere, much to the credit of staff. Rosemary Lodge DS0000004996.V328837.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The quality in this outcome area is adequate. Staffing levels were seen to be adequate to meet an expected demand, the daily care staffing rota showed adequate balance between skills and qualifications although because of sickness numbers fall short at times to provide a good standard of care. The Provider and Care Management have established a procedure for interview, selection and appointment of staff, which requires reinforcement in ensuring the protection of service users. Staff training records complement the effort placed into staff training. EVIDENCE: Three weeks of off-duty were examined, and showed adequate balance between skills, qualifications and numbers to provide a foundation for a good standard of care. However because of sickness, there were times when staffing levels fell below recommended levels, especially at weekend. The Care Manager (designate) was required to remedy this situation. The Care Manager works supernumerary and is supported by an able team of carers, led by an experienced deputy. Bank coverage has been used occasionally to support shortages of care staff, in tandem with overtime and flexible rostering to meet shortfalls. Agency staff are rarely used. Rosemary Lodge DS0000004996.V328837.R01.S.doc Version 5.2 Page 21 At the time of inspection the duty rotas confirmed a staff coverage as thus: a.m - 1 senior 2 carers p.m - 1 senior 2 carers N.D - 1 senior 1 carer There is a satisfactory complement of housekeeping and laundry staff, with a maintenance man (20 hours/week), an administrator working 30 hours/week and a satisfactory establishment of catering staff. The Provider and Care Management have established a procedure for interview, selection and appointment of staff. Three staff files were sampled and found to be generally well organised. Each staff file would be more informative with a copy of job description, interview record to support the letter of appointment, and a suitable photograph of each staff member. Two members of staff were spoken with, each being pleased and satisfied with the professional foundation offered to them through effective management. All staff have a statement of terms and conditions. Service users are supported and protected by these practises and all new staff goes through an induction process that will ensure that they are going to be the right person for the home. The Care Manager (designate) remains steadfastly committed to a learning environment. She is due to complete the final stage of the RMA in March, and the deputy to commence level 4 NVQ in April. Staff induction programmes are meaningful and well established, forming the base upon which in-service supervision and training are planned. Overall the evidence shows a satisfactory account of a training programme and record that offers a full understanding of training needs. 13 members of staff hold a valid certificate in first aid, and 40 have a NVQ level 2 or 3 qualification. Supervision is conducted by the Care Manager (designate), which would be better maintained with delegated responsibilities, cascaded throughout the staff, to include all staff, on a two-monthly basis. Rosemary Lodge DS0000004996.V328837.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38 The quality in this outcome area is good. The influence of the Care Manager (designate) has been significantly enhanced over the past 15 months, and also from the last inspection. This accountability has resulted in a much-improved level of performance through a broad avenue of issues, especially in improvement of standards, staff management and the supporting infrastructure of services. The Care Manager (designate) of the home accompanied the inspector for the day. Judy Smith has demonstrated her capacity as suitably qualified and experienced to manage the day-to-day care needs of service users. The inspector was impressed by the openness and confidence in the observed interactions of staff, relatives and service users. The relationships were seen to be of mutual trust and respect. Rosemary Lodge DS0000004996.V328837.R01.S.doc Version 5.2 Page 23 EVIDENCE: The Registered Provider and Care Manager have developed a formal approach to monitoring quality across a wide range of activities. This includes a care plan review process that is recorded at least once a month, a staff training programme and a risk assessment programme. This includes the setting of objectives, effective budgeting of plans and target dates to aim for. Mrs Smith has been able to influence the planning in setting objectives on short-term and long-term planning. Evidence was secured to acknowledge achievements, ongoing and planned objectives. Involved within this process are the views of service users and relatives, confirmed at case tracking and informal discussion. Social Workers’ review meetings are often a vehicle for assessing quality. Each service users has a personal file containing contractual, financial and personal information. Three files inspected evidenced a satisfactory standard of maintenance and security. Care plans were drawn up, implemented and reviewed on a monthly basis. This process would be enhanced with the inclusion of service users and relatives whenever possible. Case tracking and informal discussion provided evidence that participation is encouraged on an informal level. A sample of administrative, maintenance and care records were examined and found to offer an accurate reflection of a service committed to providing a safe and comfortable environment for elderly service users. These included procedures on abuse (needing review), administration of medicines, and pressure care management. Service records for water supplies, gas, PAT testing, hoist maintenance and fire equipment were examined. It was advised that a satisfactory servicing of the water system, with regards to identifying Legionnaire’s disease was appropriate. Routine maintenance ensures that essential services linked to utilities and safety, are monitored and serviced on a regular basis. Fire safety remains high priority for all staff evidenced in routine maintenance checks, regular fire drills and frequent staff training sessions organised by 3 members of staff recognised as fire marshals, whom will take an active interest in developments and fire safety audits. Accidents were seen to be addressed, risk assessed, actioned and recorded in an effective way, with access to Riddor if needed. No serious accidents have been reported. A three-month analysis was advised, with added security on filing and recording accidents. The need to separate out recording staff accidents from residents was advised. Rosemary Lodge DS0000004996.V328837.R01.S.doc Version 5.2 Page 24 The administration and management of the home is effective, uncomplicated, and very sensitive to the needs of service users. Rosemary Lodge DS0000004996.V328837.R01.S.doc Version 5.2 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 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 2 3 3 Rosemary Lodge DS0000004996.V328837.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NONE 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. 2 Standard OP27.3 Regulation 18 1 (a) (b) Requirement To maintain adequate levels of staff at all times. Timescale for action 01/04/07 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 5 6 Refer to Standard OP2 OP1 OP24 OP36.2 Good Practice Recommendations To ensure that equipment provided at the care home are kept in good repair at all times, i.e. lift and upstairs bath. Statement of Purpose and Service users Guide will need to be updated. A re-furbishment plan be drawn up to address improvements for 2007/08. All staff to receive adequate supervision, 6 times a year As a course of good practice COSHH posters should be located in areas where chemicals are stored Update procedure manual regarding abuse. DS0000004996.V328837.R01.S.doc Version 5.2 Page 27 5 Rosemary Lodge 7 9 That a water certificate be obtained to reflect Health and Safety recommendations. Rosemary Lodge DS0000004996.V328837.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Rosemary Lodge DS0000004996.V328837.R01.S.doc Version 5.2 Page 29 - 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!